- Email: [email protected]
Mo1098 Decreased Esophageal Bolus Clearance on Pre-Transplant Impedance Testing Is Associated With Lymphocytic Bronchiolitis After Lung Transplantation
ARS and chronic rejection. Subjects not meeting this outcome were censored at date of last clinic appointment or death, whichever was earlier. Fisher's exact test for binary variables and student's t-test for continuous variables were performed to assess for differences between surgical groups. Results: 117 subjects (59% men, mean age: 54, average follow-up: 3.0 years) met inclusion criteria for the study. Patient demographics, pre-transplant cardiopulmonary function, BMI, CMV status, and PPI exposure were similar between groups. 46 subjects met the chronic rejection endpoint (39.3%). Application of ARS pre- or post-transplant was associated with reduction in chronic rejection (HR 0.52, p=0.007) on univariate analysis. Kaplan-Meier curves (Figure 1) demonstrated significantly reduced chronic rejection in subjects receiving pre- (log-rank p=0.04) and post-transplant ARS (log-rank p=0.03) compared to transplant patients with reflux that did not receive ARS. Pre-transplant ARS was non-inferior to post-transplant ARS (Table 1). Complications were rare and included 1 pre-transplant fundoplication patient with recurrent symptoms, and 2 post-transplant ARS patients with recurrent symptoms and regurgitation, all requiring re-operation. One death was attributed to aspiration pneumonia following ARS in the post-transplant group. Conclusion: Among lung transplant subjects with reflux symptoms, both pre- and post-transplant ARS were associated with reduced chronic rejection compared to no ARS. Pre-transplant ARS was non-inferior to post-transplant ARS. These findings support a role for aggressive antireflux management in lung transplant patients that may allow for consideration of additional factors such as reflux severity and surgical comorbidities to minimize perioperative risks.
Bridges to Excellence (BTE) Quality Indicators in Inflammatory Bowel Disease (IBD) - Variance in Utilization Between IBD Specialists and Non-IBD Gastroenterologists Kiranpreet Khosa, Raman Khehra, Shailendra Singh, Kofi Clarke Background: The American Gastroenterology Association BTE Inflammatory Bowel Disease (IBD) Care Recognition program encourages clinicians to develop superior quality of care in the treatment of IBD. Little is known about differences in performance between IBD specialists and other gastroenterology (GI) physicians. Objective: To assess utilization of BTE measures in the care of IBD patients among IBD and non-IBD GI physicians at a tertiary care hospital with a large gastroenterology faculty (N=25). Methods: Retrospective analysis of charts of IBD patients who had received care at our center between January 2013 and December 2013. The patients were divided into two groups- 1. Care provided by IBD trained physician with more than 50% of their practice dedicated to IBD 2. Care provided by non IBD GI physician. Data collected included baseline patient characteristics (Table 1) and eight BTE measures (Table 2). One point was given for each quality measure completed and total scores were reported as a percentage adherence. The average scores as per the AGA 100 point scale was also calculated and compared between the two groups. Descriptive statistics and the Chi square test were calculated for each measure between the two groups Results: A total of 78 IBD patients who met the inclusion criteria were included in the analysis. Of these, 35 patients received care with an IBD physician and 43 had other GI non IBD physicians as their main caregiver. Characteristics of the patients in the two groups are compared in Table 1. Patients managed by IBD physicians were younger with more severe disease. The use of biologic and immunomodulator therapy was higher in the IBD physician group. The performance on BTE quality measures are compared in Table 2. IBD physicians overall performed better on average AGA 100 point scale (74.1vs 64.5, p=0.0001). The number of quality measures completed was higher for IBD physicians (65.8% vs 54.5%, p= 0.024). Conclusion: Both groups of physicians exceeded the AGA recommended score of 60. IBD physicians perform better on BTE quality measures BTE quality measures as compared to other gastroenterologists. Further larger studies are needed. Table 2. AGA Bridges to Excellence (BTE) IBD Quality Measures
Table 1. Kaplan-Meier Log-rank P-values demonstrating association between anti-reflux surgical management and reduction in chronic rejection. Pre-transplant fundoplication was non-inferior to post-transplant fundoplication in reducing chronic rejection. * = statistically significant
Patient Characteristics Figure 1. Kaplan-Meier Analysis of time to chronic rejection by timing of fundoplication in transplant patients with reflux. Patients with reflux symptoms that did not undergo surgery were at greater risk of developing chronic rejection. Mo1098 Decreased Esophageal Bolus Clearance on Pre-Transplant Impedance Testing Is Associated With Lymphocytic Bronchiolitis After Lung Transplantation Wai-Kit Lo, Sravanya Gavini, Robert Burakoff, Natan Feldman, Walter W. Chan Background: Lymphocytic bronchiolitis (LB) or B-grade rejection is an independent risk factor for bronchiolitis obliterans (chronic rejection), a primary measure of morbidity and mortality following lung transplantation. Acid reflux has been associated with early allograft injury through a proposed mechanism of aspiration and activation of the inflammatory cascade. Change in intra-thoracic pressure in severe lung disease may also affect esophageal function including clearance of content, predisposing to regurgitation and aspiration. Combined esophageal multichannel intraluminal impedance and pH (MII-pH) study allows for assessment of reflux mechanisms regardless of acidity of content. We hoped to evaluate the association between esophageal bolus clearance and reflux parameters on pre-transplant MII-pH and post-transplant outcomes. Aim: To assess the relationship between pre-transplant MII-pH measures of reflux including bolus clearance and LB in lung transplant patients. Methods: This was a retrospective cohort study of lung transplant recipients who underwent pre-transplant evaluation with MII-pH study off acid suppression at a tertiary care center in 1/2007-11/2014. Patients with pre-transplant fundoplication were excluded. Time-toevent analysis using Cox proportional hazards model was applied to assess the relationship between MII-pH measures and development of LB, which was defined histologically with clinical correlation. Subjects not meeting this outcome were censored at time of posttransplant fundoplication, last pulmonary transplant clinic visit, or death, whichever was earliest. Fisher's exact test for binary variables and student's t-test for continuous variables were performed to assess for differences between groups. Results: 44 subjects (59% men, mean age: 57, average follow-up: 1.9 years) met inclusion criteria for the study. Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis. LB was detected in 11 subjects (25%). Patient demographics and pre-transplant cardiopulmonary function were
Mo1097 Pre-Transplant Fundoplication Is Non-Inferior to Post-Transplant Fundoplication in Reducing Chronic Rejection Among Lung Transplant Recipients Wai-Kit Lo, Hilary J. Goldberg, Steve Boukedes, Walter W. Chan Background: Chronic rejection or bronchiolitis obliterans is a primary outcome measure associated with graft failure and mortality after lung transplantation. Early post-transplant anti-reflux surgery (ARS) has been associated with improved lung transplant outcomes, while pre-transplant ARS has been shown in smaller studies to improve pulmonary function among transplant candidates with evidence of reflux. However, the efficacy of pre-transplant ARS and the optimal timing of ARS in transplant recipients remain unclear. Aim: To evaluate time to chronic rejection among lung transplant recipients by timing of ARS, and assess the efficacy of pre-transplant ARS. Methods: This was a retrospective cohort study of lung transplant recipients at a tertiary care center since 2007. Patients without a clinical diagnosis of reflux were excluded. Chronic rejection was defined either clinically by pulmonary function testing, or histologically by bronchoscopy with biopsies. Time-to-event analysis using the Cox proportional hazards model was applied to assess the relationship between timing of
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AGA Abstracts
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AGA Abstracts
similar between rejection groups. In time-to-event multivariate analysis, LB was independently associated with decreased bolus clearance (HR 4.55, p=0.03) and proximal acid reflux episodes in the recumbent position (HR 1.1, p=0.04). Kaplan-Meier curves demonstrated that decreased bolus clearance was significantly associated with early development of LB (log-rank p=0.01) (Figure 1). Conclusion: Abnormal bolus clearance and elevated proximal recumbent acid reflux episodes identified on pre-transplant MII-pH study were independently associated with development of LB. This association between esophageal function and evidence of early allograft injury suggests a need for continued esophageal assessment in lung transplant candidates to identify high-risk subgroups for additional treatment and risk reduction.
of these pre-malignant and malignant outcomes. Methods: We performed a populationbased case-control study of Utah residents using information contained in the Utah Population Database, which includes demographic and medical data from inpatient discharge records, ambulatory surgery centers, death records, and cancer registries from the University of Utah Health System and other health systems in Utah. Individuals who were diagnosed with Barrett's esophagus or malignancy of the esophagus or gastric cardia were identified using ICD-9 codes for these diagnoses. Only those who also had medical records available from childhood were included as cases. Control individuals were randomly identified using a 1:5 case:control ratio and were matched by gender, birth year, and follow-up date. Exposed individuals were identified by ICD-9 codes for gastroesophageal reflux disease, esophagitis, or hiatal hernia during childhood (age ≤ 18) or who were prescribed an anti-reflux medication during childhood. Odds ratios were calculated by conditional logistic regression with multivariate adjustment for potentially confounding variables, including gender, birth year, race, body mass index (BMI), alcohol use, and tobacco use. Results: 15,590 individuals were identified who were diagnosed with Barrett's esophagus or malignancy of the esophagus or gastric cardia, 639 of whom had medical records available from childhood and were matched with 3,195 control individuals. The populations consisted of 61.5% males and 87.5% nonHispanic whites, with a mean BMI of 24.8 ± 5.5 kg/m2 and a mean year of birth of 1981 that ranged between 1976 and 2009. Individuals with Barrett's esophagus or esophageal malignancy were more likely to have had GERD or its associated conditions in childhood compared with matched controls (OR 31.21, 95% CI 18.66-52.20), and this association remained significant after adjustment for the aforementioned confounding variables (OR 31.47, 95% CI 18.53-53.44). Conclusion: This is the first reported population-based study examining the risk of developing Barrett's esophagus or esophageal malignancy in individuals diagnosed with GERD (or its associated conditions) in childhood, which we found to be increased by 31-fold compared with healthy controls. This newly-identified strong risk factor may influence screening recommendations and identify many more patients in the base of the asymptomatic "Barrett's iceberg." Mo1101 Cough-Specific Quality of Life: Relationship to Gastroesophageal Reflux in Patients With Chronic Cough Augustine Lee, Vikas Bansal, Muhammad Asif Mangi, Kenneth R. DeVault, Lesley A. Houghton
Figure 1. Kaplan-Meier analysis of time to lymphocytic bronchiolitis by pre-transplant bolus clearance time. Abnormally decreased bolus clearance resulted in earlier development of lymphocytic bronchiolitis in transplant subjects.
Background: Chronic cough defined as cough that persists for > 8 weeks, effects up to 30% of the population and significantly impairs quality of life; with physical, psychological and social consequences (1, 2). Moreover, the frequency of coughing episodes directly correlates with quality of life (3). Episodes of coughing have been shown to temporally associate with gastro-esophageal reflux events, irrespective of the presence of other concomitant conditions contributing to cough, such as nasal disease and/or asthma (4). How reflux in cough relates to cough-specific quality of life remains unclear. Methods: We retrospectively identified consecutive patients who were referred for evaluation of a chronic cough at our specialist Chronic Cough Clinic, Mayo Clinic, Jacksonville, and who had undergone ambulatory 24hr impedance/pH recording and completed the validated Cough-Specific Quality of Life Questionnaire (CSQLQ) (5). Results: Seventy nine patients had undergone 24-hr impedance/ pH [aged 63 +12 yrs (mean + SD); 56 (71%) female] and completed the CSQLQ, of whom 25 (32%) were on acid-suppressant medications. The mean total number of reflux events was 53 + 25, with 13 (29%) patients having evidence of pathologic reflux. The mean number of acid and non-acid reflux events were 28 + 25 and 25 + 19, respectively. A weak correlation was found between cough-specific quality of life (QoL) and the number of reflux events (r= 0.20, p=0.073, Pearson's correlation), which appeared to be driven by a relationship between cough-specific QoL and the number of non-acid reflux (r=0.29, p=0.009) rather than acid reflux (r=-0.016, p=0.892) events. There was no correlation between cough-specific QoL and the percentage of time pH<4 (r=0.107, p=0.352). In a multivariate analysis including age, sex, use of acid suppressants during the test, percentage of time pH<4 in the proximal/ distal esophagus, together with the total number of acid and non-acid events; only sex and the number of non-acid reflux events were significantly predictive of the subject's coughspecific QoL. On average, an increase in non-acid reflux events of 10 per 24-hrs worsened the cough-specific QoL 2.1 points. Conclusion: Cough-specific quality of life worsens with increased numbers of reflux events, particularly non-acid reflux events but not the percentage of time pH<4. Further studies are required using acoustic cough recording to determine whether this association between the number of reflux events and cough-specific QOL, is related to a worsening in the actual cough frequency. Refs: (1)French et al. Arch Intern Med 1998; 158: 1657-61; (2) Morice et al. Thorax 2006; 61(suppl 1): 11-24; (3) Decalmer et al. Thorax 2007; 62: 329-334; (4) Smith et al. Gastroenterology 2010; 139: 754-762; (5) French et al. Chest 2002; 121: 1123-1131.
Mo1099 The Impact of Gastroesophageal Reflux on the Length of Hospital Stay for COPD Exacerbations: A Report of the Nationwide Inpatient Sample Nadim Mahmud, Julia McNabb-Baltar, Walter W. Chan Background: Gastroesophageal reflux disease (GERD) has been associated with numerous pulmonary disorders including asthma, idiopathic pulmonary fibrosis, and chronic obstructive pulmonary disease (COPD). However, the underlying pathophysiology of these associations is not clear. Microaspiration of refluxate may contribute to lung diseases, while worsening pulmonary function may also lead to increased trans-diaphragmatic pressure gradient and reflux. Recent studies suggest that GERD may be associated with increased COPD exacerbations, hospitalizations, and usage of multiple therapies. However, the effect of reflux diagnosis on hospitalization outcomes for acute exacerbations of COPD (AECOPD) remains unclear. Aim: To evaluate the impact of GERD or reflux esophagitis diagnosis on hospital length of stay (LOS) for AECOPD using a large, national inpatient database. Methods: This was a population-based cohort study of adult patients admitted to U.S. hospitals for AECOPD in 1998-2010 using the Nationwide Inpatient Sample (NIS) database. The average hospital LOS in days was compared between patients with a diagnosis of GERD or reflux esophagitis and those without known reflux disease. A multiple linear regression model was constructed, adjusting for potential confounders including age, gender, medical conditions, Charlson Comorbidity Index (CCI), disease severity, and hospital characteristics. Subgroup analysis was performed to examine the impact of reflux severity (reflux esophagitis vs GERD alone) on hospitalization outcomes. Results: 2,723,541 patients (mean age 70.2 years, 53% female, mean CCI 1.067) were included in the analysis, with 9,064 (70.4 years, 57% female, CCI 1.074) with reflux esophagitis, 335,760 (69.7 years, 60% female, CCI 1.014) with GERD alone, and 2,378,717 (70.3 years, 52% female, CCI 1.075 ) without any reflux disease. The overall mean AECOPD hospitalization LOS was 6.29±6.63 days. After adjusting for potential confounders, there was an independent positive association between LOS for AECOPD hospitalization and the diagnosis of reflux esophagitis (Beta-coefficient 0.5540, p<0.0001), but not the diagnosis of GERD. On subgroup analysis, patients with reflux esophagitis were found to have a longer mean LOS compared to those with GERD alone (Beta-coefficient 1.079, p<0.0001) and those without any reflux disease (Beta-coefficient 0.4799, p<0.0001). Conclusion: A diagnosis of reflux esophagitis is independently associated with longer LOS in patients hospitalized for AECOPD compared to general COPD patients. Hospital LOS is also longer among patients with more severe reflux (reflux esophagitis) compared to those with less severe or nonerosive disease (GERD alone). Further prospective studies are needed to assess the benefit of aggressive anti-reflux therapy on the outcomes of AECOPD.
Mo1102 Bioelectric Impedance and Anthropometric Measurements in Patients With GERD Pranav Periyalwar, Jason Abdallah, Carla Maradey-Romero, Ronnie Fass Background: Increase weight and obesity have been shown to correlate with gastroesophageal reflux disease (GERD)-related symptoms and signs, complications and even the likelihood of developing Barrett's esophagus and adenocarcinoma of the esophagus. However, thus far it has been proposed that waist to hip ratio is the best parameter to correlate with GERD. However, there are other more accurate measurements of fat deposit that may serve as better predictive factors for GERD. Aim: To compare the value of bioelectric impedance, body mass index (BMI), and anthropometry in predicting the presence of GERD. Methods: Twenty two patients (≥18 years) with history of heartburn and regurgitation (more than twice a week) were enrolled into the study. Patients were sub-categorized based on BMI using World Health Organization (WHO) classification into normal (18.5-24.9), overweight (25.0-29.9) and obesity: I (30.0-34-.9), II (35-39.9) or III (extreme obese ≥40). Anthropometric measurements using skin calipers were obtained including triceps, biceps, subscapular and suprailiac skinfold measurements. Using the RJL systems analyzer, bioelectric impedance was also assessed in each patient. Subsequently patients underwent both upper endoscopy to evaluate
Mo1100 Increased Incidence of Barrett's Esophagus and Esophageal Malignancy in Individuals With Gastroesophageal Reflux Diagnosed in Childhood Ketan K. Shah, Heidi A. Hanson, Ken Smith, Mazen Jamal Background: Gastroesophageal reflux disease (GERD) is a known risk factor for Barrett's esophagus and esophageal adenocarcinoma, especially increased duration, frequency, severity, and earlier age of onset of symptoms. However, GERD diagnosed in the pediatric population has never been directly examined as a potential risk factor for the development
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Bridges to Excellence (BTE) Quality Indicators in Inflammatory Bowel Disease (IBD) - Variance in Utilization Between IBD Specialists and Non-IBD Gastroenterologists Kiranpreet Khosa, Raman Khehra, Shailendra Singh, Kofi Clarke Background: The American Gastroenterology Association BTE Inflammatory Bowel Disease (IBD) Care Recognition program encourages clinicians to develop superior quality of care in the treatment of IBD. Little is known about differences in performance between IBD specialists and other gastroenterology (GI) physicians. Objective: To assess utilization of BTE measures in the care of IBD patients among IBD and non-IBD GI physicians at a tertiary care hospital with a large gastroenterology faculty (N=25). Methods: Retrospective analysis of charts of IBD patients who had received care at our center between January 2013 and December 2013. The patients were divided into two groups- 1. Care provided by IBD trained physician with more than 50% of their practice dedicated to IBD 2. Care provided by non IBD GI physician. Data collected included baseline patient characteristics (Table 1) and eight BTE measures (Table 2). One point was given for each quality measure completed and total scores were reported as a percentage adherence. The average scores as per the AGA 100 point scale was also calculated and compared between the two groups. Descriptive statistics and the Chi square test were calculated for each measure between the two groups Results: A total of 78 IBD patients who met the inclusion criteria were included in the analysis. Of these, 35 patients received care with an IBD physician and 43 had other GI non IBD physicians as their main caregiver. Characteristics of the patients in the two groups are compared in Table 1. Patients managed by IBD physicians were younger with more severe disease. The use of biologic and immunomodulator therapy was higher in the IBD physician group. The performance on BTE quality measures are compared in Table 2. IBD physicians overall performed better on average AGA 100 point scale (74.1vs 64.5, p=0.0001). The number of quality measures completed was higher for IBD physicians (65.8% vs 54.5%, p= 0.024). Conclusion: Both groups of physicians exceeded the AGA recommended score of 60. IBD physicians perform better on BTE quality measures BTE quality measures as compared to other gastroenterologists. Further larger studies are needed. Table 2. AGA Bridges to Excellence (BTE) IBD Quality Measures
Table 1. Kaplan-Meier Log-rank P-values demonstrating association between anti-reflux surgical management and reduction in chronic rejection. Pre-transplant fundoplication was non-inferior to post-transplant fundoplication in reducing chronic rejection. * = statistically significant
Patient Characteristics Figure 1. Kaplan-Meier Analysis of time to chronic rejection by timing of fundoplication in transplant patients with reflux. Patients with reflux symptoms that did not undergo surgery were at greater risk of developing chronic rejection. Mo1098 Decreased Esophageal Bolus Clearance on Pre-Transplant Impedance Testing Is Associated With Lymphocytic Bronchiolitis After Lung Transplantation Wai-Kit Lo, Sravanya Gavini, Robert Burakoff, Natan Feldman, Walter W. Chan Background: Lymphocytic bronchiolitis (LB) or B-grade rejection is an independent risk factor for bronchiolitis obliterans (chronic rejection), a primary measure of morbidity and mortality following lung transplantation. Acid reflux has been associated with early allograft injury through a proposed mechanism of aspiration and activation of the inflammatory cascade. Change in intra-thoracic pressure in severe lung disease may also affect esophageal function including clearance of content, predisposing to regurgitation and aspiration. Combined esophageal multichannel intraluminal impedance and pH (MII-pH) study allows for assessment of reflux mechanisms regardless of acidity of content. We hoped to evaluate the association between esophageal bolus clearance and reflux parameters on pre-transplant MII-pH and post-transplant outcomes. Aim: To assess the relationship between pre-transplant MII-pH measures of reflux including bolus clearance and LB in lung transplant patients. Methods: This was a retrospective cohort study of lung transplant recipients who underwent pre-transplant evaluation with MII-pH study off acid suppression at a tertiary care center in 1/2007-11/2014. Patients with pre-transplant fundoplication were excluded. Time-toevent analysis using Cox proportional hazards model was applied to assess the relationship between MII-pH measures and development of LB, which was defined histologically with clinical correlation. Subjects not meeting this outcome were censored at time of posttransplant fundoplication, last pulmonary transplant clinic visit, or death, whichever was earliest. Fisher's exact test for binary variables and student's t-test for continuous variables were performed to assess for differences between groups. Results: 44 subjects (59% men, mean age: 57, average follow-up: 1.9 years) met inclusion criteria for the study. Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis. LB was detected in 11 subjects (25%). Patient demographics and pre-transplant cardiopulmonary function were
Mo1097 Pre-Transplant Fundoplication Is Non-Inferior to Post-Transplant Fundoplication in Reducing Chronic Rejection Among Lung Transplant Recipients Wai-Kit Lo, Hilary J. Goldberg, Steve Boukedes, Walter W. Chan Background: Chronic rejection or bronchiolitis obliterans is a primary outcome measure associated with graft failure and mortality after lung transplantation. Early post-transplant anti-reflux surgery (ARS) has been associated with improved lung transplant outcomes, while pre-transplant ARS has been shown in smaller studies to improve pulmonary function among transplant candidates with evidence of reflux. However, the efficacy of pre-transplant ARS and the optimal timing of ARS in transplant recipients remain unclear. Aim: To evaluate time to chronic rejection among lung transplant recipients by timing of ARS, and assess the efficacy of pre-transplant ARS. Methods: This was a retrospective cohort study of lung transplant recipients at a tertiary care center since 2007. Patients without a clinical diagnosis of reflux were excluded. Chronic rejection was defined either clinically by pulmonary function testing, or histologically by bronchoscopy with biopsies. Time-to-event analysis using the Cox proportional hazards model was applied to assess the relationship between timing of
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Mo1096
AGA Abstracts
similar between rejection groups. In time-to-event multivariate analysis, LB was independently associated with decreased bolus clearance (HR 4.55, p=0.03) and proximal acid reflux episodes in the recumbent position (HR 1.1, p=0.04). Kaplan-Meier curves demonstrated that decreased bolus clearance was significantly associated with early development of LB (log-rank p=0.01) (Figure 1). Conclusion: Abnormal bolus clearance and elevated proximal recumbent acid reflux episodes identified on pre-transplant MII-pH study were independently associated with development of LB. This association between esophageal function and evidence of early allograft injury suggests a need for continued esophageal assessment in lung transplant candidates to identify high-risk subgroups for additional treatment and risk reduction.
of these pre-malignant and malignant outcomes. Methods: We performed a populationbased case-control study of Utah residents using information contained in the Utah Population Database, which includes demographic and medical data from inpatient discharge records, ambulatory surgery centers, death records, and cancer registries from the University of Utah Health System and other health systems in Utah. Individuals who were diagnosed with Barrett's esophagus or malignancy of the esophagus or gastric cardia were identified using ICD-9 codes for these diagnoses. Only those who also had medical records available from childhood were included as cases. Control individuals were randomly identified using a 1:5 case:control ratio and were matched by gender, birth year, and follow-up date. Exposed individuals were identified by ICD-9 codes for gastroesophageal reflux disease, esophagitis, or hiatal hernia during childhood (age ≤ 18) or who were prescribed an anti-reflux medication during childhood. Odds ratios were calculated by conditional logistic regression with multivariate adjustment for potentially confounding variables, including gender, birth year, race, body mass index (BMI), alcohol use, and tobacco use. Results: 15,590 individuals were identified who were diagnosed with Barrett's esophagus or malignancy of the esophagus or gastric cardia, 639 of whom had medical records available from childhood and were matched with 3,195 control individuals. The populations consisted of 61.5% males and 87.5% nonHispanic whites, with a mean BMI of 24.8 ± 5.5 kg/m2 and a mean year of birth of 1981 that ranged between 1976 and 2009. Individuals with Barrett's esophagus or esophageal malignancy were more likely to have had GERD or its associated conditions in childhood compared with matched controls (OR 31.21, 95% CI 18.66-52.20), and this association remained significant after adjustment for the aforementioned confounding variables (OR 31.47, 95% CI 18.53-53.44). Conclusion: This is the first reported population-based study examining the risk of developing Barrett's esophagus or esophageal malignancy in individuals diagnosed with GERD (or its associated conditions) in childhood, which we found to be increased by 31-fold compared with healthy controls. This newly-identified strong risk factor may influence screening recommendations and identify many more patients in the base of the asymptomatic "Barrett's iceberg." Mo1101 Cough-Specific Quality of Life: Relationship to Gastroesophageal Reflux in Patients With Chronic Cough Augustine Lee, Vikas Bansal, Muhammad Asif Mangi, Kenneth R. DeVault, Lesley A. Houghton
Figure 1. Kaplan-Meier analysis of time to lymphocytic bronchiolitis by pre-transplant bolus clearance time. Abnormally decreased bolus clearance resulted in earlier development of lymphocytic bronchiolitis in transplant subjects.
Background: Chronic cough defined as cough that persists for > 8 weeks, effects up to 30% of the population and significantly impairs quality of life; with physical, psychological and social consequences (1, 2). Moreover, the frequency of coughing episodes directly correlates with quality of life (3). Episodes of coughing have been shown to temporally associate with gastro-esophageal reflux events, irrespective of the presence of other concomitant conditions contributing to cough, such as nasal disease and/or asthma (4). How reflux in cough relates to cough-specific quality of life remains unclear. Methods: We retrospectively identified consecutive patients who were referred for evaluation of a chronic cough at our specialist Chronic Cough Clinic, Mayo Clinic, Jacksonville, and who had undergone ambulatory 24hr impedance/pH recording and completed the validated Cough-Specific Quality of Life Questionnaire (CSQLQ) (5). Results: Seventy nine patients had undergone 24-hr impedance/ pH [aged 63 +12 yrs (mean + SD); 56 (71%) female] and completed the CSQLQ, of whom 25 (32%) were on acid-suppressant medications. The mean total number of reflux events was 53 + 25, with 13 (29%) patients having evidence of pathologic reflux. The mean number of acid and non-acid reflux events were 28 + 25 and 25 + 19, respectively. A weak correlation was found between cough-specific quality of life (QoL) and the number of reflux events (r= 0.20, p=0.073, Pearson's correlation), which appeared to be driven by a relationship between cough-specific QoL and the number of non-acid reflux (r=0.29, p=0.009) rather than acid reflux (r=-0.016, p=0.892) events. There was no correlation between cough-specific QoL and the percentage of time pH<4 (r=0.107, p=0.352). In a multivariate analysis including age, sex, use of acid suppressants during the test, percentage of time pH<4 in the proximal/ distal esophagus, together with the total number of acid and non-acid events; only sex and the number of non-acid reflux events were significantly predictive of the subject's coughspecific QoL. On average, an increase in non-acid reflux events of 10 per 24-hrs worsened the cough-specific QoL 2.1 points. Conclusion: Cough-specific quality of life worsens with increased numbers of reflux events, particularly non-acid reflux events but not the percentage of time pH<4. Further studies are required using acoustic cough recording to determine whether this association between the number of reflux events and cough-specific QOL, is related to a worsening in the actual cough frequency. Refs: (1)French et al. Arch Intern Med 1998; 158: 1657-61; (2) Morice et al. Thorax 2006; 61(suppl 1): 11-24; (3) Decalmer et al. Thorax 2007; 62: 329-334; (4) Smith et al. Gastroenterology 2010; 139: 754-762; (5) French et al. Chest 2002; 121: 1123-1131.
Mo1099 The Impact of Gastroesophageal Reflux on the Length of Hospital Stay for COPD Exacerbations: A Report of the Nationwide Inpatient Sample Nadim Mahmud, Julia McNabb-Baltar, Walter W. Chan Background: Gastroesophageal reflux disease (GERD) has been associated with numerous pulmonary disorders including asthma, idiopathic pulmonary fibrosis, and chronic obstructive pulmonary disease (COPD). However, the underlying pathophysiology of these associations is not clear. Microaspiration of refluxate may contribute to lung diseases, while worsening pulmonary function may also lead to increased trans-diaphragmatic pressure gradient and reflux. Recent studies suggest that GERD may be associated with increased COPD exacerbations, hospitalizations, and usage of multiple therapies. However, the effect of reflux diagnosis on hospitalization outcomes for acute exacerbations of COPD (AECOPD) remains unclear. Aim: To evaluate the impact of GERD or reflux esophagitis diagnosis on hospital length of stay (LOS) for AECOPD using a large, national inpatient database. Methods: This was a population-based cohort study of adult patients admitted to U.S. hospitals for AECOPD in 1998-2010 using the Nationwide Inpatient Sample (NIS) database. The average hospital LOS in days was compared between patients with a diagnosis of GERD or reflux esophagitis and those without known reflux disease. A multiple linear regression model was constructed, adjusting for potential confounders including age, gender, medical conditions, Charlson Comorbidity Index (CCI), disease severity, and hospital characteristics. Subgroup analysis was performed to examine the impact of reflux severity (reflux esophagitis vs GERD alone) on hospitalization outcomes. Results: 2,723,541 patients (mean age 70.2 years, 53% female, mean CCI 1.067) were included in the analysis, with 9,064 (70.4 years, 57% female, CCI 1.074) with reflux esophagitis, 335,760 (69.7 years, 60% female, CCI 1.014) with GERD alone, and 2,378,717 (70.3 years, 52% female, CCI 1.075 ) without any reflux disease. The overall mean AECOPD hospitalization LOS was 6.29±6.63 days. After adjusting for potential confounders, there was an independent positive association between LOS for AECOPD hospitalization and the diagnosis of reflux esophagitis (Beta-coefficient 0.5540, p<0.0001), but not the diagnosis of GERD. On subgroup analysis, patients with reflux esophagitis were found to have a longer mean LOS compared to those with GERD alone (Beta-coefficient 1.079, p<0.0001) and those without any reflux disease (Beta-coefficient 0.4799, p<0.0001). Conclusion: A diagnosis of reflux esophagitis is independently associated with longer LOS in patients hospitalized for AECOPD compared to general COPD patients. Hospital LOS is also longer among patients with more severe reflux (reflux esophagitis) compared to those with less severe or nonerosive disease (GERD alone). Further prospective studies are needed to assess the benefit of aggressive anti-reflux therapy on the outcomes of AECOPD.
Mo1102 Bioelectric Impedance and Anthropometric Measurements in Patients With GERD Pranav Periyalwar, Jason Abdallah, Carla Maradey-Romero, Ronnie Fass Background: Increase weight and obesity have been shown to correlate with gastroesophageal reflux disease (GERD)-related symptoms and signs, complications and even the likelihood of developing Barrett's esophagus and adenocarcinoma of the esophagus. However, thus far it has been proposed that waist to hip ratio is the best parameter to correlate with GERD. However, there are other more accurate measurements of fat deposit that may serve as better predictive factors for GERD. Aim: To compare the value of bioelectric impedance, body mass index (BMI), and anthropometry in predicting the presence of GERD. Methods: Twenty two patients (≥18 years) with history of heartburn and regurgitation (more than twice a week) were enrolled into the study. Patients were sub-categorized based on BMI using World Health Organization (WHO) classification into normal (18.5-24.9), overweight (25.0-29.9) and obesity: I (30.0-34-.9), II (35-39.9) or III (extreme obese ≥40). Anthropometric measurements using skin calipers were obtained including triceps, biceps, subscapular and suprailiac skinfold measurements. Using the RJL systems analyzer, bioelectric impedance was also assessed in each patient. Subsequently patients underwent both upper endoscopy to evaluate
Mo1100 Increased Incidence of Barrett's Esophagus and Esophageal Malignancy in Individuals With Gastroesophageal Reflux Diagnosed in Childhood Ketan K. Shah, Heidi A. Hanson, Ken Smith, Mazen Jamal Background: Gastroesophageal reflux disease (GERD) is a known risk factor for Barrett's esophagus and esophageal adenocarcinoma, especially increased duration, frequency, severity, and earlier age of onset of symptoms. However, GERD diagnosed in the pediatric population has never been directly examined as a potential risk factor for the development
AGA Abstracts
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