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Impact of age on baseline severity of esophagitis and heartburn, and subsequent healing following treatment with esomeprazole or lansoprazole
S14
Abstracts
Purpose: Boerhaave’s syndrome, a well– described cause of esophageal rupture, is associated with high morbidity and mortality. Primary surgical repair of the ruptured esophagus within 24 hours as well as mediastinal debridement, pleural drainage, broad–spectrum antibiotics, and continuous nasogastric (NG) suction constitutes standard management for this entity. When primary repair of the rupture is not feasible, esophageal diversion and exclusion procedures as well as deployment of a covered esophageal stent have been used with limited success. An 87 year– old woman with known coronary artery disease presented to the emergency department complaining of excruciating retrosternal chest pain following several episodes of vomiting. An electrocardiogram revealed no evidence of ischemia and a chest x–ray was normal. Due to the concern for potential aortic dissection, a chest CT was performed revealing mediastinal air and fluid around the distal esophagus with extension into the gastrohepatic ligament. A transmural esophageal tear was confirmed by a gastrograffin esophagram. Due to the severity of her comorbidities, conservative management was chosen with fluoroscopic placement of an NG tube to continuous suctioning, IV antibiotics and pantoprozole. A small right pleural effusion subsequently developed but she remained afebrile throughout her hospital course. An endoscopically placed nasojejunal feeding tube was inserted on hospital day 3 and revealed an edematous distal esophagus with a 2 cm. defect. Serial gastrograffin and barium esophagrams were performed until complete resolution of the esophageal defect was documented on day 21. This case demonstrates the feasibility of a conservative approach to the management of Boerhaave’s syndrome in patients who are poor surgical candidates. Factors that likely contributed to a favorable outcome in our patient included early diagnosis and intervention, and the relatively small size of the perforation. Careful endoscopic placement of feeding tubes can be safely accomplished using minimal insufflation, but is not routinely recommended due to the potential for further mediastinal contamination or extension of the perforation. 42 A PROSPECTIVE LOOK AT ESOPHAGEAL BACTERIA IN PATIENTS WITH BARRETT’S ESOPHAGUS Glenn L. Osias, M.D., Matthew Q. Bromer, D.O., Rebecca M. Thomas, M.D., David Friedel, M.D., Larry S. Miller, M.D., Byungse Suh, M.D., Bennett Lorber, M.D., Henry P. Parkman, M.D. and Robert S. Fisher, M.D.*. Medicine, Temple University Hospital, Philadelphia, PA and Pathology, Temple University Hospital, Philadelphia, PA. Purpose: To prospectively study the presence of esophageal bacteria in GERD patients with and without Barrett’s esophagus. Methods: Mucosal biopsy specimens were obtained from the distal esophagus in 18 GERD patients – 8 with Barrett’s esophagus (BE) and 10 without BE (non–BE). Biopsies were taken within the BE segment except in those patients without BE, which were taken 5 cm above the gastroesophageal junction. Patients were also divided according to whether or not they were taking proton pump inhibitors (PPI): (12) and non–PPI (6). Presence of bacteria was determined by gram staining mucosal biopsy specimens and quantitating bacterial colony counts using a serial dilution/ pour plate technique to culture aerobic organisms. A pathologist interpreted each gram stain (GS) for the presence of bacteria. A quantitative bacterial score was assigned to each specimen: none ⫽ 0, rare ⫽ 1, single cluster or few scattered ⫽ 2, few (2– 4) clusters or single cluster with numerous scattered ⫽ 3, and ⬎ 4 clusters or many scattered ⫽ 4. Mean (⫾SEM) bacterial colony counts and scores were calculated for each group and compared using Students t–test Results: Bacteria, primarily gram positive cocci, were found in 8/18 esophageal biopsies by GS (6/8 patients with BE vs. 2/10 non–BE). Distal esophageal bacterial scores in patients with BE (1.75 ⫾ 0.1) were significantly higher compared to those without BE (0.4 ⫾ 0.6; p⫽0.02). 7/8 patients with BE were on PPI, 6 of whom had bacteria present on GS. Patients on PPI had a nonsignificant increase in bacterial scores (1.2 ⫾ 0.3) compared to those non–PPI (0.7 ⫾ 0.3; p⫽0.45). Bacterial colony counts
AJG – Vol. 97, No. 9, Suppl., 2002
were similar in patients with BE (4.7 ⫾ 1.0) to those w/o BE (5.3 ⫾ 1.0) and in patients on PPI (4.6 ⫾ 0.83) and non–PPI (5.8 ⫾ 1.41). Conclusions: Bacteria in biopsies from the distal esophagus were detected more often in patients with BE than non–BE. However, quantative aerobic bacteria colony counts were similar in BE and non–BE. Quantitating anaerobic organisms may elucidate the relationship between bacteria and BE. Bacteria in the distal esophagus, possibly related to esophageal stasis or PPI therapy, may play a role in the pathogenesis of BE. 43 IMPACT OF AGE ON BASELINE SEVERITY OF ESOPHAGITIS AND HEARTBURN, AND SUBSEQUENT HEALING FOLLOWING TREATMENT WITH ESOMEPRAZOLE OR LANSOPRAZOLE David A. Johnson, M.D., FACG*, Seth Zuckerman, M.S. and Jeffrey G. Levine, M.D. Gastroenterology, Eastern Virginia School of Medicine, Norfolk, VA; Biostatistics, AstraZeneca LP, Wayne, PA and Gastroenterology, AstraZeneca LP, Wayne, PA. Purpose: To determine the relationship between age and baseline severity of erosive esophagitis (EE) and heartburn and to assess the effect of age on healing rates in patients treated with esomeprazole or lansoprazole. Methods: This retrospective analysis was based on data from a prospective double– blind multicenter trial that randomized 5240 GERD patients aged 18 to 75 years with EE to treatment with esomeprazole 40 mg (n ⫽ 2624) or lansoprazole 30 mg (n ⫽ 2616) once daily before breakfast for up to 8 weeks. Age was classified in decade– of–life cohorts. Severity of EE at baseline was graded endoscopically using the Los Angeles classification (severity progressing from grades A to D). For this analysis, grades C and D were considered severe. Healing was confirmed endoscopically at week 4; for patients not healed, endoscopy was repeated at week 8. Healing rates at week 8 with 95% confidence intervals (CI) were calculated by Kaplan– Meier life–table estimates and differences analyzed using the log–rank test stratified by baseline age category. Chi–square tests were performed to assess associations between age and the prevalence of severe heartburn and severe EE. Results: An increase in the prevalence of severe EE was observed with advancing age (p⬍0.0001). However, prevalence of severe heartburn decreased with age ⬎40 years (p⬍0.0001). Healing rates were higher with esomeprazole 40 mg compared with lansoprazole 30 mg when controlling for age (p ⫽ 0.0008).
Age (yr) ⬍21 21–30 31–40 41–50 51–60 61–70 ⬎70
n 43 520 1152 1425 1198 674 228
Severe Severe EE, Heartburn, Baseline (%) Baseline (%) 14.0 17.5 23.9 23.4 25.5 29.7 32.9
32.6 47.1 47.4 43.2 38.8 36.6 28.9
% Healing (95% CI) Esomeprazole 40 mg
% Healing (95% CI) Lansoprazole 30 mg
86.4 (72.0–100) 90.7 (87.0–94.5) 91.5 (89.1–93.5) 93.6 (91.7–95.4) 93.5 (91.4–95.5) 91.9 (88.7–95.0) 94.3 (89.8–98.7)
86.7 (69.9–100) 87.6 (83.3–91.9) 88.4 (85.6–91.1) 88.6 (86.2–91.0) 87.1 (84.3–89.9) 92.4 (89.5–95.2) 91.8 (86.7–96.9)
Conclusions: In GERD patients with EE, the prevalence of severe disease increased with advancing age while the prevalence of severe symptoms declined. Therefore, it is important to be vigilant in treating elderly EE patients irrespective of the severity of their symptoms. 44 PEMPHIGOID ASSOCIATED ESOPHAGITIS DESSICANS SUPERFICIALIS COMPLICATED BY ACQUIRED HEMOPHILIA A Fritz Francois, M.D., Babak Faroozi, M.D., Jennifer Adams, M.D. and Zoi Gamagaris, M.D.*. Gastroenterology, New York Univeristy Medical Center, New York, NY and Internal Medicine, New York University Medical Center, New York, NY.
Abstracts
Purpose: Boerhaave’s syndrome, a well– described cause of esophageal rupture, is associated with high morbidity and mortality. Primary surgical repair of the ruptured esophagus within 24 hours as well as mediastinal debridement, pleural drainage, broad–spectrum antibiotics, and continuous nasogastric (NG) suction constitutes standard management for this entity. When primary repair of the rupture is not feasible, esophageal diversion and exclusion procedures as well as deployment of a covered esophageal stent have been used with limited success. An 87 year– old woman with known coronary artery disease presented to the emergency department complaining of excruciating retrosternal chest pain following several episodes of vomiting. An electrocardiogram revealed no evidence of ischemia and a chest x–ray was normal. Due to the concern for potential aortic dissection, a chest CT was performed revealing mediastinal air and fluid around the distal esophagus with extension into the gastrohepatic ligament. A transmural esophageal tear was confirmed by a gastrograffin esophagram. Due to the severity of her comorbidities, conservative management was chosen with fluoroscopic placement of an NG tube to continuous suctioning, IV antibiotics and pantoprozole. A small right pleural effusion subsequently developed but she remained afebrile throughout her hospital course. An endoscopically placed nasojejunal feeding tube was inserted on hospital day 3 and revealed an edematous distal esophagus with a 2 cm. defect. Serial gastrograffin and barium esophagrams were performed until complete resolution of the esophageal defect was documented on day 21. This case demonstrates the feasibility of a conservative approach to the management of Boerhaave’s syndrome in patients who are poor surgical candidates. Factors that likely contributed to a favorable outcome in our patient included early diagnosis and intervention, and the relatively small size of the perforation. Careful endoscopic placement of feeding tubes can be safely accomplished using minimal insufflation, but is not routinely recommended due to the potential for further mediastinal contamination or extension of the perforation. 42 A PROSPECTIVE LOOK AT ESOPHAGEAL BACTERIA IN PATIENTS WITH BARRETT’S ESOPHAGUS Glenn L. Osias, M.D., Matthew Q. Bromer, D.O., Rebecca M. Thomas, M.D., David Friedel, M.D., Larry S. Miller, M.D., Byungse Suh, M.D., Bennett Lorber, M.D., Henry P. Parkman, M.D. and Robert S. Fisher, M.D.*. Medicine, Temple University Hospital, Philadelphia, PA and Pathology, Temple University Hospital, Philadelphia, PA. Purpose: To prospectively study the presence of esophageal bacteria in GERD patients with and without Barrett’s esophagus. Methods: Mucosal biopsy specimens were obtained from the distal esophagus in 18 GERD patients – 8 with Barrett’s esophagus (BE) and 10 without BE (non–BE). Biopsies were taken within the BE segment except in those patients without BE, which were taken 5 cm above the gastroesophageal junction. Patients were also divided according to whether or not they were taking proton pump inhibitors (PPI): (12) and non–PPI (6). Presence of bacteria was determined by gram staining mucosal biopsy specimens and quantitating bacterial colony counts using a serial dilution/ pour plate technique to culture aerobic organisms. A pathologist interpreted each gram stain (GS) for the presence of bacteria. A quantitative bacterial score was assigned to each specimen: none ⫽ 0, rare ⫽ 1, single cluster or few scattered ⫽ 2, few (2– 4) clusters or single cluster with numerous scattered ⫽ 3, and ⬎ 4 clusters or many scattered ⫽ 4. Mean (⫾SEM) bacterial colony counts and scores were calculated for each group and compared using Students t–test Results: Bacteria, primarily gram positive cocci, were found in 8/18 esophageal biopsies by GS (6/8 patients with BE vs. 2/10 non–BE). Distal esophageal bacterial scores in patients with BE (1.75 ⫾ 0.1) were significantly higher compared to those without BE (0.4 ⫾ 0.6; p⫽0.02). 7/8 patients with BE were on PPI, 6 of whom had bacteria present on GS. Patients on PPI had a nonsignificant increase in bacterial scores (1.2 ⫾ 0.3) compared to those non–PPI (0.7 ⫾ 0.3; p⫽0.45). Bacterial colony counts
AJG – Vol. 97, No. 9, Suppl., 2002
were similar in patients with BE (4.7 ⫾ 1.0) to those w/o BE (5.3 ⫾ 1.0) and in patients on PPI (4.6 ⫾ 0.83) and non–PPI (5.8 ⫾ 1.41). Conclusions: Bacteria in biopsies from the distal esophagus were detected more often in patients with BE than non–BE. However, quantative aerobic bacteria colony counts were similar in BE and non–BE. Quantitating anaerobic organisms may elucidate the relationship between bacteria and BE. Bacteria in the distal esophagus, possibly related to esophageal stasis or PPI therapy, may play a role in the pathogenesis of BE. 43 IMPACT OF AGE ON BASELINE SEVERITY OF ESOPHAGITIS AND HEARTBURN, AND SUBSEQUENT HEALING FOLLOWING TREATMENT WITH ESOMEPRAZOLE OR LANSOPRAZOLE David A. Johnson, M.D., FACG*, Seth Zuckerman, M.S. and Jeffrey G. Levine, M.D. Gastroenterology, Eastern Virginia School of Medicine, Norfolk, VA; Biostatistics, AstraZeneca LP, Wayne, PA and Gastroenterology, AstraZeneca LP, Wayne, PA. Purpose: To determine the relationship between age and baseline severity of erosive esophagitis (EE) and heartburn and to assess the effect of age on healing rates in patients treated with esomeprazole or lansoprazole. Methods: This retrospective analysis was based on data from a prospective double– blind multicenter trial that randomized 5240 GERD patients aged 18 to 75 years with EE to treatment with esomeprazole 40 mg (n ⫽ 2624) or lansoprazole 30 mg (n ⫽ 2616) once daily before breakfast for up to 8 weeks. Age was classified in decade– of–life cohorts. Severity of EE at baseline was graded endoscopically using the Los Angeles classification (severity progressing from grades A to D). For this analysis, grades C and D were considered severe. Healing was confirmed endoscopically at week 4; for patients not healed, endoscopy was repeated at week 8. Healing rates at week 8 with 95% confidence intervals (CI) were calculated by Kaplan– Meier life–table estimates and differences analyzed using the log–rank test stratified by baseline age category. Chi–square tests were performed to assess associations between age and the prevalence of severe heartburn and severe EE. Results: An increase in the prevalence of severe EE was observed with advancing age (p⬍0.0001). However, prevalence of severe heartburn decreased with age ⬎40 years (p⬍0.0001). Healing rates were higher with esomeprazole 40 mg compared with lansoprazole 30 mg when controlling for age (p ⫽ 0.0008).
Age (yr) ⬍21 21–30 31–40 41–50 51–60 61–70 ⬎70
n 43 520 1152 1425 1198 674 228
Severe Severe EE, Heartburn, Baseline (%) Baseline (%) 14.0 17.5 23.9 23.4 25.5 29.7 32.9
32.6 47.1 47.4 43.2 38.8 36.6 28.9
% Healing (95% CI) Esomeprazole 40 mg
% Healing (95% CI) Lansoprazole 30 mg
86.4 (72.0–100) 90.7 (87.0–94.5) 91.5 (89.1–93.5) 93.6 (91.7–95.4) 93.5 (91.4–95.5) 91.9 (88.7–95.0) 94.3 (89.8–98.7)
86.7 (69.9–100) 87.6 (83.3–91.9) 88.4 (85.6–91.1) 88.6 (86.2–91.0) 87.1 (84.3–89.9) 92.4 (89.5–95.2) 91.8 (86.7–96.9)
Conclusions: In GERD patients with EE, the prevalence of severe disease increased with advancing age while the prevalence of severe symptoms declined. Therefore, it is important to be vigilant in treating elderly EE patients irrespective of the severity of their symptoms. 44 PEMPHIGOID ASSOCIATED ESOPHAGITIS DESSICANS SUPERFICIALIS COMPLICATED BY ACQUIRED HEMOPHILIA A Fritz Francois, M.D., Babak Faroozi, M.D., Jennifer Adams, M.D. and Zoi Gamagaris, M.D.*. Gastroenterology, New York Univeristy Medical Center, New York, NY and Internal Medicine, New York University Medical Center, New York, NY.