Faculty Bibliography

INTRODUCTION/BACKGROUND:Despite the high prevalence of typical symptoms of gastroesophageal reflux disease (GERD), approximately 30% of patients have functional esophageal disorders (FED) on ambulatory reflux monitoring, which may include reflux hypersensitivity (RH; defined as physiologic acid exposure but temporally correlated symptoms of reflux), or functional heartburn (FH; defined as physiologic acid exposure and negative symptom correlation). There are limited epidemiological data characterizing these conditions. We investigated demographic and socioeconomic factors as well as medical comorbidities which may predispose to FED versus pathologic GERD. METHODS:Adult patients with reflux symptoms for at least 3 months were studied with 24-h pH-impedance testing from 11/2019 to 3/2021. Participants were categorized into pathologic GERD, FH, or RH using pH-impedance data and reported symptom correlation. Demographic data, including age, gender, race/ethnicity, zip code, insurance status, and medical comorbidity data were retrospectively retrieved from the electronic medical record on all participants. RESULTS:229 patients were included. Non-Hispanic Asian ethnicity (OR 5.65; p = 0.01), underweight BMI (OR 7.33; p = 0.06), chronic pain (OR 2.33; p < 0.01), insomnia (OR 2.83; p = 0.06), and allergic rhinitis (OR 3.90; p < 0.01) were associated with a greater risk for FED. Overweight BMI (OR 0.48; p = 0.03) and alcohol use (OR 0.57; p = 0.06) were associated with a decreased risk for FED. DISCUSSION/CONCLUSIONS:This is the first report of a greater risk of FED in patients with underweight BMI, insomnia, chronic pain, allergic rhinitis, or of Asian or Hispanic ethnicities. The weak associations between female gender and anxiety are corroborated in other studies. Our findings enable clinicians to better screen patients with reflux for this disorder.

BACKGROUND:Adults with cystic fibrosis (CF) have an increased risk of a variety of cancers, notably gastrointestinal cancers. In CF higher body mass index (BMI) is associated with improved long-term outcomes, yet in the general population high BMI is associated with increased cancer risk. We aimed to delineate associations between BMI and other factors with cancer risk in adults with CF. METHODS:This was a retrospective cohort study using CF Foundation Patient Registry data from 1992 to 2015. Data were collected on age, sex, CFTR mutation class, pancreatic insufficiency, and annualized data on BMI and FEV1. The primary analysis was the association between BMI and cancer, with secondary analyses focused on BMI trajectory. Multivariable logistic regression was performed, with analyses stratified by history of transplant. RESULTS:Of 26,199 adults with CF, 446 (1.7%) had cancer diagnosed by histology at a mean age of 40.0 years (SD 12.2), with a higher proportion of transplanted patients developing cancer (137 (3.8%) v 309(1.4%), p < 0.001). Among non-transplanted patients, there was no association between BMI and cancer (p for trend = 0.43). Pancreatic insufficiency (p < 0.01) and higher FEV1 (p < 0.01) were associated with increased cancer risk. In transplanted patients, higher BMI was associated with reduced risk of cancer (p for trend = 0.04). Older age was associated with increased risk in both groups (p < 0.001). BMI trajectories were not associated with cancer risk in either group. CONCLUSION/CONCLUSIONS:Higher BMI is associated with a reduced risk of cancer in transplanted adults with CF. Pancreatic insufficiency is a risk factor for cancer in non-transplanted CF patients.

Introduction: Prolonged esophageal 96-hour wireless pH monitoring can reliably diagnose pathologic gastroesophageal reflux disease (GERD), with each study providing ample time to assess dietary influences on esophageal acid exposure time (AET). There is a paucity of literature detailing the influence of acidity in the diet on esophageal AET during ambulatory pH testing. This study aimed to evaluate differences in the quantity of acid reflux during days of high acid and low acid diets during prolonged wireless pH studies.
Method(s): 96 patients who underwent esophageal 96-hour wireless pH monitoring for evaluation of potential GERD were included in the study. The patients were educated on foods of high and low acidity and instructed to consume a primarily high acid diet on one day and a primarily low acid diet on a separate day during the recording period while detailing all consumed meals in a diary. Each food diary was physician confirmed for accuracy. Demographics, BMI, and comorbidities were also assessed. Patients were considered to have pathologic GERD if the average esophageal AET was .6% for the entire pH study and considered normal on an individual day if esophageal AET was , 4%. Statistical relationships between proportions were evaluated by Fisher's exact test and continuous variables were compared using t-tests. Box plots were used to graphically represent the spread of data.
Result(s): Pathologic GERD was found in 30 patients (31.3%) of which the majority (64.7%) recorded their lowest AET on their low acid diet day (Table). Despite this, only 13.3% of patients with pathologic GERD achieved normal acid reflux on their low acid diet day. The highest AET occurred on the high acid diet day for all 30 patients (100%) with pathologic GERD and 36 (54.55%) of the 66 patients without pathologic GERD. In comparison to the high acid diet day, the low acid diet day reduced mean AET from 13% to 6.9% in those with pathologic GERD (Figure) and from 4.2% to 1.8% in patients negative for pathologic GERD. Average body mass index (BMI) was higher in patients with pathologic GERD, while age, sex, and number of the most common reflux symptom did not differ between each group.
Conclusion(s): Acid reflux is reduced overall with a low acid diet in patients with and without pathologic GERD. The majority of patients with pathologic GERD experience their lowest amount of acid reflux during a day of a low acid diet, but only a small minority normalize their acid reflux on that day

It is well established that there is an increased risk of esophageal malignancy associated with achalasia, with esophageal squamous cell carcinoma being the most common histologic subtype thought to be secondary to the detrimental effects of food and saliva stasis resulting from poor esophageal emptying. Esophageal adenocarcinoma has also been found in this population with majority of these cases occurring after achalasia treatment, presumably as a result of iatrogenic reflux. Nevertheless, the benefits of cancer screening in this population remains an area of controversy. We reviewed the literature examining the pathogenesis of malignancy among patients with achalasia and the current data examining the potential strategies for long-term surveillance in this patient population.

Functional chest pain, functional heartburn, and reflux hypersensitivity are 3 functional esophageal disorders defined by the Rome IV criteria. Specific criteria, combining symptoms and the results of objective testing, allow for an accurate diagnosis of these conditions. Management may include medications targeted at optimizing acid suppression or neuromodulation, as well as a host of complementary or alternative treatment options. Psychological and behavioral interventions, such as cognitive behavioral therapy and hypnotherapy, have displayed substantial benefits in the treatment of functional chest pain and functional heartburn. Acid suppression and focused neuromodulation are key evidence-based treatment options for reflux hypersensitivity.

Background/Aims/UNASSIGNED:To determine if patients with a positive intraoperative cholangiogram (IOC) who undergo a subsequent endoscopic retrograde cholangiopancreatography (ERCP) have an increased risk of post-ERCP pancreatitis (PEP) compared to those who undergo ERCP directly for suspected common bile duct stones. Methods/UNASSIGNED:A retrospective case-control study was performed from 2010 to 2016. Cases included inpatients with a positive IOC at cholecystectomy who underwent subsequent ERCP. The control group included age-sex matched cohorts who underwent ERCP for choledocholithiasis. Multivariate logistic regression was used to assess the association between PEP and positive IOC, adjusting for matching variables and additional potential confounders. Results/UNASSIGNED:Of the 116 patients that met the inclusion criteria, there were 91 women (78%) in each group. Nine patients (7.8%) developed PEP in the IOC group, compared to 3 patients in the control group (2.6%). The use of pancreatic duct stents and rectal indomethacin was similar in both groups. After adjusting for age, sex, total bilirubin levels, and any stent placement, patients with a positive IOC had a significantly increased risk of PEP (odds ratio, 4.79; 95% confidence interval, 1.05-21.89; p<0.05). Conclusions/UNASSIGNED:In this single-center case-control study, there was a five-fold increased risk of PEP following a positive IOC compared to an age-sex matched cohort.

INTRODUCTION: Multi-society recommendations state, "Given the importance of polyp size for informing surveillance intervals, documentation of a polyp > 10 mm within a report should be accompanied by an endoscopic photo of the polyp with comparison to an open snare or open biopsy forceps".¹ We evaluate the feasibility of the Napoleon, an endoscopically-deployed small ruler to more accurately measure and document the size of colon polyps.
METHOD(S): The Micro-Tech Endoscopic Gauge (Non-FDA approved) named Napoleon, a catheter with a 15 mm ruler calibrated in 1 mm intervals with demarcations every 5 MM, was advanced through the biopsy channel of a colonoscope and positioned adjacent to a polyp to accurately measure polyp size (Image 1). Polyps sizes were first assessed visually and then measured using the Napoleon. Patients included were 50 to 85 years of age and undergoing screening or surveillance colonoscopy. Napoleon placement, extension/retraction, and photograph acquisition were evaluated on a 1-s10 scale (1 = Easy, 10 = Difficult).
RESULT(S): 23 patients were evaluated by 6 physicians. A total of 36 polyps were found. Each score represents the average of several polyps if more than one polyp was identified per patient (Table 1). The most polyps found in any patient was 3. Each polyp size was placed into 1 of 3 categories (Table 2): 1-5 mm (Diminutive), 6-9 mm (Small) and $ 10 mm (Large). 30 of the 36 total polyps (83%) were diminutive. 3 polyps were downgraded into the next smaller size category after measurement with the Napoleon - specifically, 1 polyp (33%) dropped from small to diminutive size and 2 polyps (67%) dropped from large to small size.
CONCLUSION(S): Prior studies on polyp size have shown that visual assessment is inaccurate.² This study demonstrates the ease and feasibility of the Napoleon as an endoscopic measuring device. The majority of polyps found were diminutive (1-5 mm) and explains why there is such a minute difference noted in the weighted mean polyp size (0.28 mm). Of the 3 polyps that were visually assessed to be $ 10 mm, 2 of those polyps (67%) were measured to be < 10 mm, changing recommended surveillance from 3 years to 7-10 years.¹ Further studies utilizing an endoscopic measuring tool such as the Napoleon are needed to evaluate the effect of accurate polyp measurement on our clinical management, training, and colonoscopy surveillance intervals

INTRODUCTION: Esophageal food impaction (EFI) is a common initial presentation of eo-sinophilic esophagitis (EoE). Patients presenting with EFI requiring endoscopic intervention present an opportunity to obtain esophageal biopsies to evaluate for EoE and optimize diagnostic yield before initiation of empiric treatment. We aimed to evaluate practices of esophageal biopsy at time of EFI at our institution and identify missed opportunities to diagnose EoE.
METHOD(S): We performed a single center retrospective chart review on a subset of adult patients from 10/2015 -1/2020 who presented to NYU Langone Health with EFI. Patients who underwent upper endoscopy (EGD) and were found to have a retained esophageal food bolus were included. Those with prior diagnosis of EoE were excluded. Proportions were compared using Chi-square or Fisher's exact test, and rank sum tests were used to compare continuous variables. Logistic regression was used to assess factors associated with subsequent need for diagnostic EGD.
RESULT(S): 123 patients with EFI were reviewed, 50 (40.7%) were biopsied at the time of EGD (Table 1). Among those biopsied, a new diagnosis of EoE was found in 52%. Of the patients who did not undergo biopsy at index EGD, 23% underwent repeat EGD at our institution and were found to have a new EoE diagnosis. Biopsies performed during EGD for EFI did appear to decrease the need for repeat procedure (OR 0.63, 95% CI 0.25-1.63), although not statistically significant. Patients with furrows were more likely to be biopsied however the report of other classic endoscopic features of EoE (such as exudates, ring, stricture, edema), was not significantly associated with the rate of biopsy (Table 2). Time of procedure and history of prior EFI also did not appear to influence rate of biopsy.
CONCLUSION(S): Biopsy at the time of EFI is important to obtain a timely diagnosis of EoE. At our center, less than half of patients were biopsied at time of initial EGD for EFI, and over half of those biopsied were diagnosed with EoE. The diagnosis of EoE was missed in 23% patients who were not biopsied at time of EFI, and on subsequent EGD with biopsy were found to have EoE. This delay in biopsy likely leads to unnecessary EGDs and more patients who are unaware of their diagnosis. Future educational initiatives aimed at GI providers are needed to improve rates of biopsies during initial EGD for EFI to reduce the need for additional diagnostic procedures

INTRODUCTION: Bronchiectasis is a common chronic pulmonary condition characterized by inflammation and recurrent infections. There is evidence that gastroesophageal reflux disease (GERD) is associated with bronchiectasis and can increase the severity of pulmonary disease. Data regarding esophageal function in this population is sparse. We aimed to assess whether patients with bronchiectasis have an increased prevalence of esophageal motility disturbances and GERD.
METHOD(S): We conducted a single-center matched cohort study of all adult patients with confirmed bronchiectasis who underwent esophageal high-resolution manometry (HRM) between 11/ 2014-3/2018. All cases were randomly matched with a control by age (65 years) and sex. Chicago Classification 3.0 was used to characterize HRM findings. Combined multichannel intraluminal impedance-pH (pH-MII) was utilized to assess reflux burden. Statistical relationships between proportions were evaluated by Chi-square or Fisher's exact test and continuous variables were compared using t-test or rank sum test.
RESULT(S): 63 bronchiectasis patients underwent HRM, of which 54 underwent pH-MII. Of the controls, 63 underwent HRM, of which 39 underwent pH-MII. Baseline characteristics between cases and controls were similar. Mean age of bronchiectasis patients was 65 (SD 12.73), mean body mass index was 25.51 (SD 8.50), 70% were female, and 48% had a smoking history (Table). HRM did not demonstrate any significant differences between cases and controls. pH-MII trended towards a greater reflux burden among controls. However, nearly half of cases had conclusive evidence of pathologic reflux by esophageal acid exposure on pH-MII. On endoscopy, no significant differences were noted.
CONCLUSION(S): Esophageal motility and acid exposure did not significantly differ among patients with bronchiectasis and controls, which may indicate that esophageal physiology in bronchiectasis is not unique. Nevertheless, more than half of the bronchiectasis group had evidence of abnormal esophageal motility and almost half of patients had conclusive evidence of pathologic reflux. Small differences are likely due to the high prevalence of GERD and associated motility disorders in the control group. Larger studies are warranted to further characterize esophageal physiology in these patients and the potential impact on pulmonary pathology. (Table Presented)

BACKGROUND:Marijuana use has been assessed in patients with chronic gastrointestinal disorders and may contribute to either symptoms or palliation. Use in those with celiac disease (CD) has not been assessed. Our aim was to evaluate patterns of marijuana use in a large population-based survey among patients with CD, people who avoid gluten (PWAG), and controls. STUDY/METHODS:We analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2014. χ tests and multivariable logistic regression were used to compare participants with CD and PWAG to controls regarding the use of marijuana. RESULTS:Among respondents who reported ever using marijuana (overall 59.1%), routine (at-least monthly) marijuana use was reported by 46% of controls versus 6% of participants with diagnosed CD (P=0.005) and 66% undiagnosed CD as identified on serology (P=0.098) and 51% of PWAG (P=0.536). Subjects with diagnosed CD had lower odds of routine marijuana use compared with controls (odds ratio, 0.08; 95% confidence interval, 0.01-0.73), whereas participants with undiagnosed CD had increased odds of routine use (odds ratio, 2.26; 95% confidence interval, 0.83-6.13), which remained elevated even after adjusting for age, sex, race/ethnicity, health insurance status, alcohol, tobacco use, educational level, and poverty/income ratio. CONCLUSIONS:In all groups, marijuana use was high. Although there were no differences among subjects with CD, PWAG, and controls who ever used marijuana, subjects with diagnosed CD appear to have decreased routine use of marijuana when compared with controls and PWAG. Those with undiagnosed CD have significantly higher rates of regular use. Future research should focus on the utilization of marijuana as it may contribute to further understanding of symptoms and treatments.