Effective intra-esophageal acid control is associated with improved radiofrequency ablation outcomes in Barrett's esophagus.

BACKGROUND: Endoscopic radiofrequency ablation (RFA) is a promising new treatment of Barrett's esophagus (BE). Adjunctive intra-esophageal pH control with proton pump inhibitors and/or anti-reflux surgery is generally recommended to optimize squamous re-epithelialization after ablation. AIMS: The aims of this study were to examine the association between intra-esophageal pH control and RFA outcomes and to identify predictive factors to achieve complete elimination (CE) of BE following RFA. METHODS: We retrospectively studied the outcomes of BE patients treated with RFA. Esophageal acid exposure (EAE) was assessed utilizing 24-h pH monitoring on therapy. CE was endoscopically defined as no area suspicious for residual metaplasia following RFA. RESULTS: Of 45 patients (33 men; mean age 61.6, mean BE length C4.1 M4.6) examined for EAE, 29 % exhibited moderate-severe EAE despite therapy. Reduction in BE surface area and CE rate were higher in the normal-mild EAE group compared with the moderate-severe EAE group (99 vs. 95 %, p = 0.02; 44 vs. 15 %, p = 0.09, respectively). Using univariate analysis, age, gender, race, aspirin/NSAIDs use, baseline worst histology, baseline BE surface area, and the number or types of RFA had no correlation with CE. By multivariate multiple logistic regression analysis, normal-mild EAE and smaller hiatal hernia were independent factors associated with CE. CONCLUSIONS: Effective intra-esophageal pH control is associated with improved RFA outcomes of BE. Normal to mild EAE and smaller hiatal hernia are predictive factors to achieve CE. Given the frequent persistence of acid reflux despite therapy in BE patients, in order to maximize the RFA effects esophageal pH optimization and hernia repair should be considered.

Algorithmic approach to patients presenting with heartburn and epigastric pain refractory to empiric proton pump inhibitor therapy.

BACKGROUND: Reflux-like dyspepsia (RLD), where predominant epigastric pain is associated with heartburn and/or regurgitation, is a common clinical syndrome in both primary and specialty care. Because symptom frequency and severity vary, overlap among gastroesophageal reflux disease (GERD), non-erosive reflux disease (NERD), and RLD, is quite common. The chronic and recurrent nature of RLD and its variable response to proton pump inhibitor (PPI) therapy remain problematic. AIMS: To examine the prevalence of GERD, NERD, and RLD in a community setting using an algorithmic approach and to assess the potential, reproducibility, and validity of a multi-factorial scoring system in discriminating patients with RLD from those with GERD or NERD. METHODS: Using a novel algorithmic approach, we evaluated an outpatient, community-based cohort referred to a gastroenterologist because of epigastric pain and heartburn that were only partially relieved by PPI. After an initial symptom evaluation (for epigastric pain, heartburn, regurgitation, dysphagia), an endoscopy and distal esophageal biopsies were performed, followed by esophageal motility and 24-h ambulatory pH monitoring to assess esophageal function and pathological acid exposure. A scoring system based on presence of symptoms and severity of findings was devised. Data was collected in two stages: subjects in the first stage were designated as the derivation cohort; subjects in the second stage were labeled the validation cohort. RESULTS: The total cohort comprised 159 patients (59 males, 100 females; mean age 52). On endoscopy, 30 patients (19%) had complicated esophagitis (CE) and 11 (7%) had Barrett's esophagus (BE) and were classified collectively as patients with GERD. One-hundred and eighteen (74%) patients had normal esophagus. Of these, 94 (59%) had one or more of the following: hiatal hernia, positive biopsy, abnormal pH, and/or abnormal motility studies and were classified as patients with NERD. The remaining 24 patients (15%) had normal functional studies and were classified as patients with RLD. Utilizing the scoring system a total score was calculated for each patient and effectively distinguished patients with GERD (mean score 9), NERD (mean score 6), and RLD (mean score 3). Receiver operating characteristic (ROC) curves confirmed the optimization of the model, particularly in RLD (P = 0.0001, 95% CI: 0.91-0.98). CONCLUSION: In a community cohort of patients presenting with heartburn and epigastric pain partly refractory to empiric PPI therapy, the prevalence of CE was 19%, BE 7%, NERD 59%, and RLD 15%. An algorithmic approach coupled with a novel scoring system, effectively distinguishes GERD from NERD and RLD and facilitates further management decisions. This novel and simple scoring system is both reproducible and validated as a diagnostic aid in evaluating patients presenting with both epigastric pain and heartburn.