Tu1084 Persistent Esophageal Symptoms in Patients on PPI Therapy; A Complex Disorder With No Simple Solution

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Background: Clinical practice patterns have been shown to be variable in the management of NVUGIB. More recently, several clinical practice guidelines have been published to promote evidence-based care in NVUGIB. Aim: To assess practice and adherence to guidelines in NVUGIB across Canadian centers using the REASON registry, and to identify predictors of recommendation adherence. Methods: Patients >18 years of age requiring hospitalization for a primary or secondary diagnosis of acute UGIB (variceal and non-variceal) were identified using ICD-9/10 codes across 21 Canadian hospitals. Consecutive charts were retrospectively reviewed. Data on initial presentation, endoscopic management, and outcomes were collected. Adherence rates to guidelines were calculated. For selected recommendations, possible independent predictors of adherence to individual recommendations, including patient age, sex, Rockall and Blatchford scores, American Society of Anesthesiologists (ASA) classification, presenting hemoglobin level and time of endoscopy (regular versus after hours) were assessed using multivariable logistic regression models. Results: 2020 patients were included (66.3 ± 16.4 years, 38.4% female, mean Blatchford, pre-endoscopic Rockall scores and ASA class of 9.1 ± 4.1, 2.0 ±1.5, and 2.6 ±1.0, respectively). 1805 patients (89.4%) had non-variceal UGIB. Endoscopy was performed in 1612 patients. 1533 patients had a lesion identified on endoscopy; 63.1% ulcers (47.8% with high risk stigmata (HRS)) and 36.9% non-variceal non-ulcer bleeding. An assistant was present for 83.5% of endoscopies performed, 65.6% of patients underwent early endoscopy (≤24hours), 9.8% of patients with low risk stigmata (LRS) nonetheless received endoscopic hemostasis (against existing recommendations), 64.5% of patients with HRS were treated endoscopically, and an intravenous (IV) proton pump inhibitor (PPI) regimen was administered after successful endoscopic hemostasis in 95.9% of patients. Rebleeding was noted in 10.5%, with an overall mortality of 9.4%. Salient findings from multivariable analysis revealed that patients with ASA class of 1-2 have less assistants present during endoscopy (OR 0.63;0.48-0.83), a hemoglobin under 7g/dL predicted inappropriate use of high-dose IV PPI in patients with LRS (OR 6.84;1.97-23.76), and endoscopies performed during regular hours are associated with longer delays from presentation (OR 0.33; 0.24-0.47 for early endoscopy). Conclusion: Adherence to guidelines in NVUGIB is variable and often suboptimal. Certain patient characteristics are associated with poor guidelines adherence, as is the decision to await normal hours to perform an endoscopy. Dissemination initiatives need to focus on such considerations to improve practice.

AGA Abstracts

Guideline Adherence in Non-Variceal Upper Gastrointestinal Bleeding (NVUGIB) Is Variable and Is Influenced by Patient Characteristics and Process Considerations Yidan Lu, Alan N. Barkun, Myriam Martel

Tu1083 Overlap of Functional GI Symptoms Does Not Rule out the Presence of GERD Scott L. Gabbard, Susan E. Blain, Michael D. Crowell, Brian E. Lacy OBJECTIVES: Gastroesophageal reflux disease (GERD) symptoms commonly overlap with symptoms of functional GI disorders such as irritable bowel syndrome and functional dyspepsia; however, it is less clear if patients with functional GI symptoms are more or less likely to have abnormal 48-hr pH testing. The aim of this study was to prospectively evaluate functional GI symptoms in patients undergoing 48-h wireless pH testing off acid suppression. METHODS: Demographics, and functional GI symptoms were obtained from consecutive patients referred for wireless pH testing; 48-h pH data and endoscopic findings were recorded. Multivariate logistic regression models controlling for age, gender, and body mass index (BMI) were used to evaluate the association between functional GI symptoms, acid reflux, and symptom association probability (SAP) scores. RESULTS: Wireless pH-metry was completed in 115 patients off proton pump inhibitor (PPI) (mean (s.d.) age, 53 (14) years; BMI, 29.4 (6.36) kg/m(2); 75% female). Abnormal acid exposure was noted in 40% of patients off PPI therapy. Patients who experienced abdominal pain associated with stool evacuation had significantly higher rates of abnormal pH testing, compared to those without (53.3% vs. 32.8%, p=0.03). Patients with abdominal pain and a change in stool form also had significantly higher rates of abnormal pH testing, compared to those without (50.9% vs. 32.8%; p=0.04). Patients who complained of pain in the center of the upper abdomen had similar rates of abnormal pH testing compared to those without pain (48.8% vs. 37.5%, p= 0.26). Patients with nausea at least once weekly had similar rates of abnormal pH testing compared to those without nausea (42.6% vs. 38.8%; p=0.62) CONCLUSIONS: Patients with overlapping functional GI symptoms are not less likely to have abnormal 48-hr pH testing; in this study, patients with functional GI symptoms were more likely to have abnormal 48-hr pH testing. The presence of functional GI symptoms should not preclude pH testing in patients with GERD symptoms. The symptoms of pain in the center of the upper abdomen and nausea did not help to differentiate those with abnormal pH tests.

Tu1082 Ethnic Differences in Prevalence of Heartburn and Esophagitis in Mongoloids and Europoids of Eastern Siberia Vladislav V. Tsukanov, Elena V. Onuchina, Olga S. Amelchugova, Alexander V. Vasyutin, Oksana V. Tretyakova

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Introduction. Gastro-oesophageal reflux disorders are common in Western countries and has been reported to be increasing in the East [1, 2]. Epidemiological data of heartburn and esophagitis from Russia is scarce. Aim. To study the prevalence of heartburn and esophagitis in different ethnic groups of Mongoloids and Europoids in various regions of Eastern Siberia. Methods. We carried out cross-section epidemiological study of the prevalence of heartburn and esophagitis in rural localities of Tuva, Khakassia and Evenkia. 572 Tuvins, 2085 Khakases, 1445 Evenks, 3422 Europoids were examined. Dyspepsia was diagnosed in accordance to the Rome criteria III [3]. Heartburn was diagnosed on the basis of the Montreal Consensus [4]. The results of clinical examination and interviews were recorded using modified questionnaire of Mejo clinic [5]. 1364 Europoids, 791 Evenks, 1145 Khakases, 379 Tuvins underwent upper digestive tract endoscopy with biopsies. Esophagitis was defined on the basis of LosAngeles classification [6]. Results. We found ethnic differences in prevalence of weekly heartburn and esophagitis (Table 1). Combining the data, it was found that the prevalence of weekly heartburn and esophagitis in Mongoloids (8,0% and 5,4%) was lower than in Europoids (respectively, 13,1% (OR = 1,73, CI 1,49-2,01, p < 0,001) and 2,8 % (OR = 2,01, CI 1,59-2,56, p < 0,001). The prevalence of dyspepsia was higher in Europoids in comparison to Evenks and Khakases. In all examined groups we registered overlap syndrome of heartburn and dyspepsia. Conclusion. The prevalence of heartburn and esophagitis were higher in Europoids than in Mongoloids in Eastern Siberia. At the same time fluctuations in the prevalence of heartburn and esophagitis in different ethnic groups of Mongoloids were observed. References. 1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2013 Jul 13. [Epub ahead of print]. 2. Minatsuki C, Yamamichi N, Shimamoto T et al. Background factors of reflux esophagitis and non-erosive reflux disease: a cross-sectional study of 10,837 subjects in Japan. PLoS One. 2013; 26;8(7):e69891. 3. Tack J, Talley NJ, Camilleri M et al. Functional gastroduodenal disorders. Gastroenterology. 2006;130(5):1466-79. 4. Vakil N, van Zanden SV, Kahrilas P et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am. J. Gastroenterol. 2006; 101 (8): 19001920. 5. Locke GR, Talley NJ, Weaver AL, Zinsmeister AR. A new questionnaire for gastroesophageal reflux disease. Mayo Clin Proc. 1994;69(6):539-47. 6. Lundell LR, Dent J, Bennet JR. Endoscopic assessment of oesophagitis clinical and functional correlates and further validation of Los Angeles classification. Gut. 1999; 45: 72-180. The prevalence of esophagitis, heartburn and dyspepsia in the population of Eastern Siberia

Persistent Esophageal Symptoms in Patients on PPI Therapy; A Complex Disorder With No Simple Solution Rohan H. Mandaliya, Anthony J. DiMarino, Sidney Cohen BACKGROUND: In patients with persistent or refractory esophageal symptoms while on PPI therapy, simply changing drugs or increasing treatment to a BID dose has become a reflex strategy. AIM: To study the profile of patients with persistent heartburn on PPI in terms of (A) DeMeester score, (B) impedence and (C) SSI (symptom sensitivity index) and assess if twice a day PPI is superior to once a day PPI in controlling acid reflux. METHODS: A retrospective review of combined impedence-pH tracings on PPI therapy (QD or BID) for refractory GERD with heartburn as a primary symptom was performed. DeMeester score was considered as an index of acid control, with a score higher than 14.7 considered as abnormal. Impedence was considered as a marker of total reflux episodes of any kind with a value higher than 48 considered as abnormal. Finally SSI was considered for symptom positive reflux episode with a value >=1 considered abnormal. Statistical analysis was performed using Chi-Square test. RESULTS: A total of 100 consecutive patients, (Female: (50%) Male: (50%); mean age 54 (range 16-83) years) underwent combined impedencepH monitoring on either once a day (n=45) or twice a day PPI (n=55). Only 20% of the patients had abnormal DeMeester score while 41% had an abnormal impedence score and 56% had abnormal SSI. 71% of the patients had at least one of the indices abnormal but 29% of the patients had all indices being normal. There was no significant difference between patients taking once a day vs twice a day PPI in terms of abnormal DeMeester score (22% vs. 18%), impedence (38% vs. 44%) and SSI (24% vs. 25%) p>0.05. Out of 56 patients with positive SSI, symptoms were due to acid reflux in 8 (14%), non acid reflux in 31 (55%) and combined acid and non acid reflux in 17 (30%). On considering a cut off for SSI >= 1, there were 7 patients with SSI for non acid reflux of 1 and all 7 patients had high impedence scores suggesting the role of non acid reflux in refractory symptoms. CONCLUSIONS: Patients with persistent esophageal symptoms of heartburn on PPI therapy show a variety of disorders: (A) Persistent acid reflux (20%); (B) Non acid reflux (26%); (C) Positive symptom sensitivity index (56%); many of these patients (45%) had normal acid and non acid reflux parameters (D) No reflux by any objective measure (29%). These studies indicate that persistent symptoms while on PPI therapy is a complex problem that may not respond to simply increasing acid inhibition.

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AGA Abstracts

AGA Abstracts

Data are stated as median (IQR). Feeding success defined as full oral feeds at discharge. Table 2. Acid Suppressive Therapy and Feeding Methods: Based on Acid Reflux Index

Venn Diagram illustrating percentage of the patients having abnormal indices ( DeMeester's score, Impedence and SSI), with their relative concurrence.

Data are stated as percentage or value. † RI < 3 vs RI >7 (P<0.01) * ≥ 3 RI ≤ 7 vs RI > 7 (P<0.01) ‡ RI < 3 vs RI > 7 (P≤0.01) Percentage of patients with abnormal DeMeester's score or abnormal (DeMeester's score + abnormal impedence) or abnormal (DeMeester's score, Impedence and SSI) in patients with persistent heartburn measured on PPI therapy

Tu1086 Clinical and Histopathologic Assessments for Patients With Endoscopic Diagnosis of Reflux Esophagitis Grading Los Angeles a Xiue Yan, Rongli Cui, Hejun Zhang, Ye Wang, Liya Zhou

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The aim of the study is to determine whether patients with LA Grade A esophagitis should undergo further testing to confirm the presence of GERD. A total of 155 consecutive patients with endoscopic diagnosis of reflux esophagitis ( Los Angeles A-C) was enrolled in the study at Peking University Third Hospital from September 1,2011 to December 1, 2012. All the patients underwent GerdQ score, Ambulatory 24-h pH monitoring, biopsies from antrum, corpus, and 2cm above SCJ for histopathological assessment, PPI test with 20mg esomeprazole twice daily for 2 weeks. If the episode of the primary symptoms did not occur during the final 3 days of the 2-week treatment with PPI, positive PPI test was identified. According to the endoscopic diagnosis and results of ambulatory 24-h pH monitoring, the patients were divided into group1(n=29,reflux esophagitis LA-A, with Demmester score <14.7 and SI<50%);Group2(n=65,reflux esophagitis LA-A, with Demmester score ≥14.7 or SI≥50%); Group3 (n=61,reflux esophagitis LA-B for 49 patients and LA-C for 12 patients). We compared demographic data, clinical symtoms, PPI test results, histological changes of group1 to group2 and group3, respectively. The results showed there were no statistical differences in age, gender, BMI, propotion of GerdQ≥8, propotion of PPI test positive and histological changes including inflammation cell counts, basal cell layer ≥15% of mucosal thickness, extension of the lamina propria papillae into more than 50% of the mucosal thickness, mucosal capillary congestion, capillary ectasia between group1 and group2, group3. Group3 showed more intercellular space dilatation (P=0.002) compared to group1. So we concluded that patients with LA Grade A esophagitis would not necessarily undergo further testing to confirm the presence of GERD.

Relationship of Gastro-Esophageal Reflux (GER) Characteristics and Management Patterns in NICU Infants: Effects on Feeding Success and Feeding Failure Alecia Wagner, Xiaoyu Gao, Sudarshan Jadcherla BACKGROUND: GER disease (GERD) is a frequent conundrum in the Neonatal ICU setting. Diagnostic and management methodologies are ambiguous. Methods to seek objective evidence as well as evidence-based therapies are not widely applied. The significance of evidencebased therapies as well as the characteristics of GER events on the feeding outcomes at discharge remains unclear. AIMS: 1) To distinguish the characteristics of GER events in infants evaluated for GERD type of symptoms, stratified based on oral feeding success or failure at discharge. 2) To characterize the management therapies for objectively defined GERD, categorized based on acid reflux index (ARI) as less than 3% (normal), 3 to 7 % (Indeterminate for GERD), and more than 7% (Suspect for GERD). NASPGHAN definitions for GERD severity were used. METHODS: 110 infants (55 males) born at 31.0 ± 0.5 wks gestation were evaluated at 44.9 ± 0.85 wks postmenstrual age for feeding difficulties and GERD type of symptoms using 24-hr pH-impedance (Ohmega, MMS) methods. Meal periods were excluded. Feeding and treatment characteristics at evaluation and discharge included: feeding volume, feeding method, duration of acid-suppressive treatment, recommended and adhered use of acid suppressive medication. Analysis was stratified based on feeding success and ARI. Feeding success was defined as full oral feeding at discharge, and feeding failure as otherwise needing gastrostomy at discharge. RESULTS: A total of 6217 reflux events were analyzed from 2102 hours of recordings in 2-min epochs. Feeding volumes (ml/kg/day) at evaluation were similar between the three groups, stratified by increasing ARI (133.6 ± 3.6, 135.5 ± 4.7, 132.3 ± 3.1). Reflux characteristics are shown (Table 1), stratified by patients having either feeding success or feeding failure. Characteristics of management patterns are described (Table 2), stratified by the severity of acid-reflux index. As acid reflux index increases, there is a higher probability of feeding success (OR: 1.081; CI 95% 1.02-1.15; P=0.01). Feeding methods were similar at evaluation and discharge within the groups (Table 2). CONCLUSIONS: 1) Feeding success was significantly greater at discharge in infants that had prior significant ARI and its related characteristics. Timely and appropriate therapy may have contributed to this result. On the contrary, when the diagnosis is not acid GERD, other etiologies must be explored to prevent feeding failure. 2) Appropriately managed GERD results in a higher probability of therapeutic success. Thus, a GERD diagnosis is not predictive of feeding failure and those infants without GERD may have additional confounding factors resulting in GERD-like symptoms. *Supported in part by 2RO1DK 068158 (Jadcherla). Table 1. Prior Evaluation of GER Characteristics Based on Feeding Success or Failure at Discharge.

AGA Abstracts

Tu1087 Utility of 48hrs Wireless pH Monitoring in the Diagnosis of Functional Heartburn George Karamanolis, Nikos Viazis, Anastasios Karlaftis, Dimitris Kamberoglou, Konstantina Katopodi, Dimitrios G. Karamanolis, Spiros D. Ladas In patients with heartburn refractory to PPIs, functional heartburn (FH) is diagnosed when endoscopy and pH monitoring are negative (Rome III). Esophageal pH monitoring with wireless Bravo capsule has the advantage of prolonged measurement compared to classic pH monitoring (48 vs. 24 hrs). Aim: To evaluate the utility of prolonged wireless pH monitoring in the diagnosis of FH. Methods: 48hrs wireless pH monitoring with Bravo capsule was performed in 27 (14 men, mean age: 52yrs) patients with heartburn as predominant symptom, negative endoscopy and refractoriness to PPIs. Acid exposure time (AET) (pathological if > 5.8%) and symptom index (SI) (positive if> 50%) were calculated in each patient on each different day. In patients with normal AET and normal SI at both monitoring days the diagnosis of FH was confirmed. Results: In the first 24hrs of monitoring, FH was diagnosed in 17/27 (63%) patients. Prolonging the measurement in the following 24hrs period, 6 out of 17 patients with initial diagnosis of FH had pathological AET and/or positive SI. Thus, in 35% of patients diagnosis was changed from FH to NERD at the end of the study. Conclusion: Our data support the utility of 48hrs pH monitoring in patients with

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