Esophageal Lichen Planus: A Descriptive Multicenter Report.

GOALS: To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP). BACKGROUND: ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series. STUDY: A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States. RESULTS: Seventy-eight patients (average age 65 y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers. CONCLUSIONS: Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.

Esophageal Radiography Interpretation: a Primer for the Gastroenterologist.

PURPOSE OF REVIEW: Radiological studies can be helpful when evaluating patients with suspect esophageal disorders. From benign strictures to malignancy and motility disorders such as achalasia, imaging modalities play a significant role in diagnosis. This review explores the role of different imaging modalities in the most frequently encountered esophageal pathologies. RECENT FINDINGS: Conventional barium esophagram has long been considered the primary imaging modality of the esophagus. In the same fashion, a timed barium esophagram is a valuable tool in the evaluation of achalasia and esophagogastric junction outlet obstruction. Over the last few decades there has been an increase in CT and MRI studies, which also play a role in the evaluation of esophageal pathologies. However, not infrequently, these newer imaging techniques can result in incidental esophageal findings. It is important that gastroenterologists appreciate the value of different modalities and recognize key imaging features. The diagnosis and management of esophageal disorders is evolving. A basic understanding of esophageal radiology is essential to any gastroenterologist caring for patients with esophageal complaints.

Physiological and morphological responses of Pinus ponderosa seedlings to moisture limitations in the nursery and their implications for restoration.

Successful establishment of Pinus ponderosa seedlings in the southwestern United States is often limited by stressful and harsh site conditions related to drought severity and severe disturbances such as wildfire and mining operations. Seedling quality has an important influence on outplanting performance, but nursery practices that typically employ optimal growing environments may also be limiting seedling morphological and physiological performance on stressful outplanting sites. To address this, a study was established to test alterations in seedling characteristics subjected to irrigation limitations during nursery culture and their subsequent outplanting performance. This study was conducted as two separate experiments: (1) a nursery conditioning experiment examined seedling development of three New Mexico seed sources exposed to three irrigation levels (low, moderate, and high); (2) a simulated outplanting experiment examined a subset of the seedlings from experiment 1 in a controlled outplanting environment consisting of two soil moisture conditions (mesic, maintained via irrigation and dry, irrigated only once). In the nursery study, the lack of interactions between seed source and irrigation main effects for most response variables indicate that low irrigation treatment level responses were consistent across a range of sources. Irrigation treatment levels from the nursery resulted in few morphological differences; however, the low irrigation level increased physiological parameters such as net photosynthetic rate and water use efficiency. In the simulated outplanting experiment, seedlings subjected to less irrigation in the nursery had greater mean height, diameter, needle dry mass, and stem dry mass; additionally, low irrigation levels in the nursery increased the amount of hydraulically active xylem and xylem flow velocity. Overall, this study shows that nursery culture irrigation limitations, regardless of the seed sources tested, can improve seedling morphology and physiological functioning under simulated dry outplanting conditions. This may ultimately translate to increased survival and growth performance on harsh outplanting sites.

Role of functional luminal imaging probe in the management of postmyotomy clinical failure.

BACKGROUND AND AIMS: A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment. METHODS: This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy. RESULTS: One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n = 53, 43%) or POEM (n = 70, 57%) for the management of achalasia (n = 98) or other EDDs (n = 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) >15 mm Hg on HRM and distensibility index (DI) <2.8 mm2/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P = .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P = .03). CONCLUSIONS: The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.

Drought-Conditioning of Quaking Aspen (Populus tremuloides Michx.) Seedlings During Nursery Production Modifies Seedling Anatomy and Physiology.

In the western US, quaking aspen (Populus tremuloides Michx.) regenerates primarily by root suckers after disturbances such as low to moderate severity fires. Planting aspen seedlings grown from seed may provide a mechanism to improve restoration success and genetic diversity on severely disturbed sites. However, few studies have examined the use of container-grown aspen seedlings for restoration purposes from both the outplanting and nursery production perspective. Thus, the purpose of this novel study was to examine how alterations in irrigation levels during nursery production across three seed sources would impact seedling performance attributes on harsh, dry outplanting sites. Irrigation treatments were based on three irrigation levels, determined gravimetrically: High = 90%, Medium = 80%, and Low = 70% of container capacity. The three seed sources represented a latitudinal gradient across the aspen range (New Mexico, Utah, and Alberta). Carbon isotope analysis indicated irrigation treatments were effective in creating higher levels of water stress for both the Low and Medium irrigation levels compared to seedlings under the High irrigation level. Seedlings subject to the Low irrigation level were found to induce greater height, higher photosynthetic rates, larger percentages of hydraulically active xylem, and faster xylem flow velocities compared to the High irrigation level. The lack of an interaction between irrigation treatments and seed source for nearly all response variables suggests that nursery conditioning via irrigation limitations may be effective for a range of aspen seed sources.

Gastrointestinal pharmacology: practical tips for the esophagologist.

Gastroesophageal reflux disease (GERD) is primarily a motor disorder, and its pathogenesis is multifactorial. As a consequence, treatment should be able to address the underlying pathophysiology. Proton pump inhibitors (PPIs) are the mainstay of medical therapy for GERD, but these drugs only provide the control of symptoms and lesions without curing the disease. However, continuous acid suppression with PPIs is recommended for patients with Barrett's esophagus because of their potential chemopreventive effects. In addition to the antisecretory activity, these compounds display several pharmacological properties, often overlooked in clinical practice. PPIs can indeed affect gastric motility, exert a mucosal protective effect, and an antioxidant, anti-inflammatory, and antineoplastic activity, also protecting cancer cells from developing chemo- or radiotherapeutic resistance. Even in the third millennium, current pharmacologic approaches to address GERD are limited. Reflux inhibitors represent a promise unfulfilled, effective and safe prokinetics are lacking, and antidepressants, despite being effective in selected patients, give rise to adverse events in a large proportion of them. While waiting for new drug classes (like potassium-competitive acid blockers), reassessing old drugs (namely alginate-containing formulations), and paving the new avenue of esophageal mucosal protection are, at the present time, the only reliable alternatives to acid suppression.

Impedance in the evaluation of the esophagus.

The aim of this paper is to review esophageal electrical impedance technologies and to discuss the use of these technologies for physiological measurements, diagnostics, and therapy of esophageal disease. In order to develop a better understanding of the pathophysiology of and improve the diagnosis of esophageal disorders, such as gastroesophageal reflux disease (GERD) and achalasia, several new diagnostic tests, including intraluminal impedance, esophageal mucosal impedance, and the functional luminal imaging probe, have been developed. These technologies have proven valuable for assessment of the esophagus in recent years. They provide information on esophageal flow properties, mucosal integrity, lumen shape, and distensibility in esophageal disorders, in particular for GERD and achalasia. Despite their promise and novel clinical studies, the potential of these technologies has been far from realized. New multidisciplinary approaches will contribute to our understanding and interpretation of esophageal impedance data and disease mechanisms.

Treatment experience with a novel 30-mm hydrostatic balloon in esophageal dysmotility: a multicenter retrospective analysis.

BACKGROUND AND AIMS: The newest addition in the management of achalasia and esophagogastric junction outflow obstruction (EGJOO) is a 30-mm hydrostatic balloon dilator that uses impedance planimetry technology. It allows for the measurement of the diameter and cross-sectional area to determine effective dilation. We aimed to (1) determine the clinical success (defined as a decrease in Eckardt score to ≤3) in the treatment of esophageal motility disorders and (2) report the safety (rate/severity of adverse events). METHODS: This retrospective multicenter study involved 4 centers. Patients with esophageal motility disorders who underwent hydrostatic balloon dilation between January 2015 and October 2018 were included. RESULTS: Fifty-one patients (mean age, 54.1 years; women, 49%) underwent hydrostatic dilation for achalasia (n = 37) or EGJOO (n = 14) during the study period. Forty-seven patients had a median baseline Eckardt score of 5 (range, 3-8; achalasia, n = 35, 6 [range, 3-8]; EGJOO, n = 12, 4 [range, 3.25-6.5]). Clinical success was achieved in 60% of cases (achalasia vs EGJOO: 68.4% vs 33.3%, P = .18). Dilation resulted in a significant decrease in the median Eckardt score from 5 (range, 3-8) to 1.5 (range, 1-4.75; P < .001). Patients with achalasia had a decrease in Eckardt score from 6 (range, 3-8) to 1 (range, 1-4; P < .001), whereas those with EGJOO experienced no significant change. One patient had mild postprocedure chest pain. CONCLUSIONS: The hydrostatic balloon dilator is a new tool in our armamentarium to treat esophageal motility disorders. This is the first multicenter study showing the device to be safe and moderately efficacious.

Esophageal Manometry Competency Program Improves Gastroenterology Fellow Performance in Motility Interpretation.

INTRODUCTION: Competency-based medical education (CBME) for interpretation of esophageal manometry is lacking; therefore, motility experts and instructional designers developed the esophageal manometry competency (EMC) program: a personalized, adaptive learning program for interpretation of esophageal manometry. The aim of this study was to implement EMC among Gastroenterology (GI) trainees and assess the impact of EMC on competency in manometry interpretation. METHODS: GI fellows across 14 fellowship programs were invited to complete EMC from February 2018 to October 2018. EMC includes an introductory video, baseline assessment of manometry interpretation, individualized learning pathways, and final assessment of manometry interpretation. The primary outcome was competency for interpretation in 7 individual skill sets. RESULTS: Forty-four GI trainees completed EMC. Participants completed 30 cases, each including 7 skill sets. At baseline, 4 (9%) participants achieved competency for all 7 skills compared with 24 (55%) at final assessment (P < 0.001). Competency in individual skills increased from a median of 4 skills at baseline to 7 at final assessment (P < 0.001). The greatest increase in skill competency was for diagnosis (Baseline: 11% vs Final: 68%; P < 0.001). Accuracy improved for distinguishing between 5 diagnostic groups and was highest for the Outflow obstructive motility disorder (Baseline: 49% vs Final: 76%; P < 0.001) and Normal motor function (50% vs 80%; P < 0.001). DISCUSSION: This prospective multicenter implementation study highlights that an adaptive web-based training platform is an effective tool to promote CBME. EMC completion was associated with significant improvement in identifying clinically relevant diagnoses, providing a model for integrating CBME into subspecialized areas of training.

Jackhammer Esophagus: Symptom Presentation, Associated Distal Contractile Integral, and Assessment of Bolus Transit.

GOALS: The aim of our study was to characterize jackhammer esophagus symptoms and their relationship with the distal contractile integral (DCI) and bolus transit. BACKGROUND: Jackhammer esophagus is defined by the Chicago Classification version 3.0. This diagnosis is relatively new, with the most current definition being established in 2014. The forerunners of this diagnosis, nutcracker (or hypercontractile) esophagus, have been associated with noncardiac chest pain (NCCP). STUDY: A retrospective chart review was performed of motility studies from 2011 to 2016. Studies with a diagnosis of jackhammer esophagus, hypercontractile esophagus, nutcracker, esophagogastric junction outflow obstruction, or hypertensive lower esophageal sphincter were reread using Chicago Classification version 3.0, and were included if they met criteria for jackhammer esophagus. Unpaired t-tests were used for analysis (P≤0.05). RESULTS: In total, 142 studies were identified with the above diagnoses. After excluding 84 studies, 58 remained for analysis and 17 were found to have jackhammer esophagus (29%). The mean age was 54 (28 to 75), 5 (29%) were males and 12 (71%) were females. The primary indications were NCCP (5), dysphagia (8), and other causes (4) (cough, heartburn, or regurgitation). The mean DCIs were 17,245 mm Hg×s×cm (NCCP), 14,669 mm Hg×s×cm (dysphagia), and 11,264 mm Hg×s×cm (other causes). The mean DCIs were compared: NCCP versus dysphagia (P=0.41), and NCCP versus other causes (P=0.05). Fifteen (88%) had normal bolus transit for both liquid and viscous swallows. CONCLUSIONS: In our small sample size, dysphagia was frequently the presenting symptom followed by NCCP. Those with NCCP have a trend toward a higher DCI. Bolus transit appeared to be normal in this patient population. More data are needed to further elucidate the genesis of symptoms and how they relate to the degree of contractility.

Dosing Cefepime for Renal Function Does Not Completely Prevent Neurotoxicity in a Patient With Kidney Transplant.

Dosing cefepime for renal function does not completely prevent neurotoxicity in a kidney transplant patient. Cefepime neurotoxicity has been reported primarily among patients with renal insufficiency who received standard doses of the antibiotic. We report a case of nonconvulsive status epilepticus from dose-adjusted cefepime in a kidney transplant patient. The timing of symptoms along with clinical and electroencephalographic improvement after discontinuation of cefepime was critical to the diagnosis. Whether we should adjust the dose of cefepime differently in a patient with transplanted kidney to prevent neurotoxicity is unknown.

Use of Aldosterone Antagonist to Treat Diarrhea and Hypokalemia of Ogilvie's Syndrome.

Ogilvie's syndrome (OS) is a functional obstruction of the bowel due to an autonomic imbalance. It often presents with diarrhea and is associated with hypokalemia. We present a case of a 70-year-old male who developed severe abdominal distension, watery diarrhea, and persistent hypokalemia status after left hip arthroplasty after suffering from a femoral neck fracture due to a fall and was diagnosed with OS. The persistent hypokalemia was slow to improve despite aggressive repletion because of the high potassium losses in the stool. This is most likely mediated through the increased expression of BK channels in the colonic mucosa. Aldosterone is theorized to have a role in the regulation of BK channels. Spironolactone was subsequently given and resulted in marked improvement of the diarrhea and hypokalemia. Thus, this case suggests a novel therapeutic approach for the treatment of Ogilvie's syndrome-associated diarrhea and hypokalemia.

Proton Pump Inhibitor-Induced Remission of Lymphocytic Esophagitis.

Lymphocytic esophagitis is a chronic condition that has been described in the literature; however, there is little information describing its characteristics and treatment. We present a case of lymphocytic esophagitis that was identified following food impaction. Repeat esophagogastroduodenoscopy (EGD) with biopsy showed a marked decrease in lymphocytic infiltration after a 6-week course of twice-daily high-dose proton pump inhibitor (PPI). After initiation of the high-dose PPI regimen, the patient had no further episodes of dysphagia or food impaction. We propose that treating lymphocytic esophagitis with twice-daily PPI can improve symptoms and show histologic evidence of improvement.

Reduced translocation of current photosynthate precedes changes in gas exchange for Quercus rubra seedlings under flooding stress.

Northern red oak (Quercus rubra L.) seedlings are frequently planted on suboptimal sites in their native range in North America, subjecting them to environmental stresses, such as flooding, for which they may not be well adapted. Members of the genus Quercus exhibit a wide range of responses to flooding, and responses of northern red oak to flooding remain inadequately described. To better understand the physiological effects of root system inundation in post-transplant northern red oak seedlings and the effects of flooding on endogenous patterns of resource allocation within the plant, we observed the effects of short-term flooding initiated at the linear shoot growth stage on net photosynthetic rates, dark respiration, chlorophyll fluorescence (Fv/Fm) and translocation of (13)C-labeled current photosynthate. Downward translocation of current photosynthate declined after 4 days of flooding and was the first measured physiological response to flooding; net photosynthetic rates decreased and dark respiration rates increased after 7 days of flooding. Short-term flooding did not affect maximal potential efficiency of photosystem II (Fv/Fm). The finding that decreased downward translocation of (13)C-labeled current photosynthate preceded reduced net photosynthesis and increased dark respiration during flooding suggests the occurrence of sink-limited photosynthesis under these conditions.

A 4-week pilot study with the cannabinoid receptor agonist dronabinol and its effect on metabolic parameters in a randomized trial.

PURPOSE: Dronabinol (synthetic Δ(9)- tetrahydrocannabinol) is used in patients with nausea and vomiting from chemotherapy and in AIDS patients for appetite stimulation. Recently, dronabinol was used to successfully treat visceral hypersensitivity causing noncardiac chest pain. With widening uses of this medication, we aim to explore its effects on metabolic parameters in long-term dosing and hypothesize that it will not affect major metabolic parameters. METHODS: A double-blind, placebo-controlled, 28-day trial was performed with patients 18 to 75 years old without cardiac disease. Patients had at least 2 weekly episodes of chest pain for the last 3 months and evidence of esophageal hypersensitivity after balloon distention testing. Prior use of pain medication, psychiatric diagnosis, or significant medical comorbidities precluded inclusion in the study. Patients were randomized to receive 5 mg dronabinol or placebo twice daily with metabolic parameters examined before and after the use of medication. FINDINGS: Thirteen patients completed the study (7 with dronabinol [6 women and 1 man] and 6 with placebo [5 women and 1 man]). None of the measured values, including body mass index, HDL, triglycerides, calculated LDL, high-sensitivity C-reactive protein, glucose, insulin, leptin, aspartate aminotransferase, alanine aminotransferase, LDH, or non-HDL, differed significantly in either group before or after treatment. In general, treatment with dronabinol coincided with favorable trends in some parameters, although these trends were not statistically significant. IMPLICATIONS: Dronabinol administration does not significantly affect basic metabolic components after a period of 28 days. The implications of these findings are important because dronabinol may be able to be used in patients with metabolic disorders. The favorable trends observed here warrant further exploration into its long-term effects. ClinicalTrials.gov identifier: NCT01598207.

Carbon translocation patterns associated with new root proliferation during episodic growth of transplanted Quercus rubra seedlings.

Patterns of carbon allocation in northern red oak (Quercus rubra L.), characterized by episodic growth through recurrent single-season flushing, vary by growth stage. To examine post-transplant timing and carbohydrate sources for new root growth, dormant, bare-root, half-sibling northern red oak seedlings were transplanted to pots and placed in a favorable growth chamber environment. Unlabeled seedlings were harvested at transplant and at the bud swell stage. After leaf emergence, seedlings were exposed to (14)CO(2) at the linear shoot, linear leaf or lag growth stages. Seedlings were then placed in a growth room for 48 h to allow for translocation of (14)C-labeled current photosynthate and its stabilization in sink component plant parts. Seedlings were subsequently harvested and tissue (14)C:(12)C ratio analyzed. New root growth began during the linear shoot growth stage. However, no increase in (14)C:(12)C ratio was found in new roots until the linear leaf and lag growth stages, indicating a downward shift in translocation of current photosynthate to fuel new root growth. In old roots, (14)C:(12)C ratio increased at the lag stage. Our results indicate that both stored carbohydrates and current photosynthate contribute to new root growth of transplanted northern red oak seedlings; stored carbohydrates promote initial new root proliferation, whereas current photosynthate assumes a greater role as new leaves mature and the flush terminates. Optimizing nursery practices to increase carbohydrate reserves may reduce the time required to establish root-soil contact and facilitate early post-planting survival.