Anatomic abnormalities are common potential explanations of manometric esophagogastric junction outflow obstruction.

BACKGROUND: Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility diagnosis associated with a myriad of conditions. The frequency of EGJOO attributed to anatomic causes compared to idiopathic causes is uncertain. Our study aims to identify the frequency of EGJOO and to compare these two groups. METHODS: We conducted a case-control study of high-resolution manometry (HRM) studies with a diagnosis of EGJOO performed at a single academic center. EGJOO cases were classified as anatomic (if any potential anatomic cause was identified) or idiopathic. Clinical and manometric characteristics of idiopathic EGJOO were compared with anatomic EGJOO cases. KEY RESULTS: Criteria for EGJOO were met in 11% of HRM studies. Ancillary studies revealed 21/32 EGJOO cases had potential anatomic causes with a hiatal hernia noted in 15/21 cases of anatomic EGJOO. Idiopathic EGJOO cases met Chicago Classification criteria for hypercontractile esophagus with greater frequency than anatomic cases (p = 0.01). The mean distal contractile integral was significantly greater for idiopathic cases compared to anatomic cases (p = 0.003). Treatments used for EGJOO were varied and usually successful in alleviating symptoms. Patients with anatomic EGJOO related to a hiatal hernia who underwent an antireflux operation did not develop dysphagia postoperatively. CONCLUSIONS & INFERENCES: EGJOO is a frequently encountered manometric diagnosis, commonly associated with anatomic abnormalities potentially explaining the EGJOO. These findings support current recommendations to pursue ancillary diagnostics to investigate cases of unexplained EGJOO. Cases of idiopathic EGJOO are more likely to have hypercontractility on HRM, possibly suggesting a primary esophageal motility disorder.

Status of Competency-Based Medical Education in Endoscopy Training: A Nationwide Survey of US ACGME-Accredited Gastroenterology Training Programs.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) emphasizes the importance of medical trainees meeting specific performance benchmarks and demonstrating readiness for unsupervised practice. The aim of this study was to examine the readiness of Gastroenterology (GI) fellowship programs for competency-based evaluation in endoscopic procedural training. METHODS: ACGME-accredited GI program directors (PDs) and GI trainees nationwide completed an online survey of domains relevant to endoscopy training and competency assessment. Participants were queried about current methods and perceived quality of endoscopy training and assessment of competence. Participants were also queried about factors deemed important in endoscopy competence assessment. Five-point Likert items were analyzed as continuous variables by an independent t-test and χ(2)-test was used for comparison of proportions. RESULTS: Survey response rate was 64% (94/148) for PDs and 47% (546/1,167) for trainees. Twenty-three percent of surveyed PDs reported that they do not have a formal endoscopy curriculum. PDs placed less importance (1­very important to 5­very unimportant) on endoscopy volume (1.57 vs. 1.18, P<0.001), adenoma detection rate (2.00 vs. 1.53, P<0.001), and withdrawal times (1.96 vs. 1.68, P=0.009) in determining endoscopy competence compared with trainees. A majority of PDs report that competence is assessed by procedure volume (85%) and teaching attending evaluations (96%). Only a minority of programs use skills assessment tools (30%) or specific quality metrics (28%). Specific competencies are mostly assessed by individual teaching attending feedback as opposed to official documentation or feedback from a PD. PDs rate the overall quality of their endoscopy training and assessment of competence as better than overall ratings by trainees. CONCLUSIONS: Although the majority of PDs and trainees nationwide believe that measuring specific metrics is important in determining endoscopy competence, most programs still rely on procedure volume and subjective attending evaluations to determine overall competence. As medical training transitions from an apprenticeship model to competency-based education, there is a need for improved endoscopy curricula which are better suited to demonstrate readiness for unsupervised practice.

The natural history of eosinophilic oesophagitis in the transition from childhood to adulthood.

BACKGROUND: Eosinophilic oesophagitis (EoE) is a chronic inflammatory condition affecting both children and adults. Little is known about the natural history of EoE in the transition from childhood into adulthood. AIM: To determine the prevalence of EoE symptoms and impact of EoE on quality of life among adults diagnosed with EoE during childhood. METHODS: This is a cross-sectional study of EoE patients from the Children's Hospital of Philadelphia EoE registry. Patients ≥18 years diagnosed with EoE during childhood were administered validated dysphagia [Mayo Dysphagia Questionnaire (MDQ)-30] and Quality of Life (PAGI-QOL) questionnaires. Ongoing EoE treatments were ascertained. RESULTS: A total of 140 EoE patients ≥18 years were identified; 53 completed all questions. Only 6 (11%) subjects had positive (n = 2) or indeterminate (n = 4) dysphagia scores. However, of 47 patients with negative scores, 18 (37%) reported ongoing difficulty swallowing. The mean PAGI-QOL score was 4.58/5. The dietary dimension score was 3.73/5. Current pharmacological EoE treatments were topical steroids (3/53) and interleukin-5 antagonists (3/53). Additionally, 26/53 (49%) were on PPI therapy and 40/53 (76%) were following allergy directed diets. CONCLUSIONS: The majority of young adults diagnosed with EoE during childhood continue to require pharmacological treatment and/or dietary modification for EoE. A substantial proportion of this population experiences ongoing swallowing difficulties that a standard dysphagia questionnaire fails to capture. Dietary quality of life, but not total quality of life, appears to be adversely affected. These data suggest that EoE diagnosed during childhood remains a significant medical issue during early adulthood, and that better EoE symptom measurement instruments are needed.