Faculty Bibliography

Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD.

Dysphagia, or difficulty swallowing, is a common problem in the elderly. Based on the initial clinical history and physical examination, the dysphagia is assessed as either primarily oropharyngeal or esophageal in origin. Most oropharyngeal dysphagia is of neurologic origin, and management is coordinated with a clinical swallow specialist in conjunction with an ear, nose, and throat (ENT) physician if warning signs imply malignancy. Several structural and functional esophageal disorders can cause dysphagia. If a patient has likely esophageal dysphagia, a video barium esophagram is a good initial test, and referral to a gastroenterologist is generally warranted leading to appropriate treatment.

BACKGROUND: Although esophageal dilation after laparoscopic adjustable gastric banding (LAGB) has been reported, the effect of banding on esophageal peristalsis, including the development of aperistalsis and its potential reversibility, have received only little attention. GOALS: Our aim was to report our experience with 6 patients who developed manometric evidence of esophageal aperistalsis after LAGB. STUDY: We retrospectively reviewed the clinical, manometric, and radiologic data of 6 patients referred between September 2005 and June 2007 to our Center for Esophageal Disease for evaluation of dysphagia or heartburn that developed after LAGB, and in whom manometric studies showed aperistalsis. Patients had the fluid in the band completely removed (N=5) or had the band removed (N=1). Reversibility of esophageal aperistalsis was then assessed. Clinical follow-up was obtained from 2009 to early 2010. RESULTS: Six patients (all female, age range, 37 to 55 y old) were evaluated because of dysphagia or heartburn after LAGB and had complete aperistalsis on manometry. Five of the 6 patients had manometry after removal of all the fluid from the band (N=4) or after surgical removal of the band (N=1). Two patients had partial return of peristalsis, 1 had normal peristalsis, and 2 others had continued aperistalsis but did show clinical improvement. Another patient had improvement of radiologic esophageal dilation but declined repeat manometry. CONCLUSIONS: LAGB can cause an achalasia-like esophageal aperistalsis that may be reversible. Gastroenterologists caring for bariatric patients need be aware of this pseudoachalasia, as the treatment of such patients differs from those with primary achalasia

Purpose The aim of this study was to characterize the reflux events in patients with laryngeal symptoms unresponsive to proton pump inhibitor (PPI) therapy. Background Gastroesophageal reflux disease (GERD) is commonly implicated as the cause of laryngeal symptoms. Methods We retrospectively reviewed the pH/impedance records of 21 patients evaluated for persistent throat symptoms despite PPI therapy. They were compared to 30 others with typical reflux symptoms despite medication. Results Five of 21 (24%) patients in the 'throat group' had normal reflux values, 13 (62%) continued to have abnormal acid reflux, and three (14%) had abnormal nonacid reflux but normal acid reflux while on medication. These results did not differ from those with typical symptoms unresponsive to medication. Conclusion In patients with chronic laryngeal symptoms despite PPI therapy, a substantial minority have no reflux at all, but the majority have abnormal amounts of acid reflux despite their taking PPI medication