This year’s session on esophagus/upper GI at the AGA Spring Postgraduate Course was packed with pragmatic, useful information for the evaluation of patients with upper GI disorders. The session began with a talk on the manifestations of extraesophageal reflux disease. The take-home message of this talk was that putative extraesophageal manifestations of gastroesophageal reflux disease rarely respond to high-dose therapy with PPIs (proton-pump inhibitors), in the absence of concurrent esophageal symptoms such as heartburn or regurgitation. In such situations, investigation of other etiologies of patients’ symptoms, including occult postnasal drainage or cough-variant asthma, may be more rewarding than escalating anti-acid therapy.
Dr. John E. Pandolfino, AGAF, of Northwestern University, Chicago, discussed the utilization of high-resolution manometry in the evaluation of dysphagia. A central focus of this discussion was the use of the Chicago classification of motility abnormalities in assessing these patients. In the future, it is likely that the care of these patients will be dictated by the type of abnormality the patient has in this classification scheme. Especially in the setting of achalasia, data are emerging that some subtypes of achalasia are less likely to respond to some therapies. For instance, type 3 achalasia is unlikely to respond to pneumatic balloon dilatation.
Dr. Rhonda Souza of the University of Texas Southwestern Medical Center, Dallas, taught us that a diagnosis of eosinophilic esophagitis requires an 8-week trial of PPI therapy with no resolution of the eosinophilia. Esophageal dilation is generally safe in the setting of a dominant stricture, but it can be delayed prior to medical therapy if the patient is tolerating oral intake well. Although the most commonly used therapies for EoE now involve either swallowed steroids or dietary elimination therapy, several new agents are on the horizon that may give us new treatment options.
Finally, Dr. Amitabh Chak of Case Western Reserve University, Cleveland, reviewed the care of patients with Barrett’s esophagus and low-grade dysplasia. This is an especially difficult group of patients to care for, due in part to the low reproducibility in the diagnosis of low-grade dysplasia, as well as the highly variable reported cancer outcomes in this patient population. Level 1 evidence now exists demonstrating that treatment with radiofrequency ablation decreases the incidence of cancer in patients with low-grade dysplasia, but most patients with this finding will not progress. Therefore, the field would benefit from better risk stratification of these patients.
Dr. Shaheen is professor of medicine and epidemiology and chief of the division of gastroenterology & hepatology, University of North Carolina School of Medicine, Chapel Hill. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2015.