EP.WE.264How much are we spending on Botulinum Toxin A injections for functional Upper Gastrointestinal conditions?

A number of Oesophagogastric (OG) conditions such as Achalasia, Gastroparesis, Oesophageal dysmotility (OD) and Pyloric dysfunction (PD) can be treated with Botulinum Toxin A (BTxA). The aim of our study was to assess the use and costs of Botulinum Toxin A endotherapy within a tertiary Oesophagogastric unit. We performed a retrospective analysis of data collected over a 2-year period at a tertiary Oesophagogastric unit from November 2015 to November 2017. We found 68 eligible patients with Achalasia, Gastroparesis, Oesophageal dysmotility, Pyloric dysfunction. The median number of treatment sessions were Achalasia 2 (1-3), Gastroparesis: 2 (1-9), Oesophageal dysmotility: 1 (1-5) and Pyloric dysfunction: 1.5 (1-3). The mean number of units of BTxA used per procedure (Unit) were Achalasia 200, Gastroparesis 170, Oesophageal dysmotility 190 and Pyloric dysfunction 270. A total of 126 vials containing 63000 units (£19530) were opened. 25520 units were used, and 37480 2. Vbn vcfunits were wasted (£11618) over 2 years. On average, 67% of each vial of Dysport was wasted. The local annual wastage was £5810 per year, which roughly equates to a national wastage cost of £348,600 per year for these 4 OG conditions alone (assuming we serve population of around 1 million people and therefore multiplying by 60). An option for cost saving would be to consider using smaller volume vials to reduce wastage. We would recommend that guidelines are produced in order to standardise the optimal dose required and the vial sizes to stock for treatment of these conditions and avoid unnecessary expenditure.

A rare cause of dysphagia: CREST syndrome

<p class="abstract">Reporting a case of a 29-year-old female patient who came to the outpatient department with features of CREST syndrome. This case report illustrates the ENT presentation of CREST syndrome. A 29 year female with features of CREST syndrome (Calcinosis+, Raynaud’s phenomena +, oesophageal dysmotility+ sclerodactyly+ and Telangiectasias+, with no pulmonary hypertension) with ANA titres positive. Complete blood count, serum electrolytes, renal function tests, liver function tests, chest X-ray ,barium swallow ,ECG was done. Rigid oesophagoscope was used for the bougie dilatation of the stricture of oesophagus and was conservatively treated for her symptoms and being followed up at present. GI disturbances such as heartburn, dysphagia or respiratory complaints. Example: dyspnoea are occasionally the first manifestations of the disease. Dysphagia, manifested by various abnormal swallowing sensation, is intially caused by impaired oesphageal motility but later can result from gastroesophageal reflux disease and secondary stricture formation. Hereby concluding that any patient coming in OPD with similar features as mentioned above we should have a differential diagnosis of CREST syndrome and limited cutaneous scleroderma, yet it is a rare case.</p>

Reflux aspiration associated with oesophageal dysmotility but not delayed liquid gastric emptying

Introduction Severe oesophageal dysmotility is associated with treatment resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying (SGE) has been associated with oesophageal dysmotility, however the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration and oesophageal dysmotility. Methods Data was extracted from a prospectively populated database of patients with severe treatment resistant gastro-oesophageal reflux disease (GORD). All patients with validated reflux aspiration scintigraphy (RASP) and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal (GOR) or laryngo-pharyngeal (LPR) reflux. LGE time of 22 minutes or longer was considered delayed. Results Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81min. Refux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p=0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p<0.001). GOR dominant symptoms were more common in patients with delayed LGE (p=0.03). Conclusion Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.

Upper gastrointestinal and hepatopancreatobiliary surgery

This chapter reviews upper gastrointestinal surgery (UGI) for diseases of the oesophagus, stomach, gall bladder and biliary system, and the duodenum as well as an overlap with hepatopancreatobiliary (HPB) surgery. It highlights ‘places to be’ to see UGI conditions including the emergency department, radiology, ward, theatre, and intensive therapy unit, and radiology and endoscopy procedures to see. Common UGI conditions are discussed including oesophageal dysmotility and cancer, hiatus hernia, gastro-oesophageal reflux disease, and gastric cancer. There is a helpful section detailing bariatric surgery with appropriate information for a medical student. It also discusses HPB conditions such as gallstone disease, biliary colic, and acute pancreatitis. It also reviews pancreatic operations such as Whipple’s procedure. This chapter includes good pictorial guidance and is written for both those looking to apply for medicine, and those in medical school.

Hypertrophic pyloric stenosis following repair of oesophageal atresia and tracheo-oesophageal fistula in a neonate

Development of hypertrophic pyloric stenosis (HPS) after a few weeks of repair of an oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) is a rare condition in early infancy. Although vomiting or feeding intolerance in operated cases of OA+TOF are attributed to oesophageal stricture, gastro-oesophageal reflux and oesophageal dysmotility, it may also be caused by HPS. Herein, we report a newborn infant who had OA and TOF operation on day 2 of life and diagnosed to have HPS at 15th day of age. Even though it is a rare anomaly, HPS should be kept on mind in the presence of persistent vomiting following repair of OA.

The role of oesophageal physiological testing in the assessment of noncardiac chest pain

Oesophageal physiology testing plays an important role in the diagnosis of noncardiac chest pain (NCCP) after cardiac, structural and mucosal abnormalities have been ruled out. Endoscopy can establish the presence of structural causes of chest pain such as cancer, oesophageal webs and diverticula. Even if macroscopically normal, eosinophilic oesophagitis is a common cause of chest pain and needs to be ruled out with an adequate biopsy regimen. In the remaining cases, diagnosis is focused on the identification of often subtle mechanisms that lead to NCCP. The most common oesophageal aetiologies for NCCP are gastro-oesophageal reflux disease (GORD), oesophageal dysmotility and functional chest pain. Ambulatory pH studies (with or without impedance or wireless measurements) can establish the presence of GORD, nonerosive reflux as well any association with symptoms of chest pain. High-resolution manometry, particularly with the inclusion of adjunctive testing, can rule out major motility disorders such as spasm, hypercontraction or achalasia. The EndoFLIP device can help define disorders with reduced distensibility, not easily appreciated with endoscopy or manometry. When all tests remain negative, a diagnosis of oesophageal hypersensitivity is normally made and therapy is shifted from targeting a disease to treating symptoms and patient affect.

PS01.011: PATHOPHYSIOLOGY OF LARYNGOPHARYNGEAL REFLUX DISEASE: ASSOCIATION WITH PULMONARY ASPIRATION ON SCINTIGRAPHY AND INEFFECTIVE OESOPHAGEAL MOTILITY

Background Gastro-oesophageal reflux disease (GORD) can present with typical symptoms or atypical or laryngopharyngeal reflux (LPR) symptoms. The role of impaired oesophageal motility in these two clinically distinct groups has not been previously examined. Methods This study is a retrospective analysis of 361 consecutive patient records that was extracted from a prospectively populated research database. Patients were categorised by symptom profile as predominantly LPR or GORD (98 GOR and 263 LPR). Presenting symptom profile, pH studies, oesophageal manometry and scintigraphy and the relationship between the above were analysed. Results Severe oesophageal dysmotility was more prevalent in LPR group (P = 0.037). Severe oesophageal dysmotility was strongly associated with isotope aspiration in both groups (P = 0.001). 24 per cent of patients showed evidence of pulmonary aspiration on scintigraphy. Significant correlation was established between total proximal acid on 24-hour pH monitoring and isotope aspiration in both groups (P = 0.00). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (P = 0.00). Conclusion Early research on oesophageal dysmotility has suggested reduced oesophageal clearance in individuals with IOM. This selected group of patients showed a high degree of impaired oesophageal motility, which was associated with rising time-activity curves in both the upper oesophagus and pharynx. The presence of refluxate in the upper oesophagus can stimulate cough via ‘reflex’ afferent pathways and the presence of gastric contents in the pharynx can cause direct irritation to upper airways, both resulting in cough. Reduced pressures in the lower oesophageal sphincter were equally prevalent in LPR and GORD groups and therefore were not discriminatory between the clinical groups. The impairment of oesophageal clearance secondary to diminished oesophageal motility, may offer a plausible explanation for the development of symptoms via combined ‘reflux’ and ‘reflex’ pathways, allowing continued oesophageal exposure or proximal exposure to refluxate. The ROC and cluster analysis demonstrated strong predictive values and linkages between ineffective oesophageal motility and rising pharyngeal time-activity curves for the prediction of lung aspiration. This may form the basis of a new approach to the definitive diagnosis of LPR and lung aspiration. Oesophageal dysmotility is a key factor in pathophysiology of LPR. Severe impaired oesophageal motility is strongly associated with pulmonary aspiration in both LPR and GORD. Disclosure All authors have declared no conflicts of interest.

PS01.062: REFLUX ASPIRATION SURGICAL OUTCOMES: DOES LAPAROSCOPIC FUNDOPLICATION SIGNIFICANTLY DECREASE QUANTITATIVE AND SYMPTOMATIC PULMONARY ASPIRATION?

Background Pulmonary aspiration of gastric refluxate is one of the indications for anti-reflux surgery. Effectiveness of surgery in preventing pulmonary aspiration post-operatively has not been previously tested. Methods Retrospective analysis of prospectively populated database of patients with confirmed aspiration of gastric refluxate on scintigraphy. Patients that have undergone anti-reflux surgery between 01/01/2014 and 31/12/2015 and had scintigraphy post-operatively were included. Objective data such as resolution of aspiration, degree of proximal aero-digestive contamination, surgical complications and oesophageal dysmotility as well as patient quality of life data was analysed. Results Inclusion criteria were satisfied by 39 patients (11 male and 28 female). Pulmonary aspiration was prevented in 24 out of 39 patients (61.5%) post operatively. Significant reduction of isotope contamination of upper oesophagus supine and upright (P = 0.002) and pharynx supine and upright (P = 0.027) was confirmed on scintigraphy post operatively. Severe oesophageal dysmotility was strongly associated with continued aspiration post-operatively OR 15.3 (95% CI 2.459–95.194; P = 0.02). Majority (24/31, 77%) of patients were satisfied or very satisfied with surgery, whilst 7/31 (23%) were dissatisfied. Pre-operative GIQLI scores were low (mean 90.5, SD 18.8), modest improvements at 6 months (mean 92.8, SD 23.9) and 12 months (mean 92.2, SD 27), were not significant (P = 0.07). Conclusion Surgery is partially effective in reversing pulmonary aspiration of gastric refluxate on short-term follow up. Severe oesophageal dysmotility is a predictor of inferior control of aspiration with surgery. Overall satisfaction with surgery in patients with pulmonary aspiration is inferior compared to other patients undergoing anti-reflux surgery. Disclosure All authors have declared no conflicts of interest.

Benign oesophageal disease

Benign oesophageal disease includes several conditions. Gastro-oesophageal reflux disease (GORD) is the reflux of gastric juices into the oesophagus with or without mucosal injury (oesophagitis). Achalasia is an oesophageal dysmotility disorder characterized by aperistalsis in the distal oesophagus, and failure of lower oesophageal sphincter relaxation. Motility disorders include oesophageal spasm, which is characterized by simultaneous, non-propagated contractions; nutcracker oesophagus, which is diagnosed by high-amplitude (≥180 mm Hg) contractions associated with chest pain; and ineffective oesophageal motility, which is characterized by low-amplitude contractions (≤30 mm Hg) in the distal oesophagus. Eosinophilic oesophagitis is diagnosed on a combination of clinical features and oesophageal biopsies confirming the presence of >15 eosinophils per high-powered film