Performance of the UCLA Scleroderma Clinical Trials Consortium Gastrointestinal Tract 2.0 instrument as a clinical decision aid in the routine clinical care of patients with systemic sclerosis

Background and objectives The University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument 2.0 (UCLA GIT 2.0) is validated to capture gastrointestinal (GI) tract morbidity in patients with systemic sclerosis (SSc). The aims of this study were to determine in a large SSc cohort if the UCLA GIT 2.0 is able to discriminate patients for whom a rheumatologist with experience in SSc would recommend an esophago-gastro-duodenoscopy (EGD), and if it could identify patients with endoscopically proven esophagitis or with any pathologic finding on EGD. Methods We selected patients fulfilling the ACR/EULAR 2013 criteria for SSc from our EUSTAR center having completed at least once the UCLA GIT 2.0 questionnaire, and we collected data on gastrointestinal symptoms and EGD from their medical charts. We analyzed by general linear mixed effect models several parameters, including UCLA GIT 2.0, considered as potentially associated with the indication of EGD, as well as with endoscopic esophagitis and any pathologic finding on EGD. Results We identified 346 patients (82.7% female, median age 63 years, median disease duration 10 years, 23% diffuse cutaneous SSc) satisfying the inclusion criteria, who completed UCLA GIT 2.0 questionnaires at 940 visits. EGD was recommended at 169 visits. In multivariable analysis, UCLA GIT 2.0 and some of its subscales (reflux, distention/bloating, social functioning) were associated with the indication of EGD. In 177 EGD performed in 145 patients, neither the total ULCA GIT 2.0 score nor any of its subscales were associated with endoscopic esophagitis, nor with any pathologic EGD findings. Conclusions In a real-life setting, the UCLA GIT 2.0 and its reflux subscale were able to discriminate patients with SSc who had an indication for EGD, but did not correlate with findings in EGD. We conclude that, while using the UCLA GIT 2.0 in the routine care of patients with SSc may help the rheumatologist to better understand the burden of GI symptoms in the individual patient, it should not be used as a stand-alone instrument to identify an indication of EGD.

FAILURE AFTER FUNDOPLICATION: RE-FUNDOPLICATION? IS THERE A ROOM FOR GASTRECTOMY? IN WHICH CLINICAL SCENARIES?

ABSTRACT Background: Re-fundoplication is the most often procedure performed after failed fundoplication, but re-failure is even higher. Aim: The objectives are: a) to discuss the results of fundoplication and re-fundoplication in these cases, and b) to analyze in which clinical situation there is a room for gastrectomy after failed fundoplication. Method: This experience includes 104 patients submitted to re-fundoplication after failure of the initial operation, 50 cases of long segment Barrett´s esophagus and 60 patients with morbid obesity, comparing the postoperative outcome in terms of clinical, endoscopic, manometric and 24h pH monitoring results. Results: In patients with failure after initial fundoplication, redo-fundoplication shows the worst clinical results (symptoms, endoscopic esophagitis, manometry and 24 h pH monitoring). In patients with long segment Barrett´s esophagus, better results were observed after fundoplication plus Roux-en-Y distal gastrectomy and in obese patients similar results regarding symptoms, endoscopic esophagitis and 24h pH monitoring were observed after both fundoplication plus distal gastrectomy or laparoscopic resectional gastric bypass, while regarding manometry, normal LES pressure was observed only after fundoplication plus distal gastrectomy. Conclusion: Distal gastrectomy is recommended for patients with failure after initial fundoplication, patients with long segment Barrett´s esophagus and obese patients with gastroesophageal reflux disease and Barrett´s esophagus. Despite its higher morbidity, this procedure represents an important addition to the surgical armamentarium.

Clinical and manometric profile of patients with GERD in a tertiary care hospital

Background: Abnormal esophageal motility and low Lower Esophageal Pressure (LES) play an integral role among various etiologies implicated in pathogenesis and severity of Gastro Esophageal Reflux Disease (GERD). Delayed clearance of refluxate leads to prolonged mucosal exposure to gastro duodenal contents which promotes esophagitis and its complications. To find out the association of ineffective esophageal motility (IEM) and low Lower Esophageal Sphincter (LES) pressure with endoscopic esophagitis in patients presenting with symptoms of GERD. Settings and designs: Prospective cross sectional study done in a tertiary medical care center in south India from October 2016 to March 2017.Methods: This cross sectional study was carried out among patients presenting with symptoms of GERD (heart burn and regurgitation,) at least twice per week for past three months. Based on their endoscopy findings patients with GERD are grouped into two having erosive and nonerosive reflux disease. After general and systemic clinical examination, High resolution Manometry was performed, and data was analyzed using Trace 1.2.3a V software. Statistical methods: Data was analysed using SPSS version 19. Chi square test was used to analyze categorical variables and independent ’t’ test was used for continuous variables.Results: A total of 66 patients with GERD symptoms were subjected to esophageal manometry. Out of these 66 patients 42 were males and 22 were females with their mean age 40.82±12.86 years. Among 66 patients presented with GERD symptoms 26.7% were found to have ineffective esophageal motility and only 11.7% had low LES pressure. Ineffective esophageal motility was also found to be more common among older age group individuals with their mean age being 44.64 ±14.154. Among the patients with erosive reflux disease (70.21%), 66.7% had low LES pressure and 75 % had IEM; the association was not statistically significant.Conclusions: The incidence of Ineffective esophageal motility in patients with GERD is found to be higher than that of low LES pressure. There was no significant association observed between IEM and low LES pressure with endoscopic esophagitis in patients with GERD.