DAY 3: Clinical Approaches to Esophageal Disorders

Dr. C. Prakash Gyawali, from Washington University in St. Louis, MO, reviewed the clinical approaches to abelchia, supragastric belching, and hiccups. Abelchia, also called retrograde cricopharyngeal dysfunction, is defined as the inability to belch. It is caused by failure of the upper esophageal sphincter to relax, which traps air in the esophagus that is pushed back down toward the stomach by secondary peristalsis. Patients may present with chest pain and gurgling noises in the chest. High-resolution manometry with a carbonated beverage challenge can help with diagnosis. In supragastric belching, air is sucked into the esophagus and expelled before reaching the stomach, without the lower esophageal sphincter relaxation seen in gastric belching. Patients present with repetitive, loud belching that can subside with distraction and is absent during sleep. Impedance monitoring can help with diagnosis, and treatment includes diaphragmatic breathing and cognitive behavioral therapy. Hiccups are distinct from belching and it is important to exclude other foregut problems with endoscopy, as well as cardiovascular and other potential causes. Hiccups can be interrupted with various maneuvers and vagus nerve stimulation, for example, by biting on a lemon or ingesting granulated sugar, though these strategies are anecdotal. 

In a presentation on GERD and laryngopharyngeal reflux (LPR), Dr. Christopher D. Vélez from Massachusetts General Hospital in Boston, MA, described a 48-year-old woman who presented with atypical heartburn and persistent hoarseness that was not controlled on medications. She had previously undergone wireless ambulatory reflux testing with poor correlation of results and symptoms. She was referred to a surgeon who felt she did not meet the criteria for anti-reflux surgery, but was also told that despite her symptoms, she did not meet the criteria for LPR. The Lyon 2.0 consensus provides algorithms to guide GERD diagnosis and test selection and whether to test on or off PPI therapy. The San Diego consensus is used to evaluate laryngopharyngeal reflux (LPR). If patients do not have symptoms related to reflux disease, they are treated with behavioral therapy and neuromodulation to spare them from long-term PPI use. The Rome V criteria can help determine whether the symptoms are caused by acid exposure or esophageal hypersensitivity. When reflux symptoms are real but GERD has been ruled out, treatment involves a combination of pharmacotherapy, complementary/integrative medicine, and GI-directed behavioral therapy. For the patient in the presented case, addressing the hoarseness when LPR had been ruled out involved deescalation of anti-reflux therapy and treatment with gabapentin in addition to histamine as needed.

Dr. Joan W. Chen of the University of Michigan, Ann Arbor, MI, described the Rome V diagnostic criteria for rumination and regurgitation, which presents as a seemingly effortless regurgitation of recently ingested food that is not preceded by retching or nausea. High-resolution manometry and impedance testing can help provide an objective diagnosis. Rumination syndrome has a prevalence of 3.1%, and is seen most often in patients 30-60 years of age. Predictors include female sex, high BMI, depression, and anxiety. Diagnosis is challenging and delays of up to 3 years is common, as symptoms overlap with those of other disorders, including GERD, esophageal motility disorder, gastric outlet obstruction or gastroparesis, and psychiatric disorders such as bulemia. 
pH impedance testing can detect early postprandaial nonacidic reflux events indicative of rumination. The main difference between rumination GERD is gastric and esophageal pressure, and the gastro-sphincteric pressure gradient has been proposed as a new diagnostic measure. Treatment comprises cognitive behavioral therapy and diaphragmatic breathing exercises, and some patients may benefit from reflux inhibitors (baclofen) and neuromodulators (TCA). Diaphragmatic breathing increases esophogastric junction pressure and restores a negative pressure gradient. Management of any underlying comorbid conditions is important. Anti-reflux surgery should only be considered in rare cases as a last resort. The 2018 AGA clinical practice update provides an algorithmic approach to diagnosis and treatment of postprandial regurgitation.

Dr. Ronnie Fass of MetroHealth Medical Center in Cleveland, OH, made the case for the use of proton pump inhibitors (PPIs) for GERD. He described the introduction of PPIs in the early 1990s as a tremendous advance in GERD treatment, particularly in severe disease and for the prevention of complications. PPIs have been shown to promote healing in patients with erosive esophagitis and reduce the recurrence of peptic stricture. Unfortunately, improper use and overuse of PPIs in the hospital setting led to reports of increased adverse events (AEs), including vitamin deficiencies, chronic kidney disease, bone fractures, and even MI and dementia. Dr. Fass noted that all the studies reporting PPI AEs were observational population-based studies, with bias and residual confounding. It is clear now that there is no clear high-quality evidence of serious adverse events with PPIs, and when used appropriately, the benefits of PPIs for the treatment of GERD/NERD outweigh the risks.

Dr. Anh D. Nguyen continued the session with a discussion on the use of PCABs in GERD. Many patients struggle with the timing of PPIs with meals, and often forget the second daily dose. Unlike PPIs, PCABs do not need to be taken with food, are stable in acidic environments, and have a more rapid and sustained effect. Currently, vonoprazan is the only PCAB available in the US. An NDA for tegoprazan was submitted recently, and it is expected to enter the market in 2027. Studies have shown the benefits of PCABs for GERD, erosive esophagitis, and NERD, and use as needed has been shown to be effective in relieving symptoms. PCABs have a similar safety profile as PPIs, though vonoprazan should be avoided in patients taking anti-platelet medications, and there is no data on use in pregnancy or during breastfeeding. In addition, high doses of PCABs should be avoided in patients with CKD or cirrhosis. Candidates for PCABs include those experiencing challenges with PPI timing, patients with CYP2C19 polymorphisms that affect PPI metabolism, patients with LA grade C or D esophagitis, and poor surgical candidates with refractory GERD and absent esophageal contractility, hiatal hernia, or lack of success with prior foregut surgeries. The multifactorial mechanisms underlying GERD, beyond acid production, support other primary or adjunctive pharmacologic therapies: alginates, baclofen, H2 blockers as needed to reduce risk of tachyphylaxis, sucralfate in pregnant patients, and prokinetics in patients with concurrent gastroparesis. Lifestyle and dietary modification can also reduce symptoms and are included in various guidelines. Dr. Nguyen emphasized the importance of patient communication about the causes of GERD and the various approaches to optimizing therapy.

Dr. Swathi Eluri from Mayo Clinic, in Jacksonville, FL, concluded the session with a discussion of screening tools and treatment of Barrett’s esophagus. She compared various recommendations for screening, including the use of the Kunzmann tool to assess risk and determine the most appropriate screening approach. Patients with intermediate risk scores may undergo a triage test and move on to esophagogastroduodenoscopy (EGD) if positive. A family history can justify moving forward with EGD in shared decision-making with patients. She described the development of minimally invasive, swallowable cell collection devices and predicted that their use will likely increase in clinical care. Surveillance after diagnosis of Barrett’s is recommended by current guidelines, but the evidence base is not strong. A high-quality endoscopic exam and biopsy is considered the most effective surveillance modality, and although adjunctive tools are available to increase yield, the evidence is of low quality. The 2022 ACG guidelines suggest that the frequency of surveillance be guided by the degree of dysplasia found on biopsy and the segment length. In patients with low grade dysplasia, endoscopic eradication therapy (EET) is favored over surveillance, though some patients may be worried about adverse events with EET.