6/2/2014
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What’s New in the Management of Esophageal Disease
Philip O. Katz, MD Chairman, Division of Gastroenterology
Einstein Medical Center Philadelphia Clinical Professor of Medicine
Jefferson Medical College Philadelphia, PA
Disclosure of Conflicts of Interest
• Philip O. Katz, MD, FACG, has affiliations with Takeda Pharmaceuticals (Honoraria); Ironwood Pharmaceuticals, Inc., Pfizer Consumer Health (Consultant).
6/2/2014
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Comparative Effectiveness of Novel Techniques for Barrett’s Esophagus
Screening in the Community: A Prospective Randomized Trial
Gastrointest Endosc 2014; 79 (5S) [Abstract 160] AB113-114
Comparative Effectiveness of Novel Techniques for Barrett’s Esophagus Screening in the Community:
A Prospective Randomized Trial (cont’d)
• Screening for Barrett’s controversial
• Cost is major reason
• Transnasal EGD is less expensive (no sedation, etc.)
• Patients randomized to TNE or sedated EGD
6/2/2014
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Comparative Effectiveness of Novel Techniques for Barrett’s Esophagus Screening in the Community:
A Prospective Randomized Trial (cont’d)
Results:
• Each completed at same rate
• Sedated better tolerated, shorter esophagus evaluation time
• Biopsy success better with sedated EGD
• Findings overall similar
Conclusion: TNE feasible for screening
A FISH Biomarker Panel for the Prediction of High-grade Dysplasia
and Adenocarcinoma in Non-Dysplastic Barrett’s Esophagus:
Results from a Long-term Prospective Cohort Study
Gastrointest Endosc 2014; 79 (5S) [Abstract 164] AB115-116
6/2/2014
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A FISH Biomarker Panel for the Prediction of High-grade Dysplasia and Adenocarcinoma in
Non-Dysplastic Barrett’s Esophagus: Results from a Long-term Prospective Cohort Study (cont’d)
• Stratifying risk for Barrett’s difficult
• Biomarkers are still under investigation
• Prospective study in 428 non-dysplastic patients
• P16, 53 Her-2/neu, 20 q and MYC aneuploidy
• -16, aneuploidy double risk for HGD/EAC
• Increase risk to 2%/year
Conclusion: Markers may be useful but still not mainstream
6/2/2014
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Esophageal Brush Biopsy with Computer-assisted Tissue Analysis
Increases Detection of Barrett’s Esophagus and Dysplasia in a
Multi-site Community-based Setting
Gastrointest Endosc 2014; 79 (5S) [Abstract 371] AB294
Esophageal Brush Biopsy with Computer-assisted Tissue Analysis Increases Detection of
Barrett’s Esophagus and Dysplasia in a Multi-site Community-based Setting (cont’d)
• Standard biopsy protocol for Barrett’s maligned
• Wide area transepithelial sampling (WATS3D) can improve detection of dysphagia
• 2559 patients – EGD plus WATS3D
– GERD, possible or proven BE
• Overall – 377 cases of BE (15.1%)
• Dysplasia detection 10 cases of dysplasia and only EAC missed by biopsy
Conclusion: Adding WATS3D increases yield
6/2/2014
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Inter-observer Agreement Among Pathologists Using Wide Area
Transepithelial Sampling of Barrett’s Esophagus with
Computer-assisted Analysis
Gastrointest Endosc 2014; 79 (5S) [Abstract 165] AB116
Inter-observer Agreement Among Pathologists Using Wide Area Transepithelial Sampling of Barrett’s
Esophagus with Computer-assisted Analysis (cont’d)
Overall (95% CI) HGD/EAC (95% CI) IND/LGD (95% CI) NDBE (95% CI)
0.86 (0.75-0.97) 0.95 (0.88-0.99) 0.74 (0.61-0.85) 0.88 (90.81-0.94)
6/2/2014
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Modifiable Risk Factors Predict Recurrence of Barrett’s Esophagus
After Successful Radiofrequency Ablation
Gastrointest Endosc 2014; 79 (5S) [Abstract 163] AB115
Modifiable Risk Factors Predict Recurrence of Barrett’s Esophagus After Successful Radiofrequency Ablation (cont’d)
All (n=180) Recurrence (n=20) No Recurrence (n=160) p-value
Age mean years + SD 68 + 10 63 + 10 69 + 10 0.01
White n (%) 171 (98) 20 (100) 151 (98) 0.52
Male n (%) 132 (73) 13 (65) 119 (74) 0.37
BMI mean + SD 30 + 5.7 31 + 8.5 29 + 5.3 0.62
Current Alcohol n (%) 81 (45) 4 (20) 77 (48) 0.02
Current Tobacco n (%) 27 (15) 8 (40) 19 (12) 0.0009
Current NSAID n (%) 86 (48) 6 (30) 80 (50) 0.09
Anti-reflux Surgery n (%) 8 94) 0 (0) 8 (5) 0.31
Hiatal Hernia n (%) 161 (89) 18 (90) 143 (89) 0.93
Prague C mean cm + SD 1.2 + 2.3 1.7 + 2.8 1.1 + 2.2 0.36
Prague M mean cm + SD 4.4 + 3.0 5.5 + 2.9 4.2 + 2.9 0.051
Days Treatment mean + SD 171 + 166 170 + 131 171 + 170 0.58
Days Surveillance mean + SD 863 + 520 1032 + 608 842 + 506 0.17
6/2/2014
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Modifiable Risk Factors Predict Recurrence of Barrett’s Esophagus After Successful Radiofrequency Ablation (cont’d)
All (n=180) Recurrence (n=20) No Recurrence (n=160) p-value
Worst Treatment Histology
NDBE 5 (3) 1 (5) 4 (3)
LGD 56 (31) 6 (30) 50 (31)
HGD 102 (57) 12 (60) 90 (56)
EAC, non-invasive 17 (9) 1 (5) 16 (10)
Unadjusted OR [95% Cl] Adjusted * OR [95%CI]
Current Alcohol 0.26 [0.08, 0.85] 0.30 [0.09, 0.99]
Current Tobacco 5.02 [1.76, 14.30] 4.76 [1.49, 15.22]
Modifiable Risk Factors Predict Recurrence of Barrett’s Esophagus After Successful Radiofrequency Ablation (cont’d)
Table 2: Odds Ratio from Logistic Regression Predicting Recurrence
6/2/2014
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The Yield of Early Follow-up Endoscopy in Patients with Initial
Nondysplastic or Low-grade Dysplasia Barrett’s Esophagus
Gastrointest Endosc 2014; 79 (5S) [Abstract 162] AB114-115
The Yield of Early Follow-up Endoscopy in Patients with Initial Nondysplastic or
Low-grade Dysplasia Barrett’s Esophagus (cont’d)
• Missed HGD or EAC in 2.2% (4 patients) on initial EGD
• Long segment
• All white men
6/2/2014
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Surveillance Endoscopy is Associated with Improved Outcomes of
Esophageal Adenocarcinoma (EA) Detected in Patients with Barrett’s
Esophagus (BE)
Gastroenterology 2014; 146 (S1) [Abstract 709] S123
Surveillance Endoscopy is Associated with Improved Outcomes of Esophageal Adenocarcinoma (EA) Detected in Patients with Barrett’s Esophagus (BE) (cont’d)
• Surveillance for Barrett’s debated to efficacy
• VA database – 29,504 cases of BE, 433 EAC
• All men, 86% white, mean age 67
• 192 diagnosed on surveillance EGD/241 diagnostic
• Surveillance cases earlier stage (OR 2.94, 1.87-4.64)
• Surveillance decreased mortality (HR 0.51, 0.38-0.60)
6/2/2014
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Prevalence and Characteristics of Esophagitis and Barrett’s
Esophagus in Population Subjects Without Gastroesophageal Reflux Symptoms: Results From a Large
Randomized Controlled Study
Gastroenterology 2014; 146 (S1) [Abstract 105] S28-29
Prevalence and Characteristics of Esophagitis and Barrett’s Esophagus in Population Subjects Without Gastroesophageal Reflux Symptoms: Results From a Large Randomized Controlled Study (cont’d)
Symptomatic GER Group (69)
Asymptomatic GER Group (140)
Comparison p value
Esophagitis Prevalence Grade A Grade B Grade C
22 (31.9%) 8 12 2 40 (28.5%) 21 17 2 0.78
BE Prevalence Mean (SD) length 6 (8.7%) 3.5 (2.4) I (1.4%)
11 (7.9%) 2.6 (1.4) 2 (1.4%)
0.49 0.62
Diaphragmatic hernia present (%) Mean (SD) size (cm)
44 (63.7%) 3.6 (2.1)
79 (56.4%) 2.6 (0.9) 026 0.001*
6/2/2014
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Prevalence and Characteristics of Esophagitis and Barrett’s Esophagus in Population Subjects Without Gastroesophageal Reflux Symptoms: Results From a Large Randomized Controlled Study (cont’d)
Group 1: No Esophageal Injury + (142)
Group 2: Symptomatic GER Group with Esophageal Injury or Metaplasia + (23)
Group 3: Asymptomatic GER Group with Esophageal Injury or Metaplasia + (44)
Comparison of Group 1 vs. Group 2 & 3 p value
Comparison of Group 2 vs. Group 3 p value
Age (SD) 70 (9) 73 (9) 69 (9) 0.91 0.89
Male proportion (%)
55 (38.7%) 12 (52.2%) 29 (65.9%) 0.004* 0.15
WHR Mean (SD) 0.89 (0.1) 0.91 (0.09) 0.95 (0.09) 0.013* 0.15
BMI Mean (SD) 29.2 (10.7) 30.8 (6.0) 29.5 (5.1) 0.62 0.33
Smoker (>30 PY) (%)
20 (14.1%) 2 (13.1%) 6 (13.6%) 0.89 0.94
Excess Alcohol Use ‡ (%)
10 (8.7%) 3 (13.1%) 11 (25.0%) 0.014* 0.23
+ Esophageal injury includes presence of BE or esophagitis LA criteria Grade A, B, C
‡ Excess alcohol consumption classified as greater than 2 alcoholic beverages per day * p<0.05 considered significant
Gaviscon Double Action (Antacid + Alginate) Versus Equivalent Antacid
for Postprandial Acid Reflux: A Double-blind Crossover Study in
GERD Patients
Gastroenterology 2014; 146 (S1) [Abstract 103] S27-28
6/2/2014
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Gaviscon Double Action (Antacid + Alginate) Versus Equivalent Antacid for Postprandial Acid Reflux: A
Double-blind Crossover Study in GERD Patients (cont’d)
Proximal extent of reflux
Reflux events, Gaviscon Reflux Events, Antacid
Acid, n=34* n (%)
Total, n=144 n (%)
Acid, n=78 n (%)
Total, n=169 n (%)
LES + 5 cm 5 (15%) 18 (13%) 7 (%) 19 (11%)
LES + 7 cm 9 (27%) 24 (17%) 13 (7%) 35 (21%)
LES + 9 cm 18* (53%) 76 (53%) 47 (60%) 85 (50%)
LES + 15 cm 1 (3%) 8 (6%) 4 (5%) 6 (4%)
LES + 17 cm 1* (3%) 18 (13%) 7 ((%) 24 (14%)
* P<0.05 vs antacid, Student’s T=test or Kruskal-Wallis
6/2/2014
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Long-term Efficacy of PPI Therapy in Patients with PPI-responsive
Esophageal Eosinophilia: An International Multicenter Study
Gastroenterology 2014; 146 (S1) [Abstract 58] S17
Long-term Efficacy of PPI Therapy in Patients with PPI-responsive Esophageal Eosinophilia: An International Multicenter Study (cont’d)
• 40 PPI-REE patients
• PPI equivalent to OME 20, 40/day or 40 BID to remission
• Taper based on symptoms
• EGD, biopsy @ 12 months (or more)
6/2/2014
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Long-term Efficacy of PPI Therapy in Patients with PPI-responsive Esophageal Eosinophilia: An International Multicenter Study (cont’d)
• Initial dose – 18 (high) 22 (40)
• Maintenance – 19 (40 Ome) 22 (20 Ome)
• 26/40 remained in remission
• Most recurrence distal and resolved with increased dose
Two New Budesonide Formulations Are Highly Efficient for Treatment of
Active Eosinophilic Esophagitis: Results From a Randomized, Double-
blind, Double-dummy, Placebo-controlled Multicenter Trial
Gastroenterology 2014; 146 (S1) [Abstract 55] S16
6/2/2014
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Two New Budesonide Formulations Are Highly Efficient for Treatment of Active Eosinophilic Esophagitis: Results From a Randomized, Double-blind, Double-dummy, Placebo-controlled Multicenter Trial (cont’d)
• Steroids are commonly used in EoE
• Optimal dose and delivery system are not known
• Budesonide effervescent tablet (2 x 1 mg/d) and viscous suspension (2 x 2 mg/d)
• Dysphagia improved in both groups
• Tolerated well
Presence of Basal Cell Hyperplasia and Dilation of Intercellular Spaces and Their Association with Baseline Impedance Values in Patients with
Positive Symptom Association Despite Normal Acid Exposure Further
Supports Their Role in Symptoms Generation In NERD
Gastroenterology 2014; 146 (S1) [Abstract 17] S6
6/2/2014
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Presence of Basal Cell Hyperplasia and Dilation of Inter- cellular Spaces and Their Association with Baseline Impedance Values in Patients with Positive Symptom Association Despite Normal Acid Exposure Further Supports Their Role in Symptoms Generation In NERD (cont’d)
BCH PE DIS Neu/Eos
B1 at 3 cm
B1 at 5 cm
B1 at 3 cm
B1 at 5 cm
B1 at 3 cm
B1 at 5 cm
B1 at 3 cm
B1 at 5 cm
Grade 0-1
2300 (840-4225)
2100 (560-3300)
2415 (560-4225)
2282 (640-3300)
2930 (880-4225)
2850 (560-3540)
2200 (560-4225)
2080 (580-4060)
Per-oral Endoscopic Myotomy for Achalasia: Outcomes of a Large
Prospective Series
Gastrointest Endosc 2014; 79 (5S) [Abstract 731] AB166
6/2/2014
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Per-oral Endoscopic Myotomy for Achalasia: Outcomes of a Large Prospective Series (cont’d)
• POEM is new treatment for achalasia
• Place not known as technique expertise, results evolving
• 119 patients underwent POEM; 81 classic 38 vigorous (Type III)
• Successful POEM in 95%, 6 aborted
• Follow up 12-24 months
• GERD 46%, EE 25%, 14 complained of heartburn
Conclusion: POEM feasible but NOT in all, successful mostly GERD common by tests
Questions?