The session at the AGA Spring Postgraduate Courses entitled "Burning Issues in the Upper Gastrointestinal Tract" covered a number of hot topics in the management of patients with upper GI disorders.

Dr. Glenn Furuta, a pediatric gastroenterologist at Children’s Hospital Colorado, Aurora, presented a new definition of eosinophilic esophagitis (EoE) as a chronic, immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. He discussed the recently recognized condition called "PPI-responsive esophageal eosinophilia" in which patients have typical EoE symptoms and histology with no evidence of gastroesophageal reflux disease (GERD), and yet they respond to PPI therapy.

Dr. Furuta explained that these patients might have GERD with acid reflux causing esophageal eosinophilia, even though endoscopy and esophageal pH monitoring are normal. But he also proposed that they might have EoE responding to anti-inflammatory effects of PPIs that are independent of their effects on acid inhibition. And Dr. Furuta showed data that a six-food elimination diet that prohibits milk, soy, eggs, wheat, nuts, and seafood is effective therapy for adults with EoE.

Dr. Ronnie Fass, a professor of medicine at the University of Arizona in Tucson and director of the GI Motility Laboratory at the Southern Arizona VA Health Care System and head of the Neuro-Enteric Clinical Research Group, discussed the management of heartburn that is refractory to PPI therapy, and explained that potential underlying mechanisms include poor patient compliance, improper PPI dosing, persistent acidic reflux, non-acidic reflux, and the presence of non-GERD esophageal disorders like EoE. But he also noted that functional heartburn is the most common mechanism underlying PPI-refractory heartburn.

Although it is a common clinical practice to double the PPI dose for patients with this problem, Dr. Fass pointed out that there is little evidence to support this practice, and he encouraged clinicians instead to consider alternative strategies such as emphasizing proper compliance, implementing lifestyle modifications like weight loss, switching to another PPI, using baclofen (which reduces the transient LES relaxations that underlie most reflux episodes), and prescribing tricyclic antidepressants for pain modulation.

I presented recent data indicating that the risk of cancer is lower than we had thought it is for patients with non-dysplastic Barrett’s esophagus. Cancer affects approximately 1 in 400 such patients each year, and the risk appears to decrease over time. But for patients who have Barrett’s with high-grade dysplasia, the annual risk of cancer is approximately 6%, which warrants intervention. I discussed the AGA guideline recommending endoscopic eradication therapy rather than surveillance for the treatment of patients with confirmed high-grade dysplasia. This includes endoscopic mucosal resection of mucosal irregularities for staging, and ablation of all the remaining Barrett’s metaplasia. I showed the results of a recent systematic review that found that the risk of lymph node metastases for patients with high-grade dysplasia or intramucosal carcinoma in Barrett’s esophagus is in the range of 1%-2%. And finally, I pointed out that the AGA does not recommend endoscopic eradication therapy for the general population of patients with Barrett’s esophagus in the absence of dysplasia.

Dr. Nicholas Talley, professor of epidemiology and medicine in the department of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minn., explained that the Rome III criteria for functional dyspepsia include one or more of the symptoms of epigastric pain, epigastric burning, early satiation and bothersome postprandial fullness. In addition, patients must have no evidence of structural disease that is likely to explain the symptoms.

Dr. Talley noted that patients with functional dyspepsia are often misdiagnosed as having GERD, and that one way to distinguish between those disorders is to look for meal-related symptoms – if symptoms like early satiation and postprandial fullness predominate, then functional dyspepsia is the likely diagnosis. The duodenum might play an important role in the pathogenesis of functional dyspepsia, he said, noting that the duodenum in these patients is hypersensitive to acid and distention, and that functional dyspepsia is associated with duodenal eosinophilia and with T-cells that home to the small bowel.

Finally, Dr. Nicholas Shaheen, professor of medicine and epidemiology and director of the Center for Esophageal Diseases & Swallowing at the University of North Carolina, Chapel Hill,discussed the management of non-variceal upper GI bleeding, encouraged clinicians to consider using a scoring system like the Rockall or Blatchford scores for patient risk stratification.

Dr. Shaheen said that patients with upper GI bleeding should have endoscopy within 24 hours of admission but, for patients who are hemodynamically stable, very early endoscopy within 12 hours does not reduce rebleeding or improve survival. This means that endoscopy safely can be postponed until the light of day for most patients, but they should be treated overnight with intravenous PPIs prior to the morning endoscopy because this treatment has been shown to decrease the need to administer endoscopic therapy. During the endoscopy, Dr. Shaheen recommended endoscopic therapy for ulcers that are actively spurting or oozing, and for non-bleeding visible vessels. He also recommended that we remove adherent clots to expose lesions that might need endoscopic therapy. He cautioned that injection therapy with epinephrine should not be used alone, but epinephrine injection can be combined with thermal therapy (heater probe and bipolar electrocoagulation), with the injection of sclerosants, and with the application of hemoclips, all of which are reasonable options that appear to have similar efficacy.

Stuart J. Spechler, M.D., is professor of medicine and the Berta M. and Cecil O. Patterson Chair in Gastroenterology at the University of Texas Southwestern Medical Center at Dallas, and chief of the division of gastroenterology at the Dallas VA Medical Center.

Intake of New Ideas in the Upper GI Tract