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Variability in endoscopic assessment of Nissen fundoplication wrap integrity and hiatus herniation

Song, Erin J; Yadlapati, Rena; Chen, Joan W; Parish, Alice; Whitson, Matthew J; Ravi, Karthik; Patel, Amit; Carlson, Dustin A; Khan, Abraham; Niedzwiecki, Donna; Leiman, David A
BACKGROUND:Upper endoscopy (EGD) is frequently performed in patients with esophageal complaints following anti-reflux surgery such as fundoplication. Endoscopic evaluation of fundoplication wrap integrity can be challenging. Our primary aim in this pilot study was to evaluate the accuracy and confidence of assessing Nissen fundoplication integrity and hiatus herniation among gastroenterology (GI) fellows, subspecialists, and foregut surgeons. METHODS:Five variations of post-Nissen fundoplication anatomy were included in a survey of 20 sets of EGD images that was completed by GI fellows, general GI attendings, esophagologists, and foregut surgeons. Accuracy, diagnostic confidence, and inter-rater agreement across providers were evaluated. RESULTS:There were 31 respondents in the final cohort. Confidence in pre-survey diagnostics significantly differed by provider type (mean confidence out of 5 was 1.8 for GI fellows, 2.7 for general GI attendings, 3.6 for esophagologists, and 3.6 for foregut surgeons, P = 0.01). The mean overall accuracy was 45.9%, which significantly differed by provider type with the lowest rate among GI fellows (37%) and highest among esophagologists (53%; P = 0.01). The accuracy was highest among esophagologists across all wrap integrity variations. Inter-rater agreement was low across wrap integrity variations (Krippendorf's alpha <0.30), indicating low to no agreement between providers. CONCLUSION/CONCLUSIONS:In this multi-center survey study, GI fellows had the lowest accuracy and confidence in assessing EGD images after Nissen fundoplication, whereas esophagologists had the highest. Diagnostic confidence varied considerably and inter-rater agreement was poor. These findings suggest experience may improve confidence, but highlight the need to improve the evaluation of fundoplication wraps.
PMID: 34963133
ISSN: 1442-2050
CID: 5108152

Oral and gastric microbiome in relation to gastric intestinal metaplasia

Wu, Fen; Yang, Liying; Hao, Yuhan; Zhou, Boyan; Hu, Jiyuan; Yang, Yaohua; Bedi, Sukhleen; Sanichar, Navin Ganesh; Cheng, Charley; Perez-Perez, Guillermo; Tseng, Wenche; Tseng, Wenzhi; Tseng, Mengkao; Francois, Fritz; Khan, Abraham R; Li, Yihong; Blaser, Martin J; Shu, Xiao-Ou; Long, Jirong; Li, Huilin; Pei, Zhiheng; Chen, Yu
Evidence suggests that Helicobacter pylori plays a role in gastric cancer (GC) initiation. However, epidemiologic studies on the specific role of other bacteria in the development of GC are lacking. We conducted a case-control study of 89 cases with gastric intestinal metaplasia (IM) and 89 matched controls who underwent upper gastrointestinal endoscopy at three sites affiliated with NYU Langone Health. We performed shotgun metagenomic sequencing using oral wash samples from 89 case-control pairs and antral mucosal brushing samples from 55 case-control pairs. We examined the associations of relative abundances of bacterial taxa and functional pathways with IM using conditional logistic regression with and without elastic-net penalty. Compared with controls, oral species Peptostreptococcus stomatis, Johnsonella ignava, Neisseria elongata and Neisseria flavescens were enriched in cases (odds ratios [ORs] = 1.29-1.50, P = .004-.01) while Lactobacillus gasseri, Streptococcus mutans, S parasanguinis and S sanguinis were under-represented (ORs = 0.66-0.76, P = .006-.042) in cases. Species J ignava and Filifactor alocis in the gastric microbiota were enriched (ORs = 3.27 and 1.43, P = .005 and .035, respectively), while S mutans, S parasanguinis and S sanguinis were under-represented (ORs = 0.61-0.75, P = .024-.046), in cases compared with controls. The lipopolysaccharide and ubiquinol biosynthesis pathways were more abundant in IM, while the sugar degradation pathways were under-represented in IM. The findings suggest potential roles of certain oral and gastric microbiota, which are correlated with regulation of pathways associated with inflammation, in the development of gastric precancerous lesions.
PMID: 34664721
ISSN: 1097-0215
CID: 5043202

Classifying Esophageal Motility by FLIP Panometry: A Study of 722 Subjects With Manometry

Carlson, Dustin A; Gyawali, C Prakash; Khan, Abraham; Yadlapati, Rena; Chen, Joan; Chokshi, Reena V; Clarke, John O; Garza, Jose M; Jain, Anand S; Katz, Philip; Konda, Vani; Lynch, Kristle; Schnoll-Sussman, Felice H; Spechler, Stuart J; Vela, Marcelo F; Prescott, Jacqueline E; Baumann, Alexandra J; Donnan, Erica N; Kou, Wenjun; Kahrilas, Peter J; Pandolfino, John E
INTRODUCTION/BACKGROUND:Functional luminal imaging probe (FLIP) panometry can evaluate esophageal motility in response to sustained esophageal distension at the time of sedated endoscopy. This study aimed to describe a classification of esophageal motility using FLIP panometry and evaluate it against high-resolution manometry (HRM) and Chicago Classification v4.0 (CCv4.0). METHODS:Five hundred thirty-nine adult patients who completed FLIP and HRM with a conclusive CCv4.0 diagnosis were included in the primary analysis. Thirty-five asymptomatic volunteers ("controls") and 148 patients with an inconclusive CCv4.0 diagnosis or systemic sclerosis were also described. Esophagogastric junction (EGJ) opening and the contractile response (CR) to distension (i.e., secondary peristalsis) were evaluated with a 16-cm FLIP during sedated endoscopy and analyzed using a customized software program. HRM was classified according to CCv4.0. RESULTS:In the primary analysis, 156 patients (29%) had normal motility on FLIP panometry, defined by normal EGJ opening and a normal or borderline CR; 95% of these patients had normal motility or ineffective esophageal motility on HRM. Two hundred two patients (37%) had obstruction with weak CR, defined as reduced EGJ opening and absent CR or impaired/disordered CR, on FLIP panometry; 92% of these patients had a disorder of EGJ outflow per CCv4.0. DISCUSSION/CONCLUSIONS:Classifying esophageal motility in response to sustained distension with FLIP panometry parallels the swallow-associated motility evaluation provided with HRM and CCv4.0. Thus, FLIP panometry serves as a well-tolerated method that can complement, or in some cases be an alternative to HRM, for evaluating esophageal motility disorders.
PMID: 34668487
ISSN: 1572-0241
CID: 5043282

Functional Chest Pain and Esophageal Hypersensitivity: A Clinical Approach

Bhardwaj, Richa; Knotts, Rita; Khan, Abraham
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.
PMID: 34717874
ISSN: 1558-1942
CID: 5037692

Chicago Classification update (version 4.0): Technical review on diagnostic criteria for achalasia

Khan, Abraham; Yadlapati, Rena; Gonlachanvit, Sutep; Katzka, David A; Park, Moo In; Vaezi, Michael; Vela, Marcelo; Pandolfino, John
The recommended diagnostic criteria for achalasia have been recently updated by Chicago Classification version 4.0 (CCv4.0), the widely accepted classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). CCv4.0 continued upon prior versions by subtyping achalasia into type I, type II, and type III on HRM. The achalasia subgroup of the CCv4.0 Working Group developed both conclusive and inconclusive statements for the HRM diagnoses of achalasia subtypes. Conclusive achalasia on HRM is defined as an abnormal median integrated relaxation pressure (IRP) in the primary position of wet swallows along with 100% failed peristalsis, with type I achalasia having 100% failed peristalsis without panesophageal pressurization (PEP), type II achalasia with PEP in at least 20% of swallows, and type III achalasia having at least 20% of swallows premature with no appreciable peristalsis. An inconclusive HRM diagnosis of achalasia can arise when there is an integrated relaxation pressure (IRP) that is borderline or at the upper limit of normal in at least one position, there is an abnormal IRP in both positions but evidence of peristalsis with PEP or premature swallows, or there is peristalsis in the secondary position after apparent achalasia in the primary position. In patients with dysphagia and an inconclusive HRM diagnosis of achalasia, supportive testing beyond HRM such as a timed barium esophagram (TBE) for functional lumen imaging probe (FLIP) is recommended. The review recommends a diagnostic algorithm for achalasia, discusses therapeutic options for the disease, and outlines future needs on this topic.
PMID: 34190376
ISSN: 1365-2982
CID: 4950982

Validation of secondary peristalsis classification using FLIP panometry in 741 subjects undergoing manometry

Carlson, Dustin A; Baumann, Alexandra J; Prescott, Jacqueline E; Donnan, Erica N; Yadlapati, Rena; Khan, Abraham; Gyawali, C Prakash; Kou, Wenjun; Kahrilas, Peter J; Pandolfino, John E
BACKGROUND AND AIMS/OBJECTIVE:This study aimed to systematically evaluate a classification scheme of secondary peristalsis using functional luminal imaging probe (FLIP) panometry through comparison with primary peristalsis on high-resolution manometry (HRM). METHODS:706 adult patients that completed FLIP and HRM for primary esophageal motility evaluation and 35 asymptomatic volunteers ("controls") were included. Secondary peristalsis, that is, contractile responses (CRs), was classified on FLIP panometry by the presence and pattern of contractility as normal (NCR), borderline (BCR), impaired/disordered (IDCR), absent (ACR), or spastic-reactive (SRCR). Primary peristalsis on HRM was assessed according to the Chicago Classification. RESULTS:All 35 of the controls had antegrade contractions on FLIP panometry with either NCR (89%) or BCR (11%). The average percentages of normal swallows on HRM varied across contractile response patterns from 84% in NCR, 68% in BCR, 39% in IDCR, to 11% in ACR, as did the percentage of failed swallows on HRM: 4% in NCR, 12% in BCR, 36% in IDCR, and 79% in ACR. SRCR on FLIP panometry was observed in 18/57 (32%) patients with type III achalasia, 4/15 (27%) with distal esophageal spasm, and 7/15 (47%) with hypercontractile esophagus on HRM. CONCLUSIONS:The FLIP panometry contractile response patterns reflect a pathophysiologic transition from normal to abnormal esophageal peristaltic function with shared features with primary peristaltic function/dysfunction on HRM. Thus, these patterns of the contractile response to distension can facilitate the evaluation of esophageal motility using FLIP panometry.
PMID: 34120383
ISSN: 1365-2982
CID: 4907172

Frequency and burden of gastrointestinal symptoms in familial dysautonomia

Ramprasad, Chethan; Norcliffe-Kaufmann, Lucy; Palma, Jose-Alberto; Levy, Joseph; Zhang, Yian; Spalink, Christy L; Khan, Abraham; Smukalla, Scott; Kaufmann, Horacio; Chen, Lea Ann
PURPOSE/OBJECTIVE:Familial dysautonomia (FD) is a rare hereditary sensory and autonomic neuropathy (HSAN-3) that is clinically characterized by impaired pain and temperature perception and abnormal autonomic function. Patients with FD have gastrointestinal dysmotility and report a range of gastrointestinal symptoms that have yet to be systematically evaluated. The aim of this study was to establish the frequency and severity of gastrointestinal symptoms in patients with FD. METHODS:The validated National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) survey questionnaire, together with additional FD-specific questions, were distributed to 202 living patients with genetically confirmed FD who had been identified from the New York University FD Patient Registry or, when relevant, to their respective caretaker. As a comparison group, we used a general US adult population for whom PROMIS scores were available (N = 71,812). RESULTS:Of the 202 questionnaires distributed, 77 (38%) were returned, of which 53% were completed by the patient. Median age of the respondents was 25 years, and 44% were male. Gastrostomy tube was the sole nutrition route for 25% of the patients, while 53% were reliant on the gastrostomy tube only for liquid intake. The prevalence of gastrointestinal symptoms was significantly higher in each of the eight domains of PROMIS in patients with FD than in the controls. Gastrointestinal symptoms as measured by raw scores on the PROMIS scale were significantly less severe in the FD patient group than in the control population in all domains with the exception of the abdominal pain domain. The surveys completed by caregivers reported the same burden of symptoms as those completed only by patients. CONCLUSION/CONCLUSIONS:Gastrointestinal symptoms affect nearly all patients with FD. Gastrointestinal symptoms are more prevalent in adult patients with FD than in the average US adult population but are less severe in the former.
PMID: 33025279
ISSN: 1619-1560
CID: 4631552

Response to Richter and Vaezi [Comment]

Gyawali, C Prakash; Baker, Jason R; Moshiree, Baha; Rao, Satish; Neshatian, Leila; Nguyen, Linda; Chey, William D; Saad, Richard; Garza, Jose M; Waseem, Shamaila; Khan, Abraham R; Pandolfino, John E
PMID: 33136562
ISSN: 1572-0241
CID: 4770732

Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©

Yadlapati, Rena; Kahrilas, Peter J; Fox, Mark R; Bredenoord, Albert J; Prakash Gyawali, C; Roman, Sabine; Babaei, Arash; Mittal, Ravinder K; Rommel, Nathalie; Savarino, Edoardo; Sifrim, Daniel; Smout, André; Vaezi, Michael F; Zerbib, Frank; Akiyama, Junichi; Bhatia, Shobna; Bor, Serhat; Carlson, Dustin A; Chen, Joan W; Cisternas, Daniel; Cock, Charles; Coss-Adame, Enrique; de Bortoli, Nicola; Defilippi, Claudia; Fass, Ronnie; Ghoshal, Uday C; Gonlachanvit, Sutep; Hani, Albis; Hebbard, Geoffrey S; Wook Jung, Kee; Katz, Philip; Katzka, David A; Khan, Abraham; Kohn, Geoffrey Paul; Lazarescu, Adriana; Lengliner, Johannes; Mittal, Sumeet K; Omari, Taher; Park, Moo In; Penagini, Roberto; Pohl, Daniel; Richter, Joel E; Serra, Jordi; Sweis, Rami; Tack, Jan; Tatum, Roger P; Tutuian, Radu; Vela, Marcelo F; Wong, Reuben K; Wu, Justin C; Xiao, Yinglian; Pandolfino, John E
Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.
PMID: 33373111
ISSN: 1365-2982
CID: 4762642

Oropharyngeal dysphagia

Chapter by: Nyabanga, C; Khan, Abraham; Knotts, RM
in: Geriatric gastroenterology by Pitchumoni, CS; Dharmarajan, TS (Eds)
[S.l.] : Springer, 2021
pp. 1127-1144
ISBN: 978-3-030-30193-4
CID: 4306212