Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus

Quality of Life Factors in Adults with Eosinophilic Oesophagitis in New Zealand

BACKGROUND

Eosinophilic oesophagitis (EoE) is an immune-mediated oesophageal disorder causing dysphagia. Patients with EoE experience reduced QoL due to symptoms; however, this has not been assessed in the New Zealand population. The aim of this study was to assess QoL in patients with EoE in New Zealand.

METHODS

This observational study recruited participants from two New Zealand hospitals. Records were reviewed to confirm diagnoses, and consenting participants completed an electronic survey, consisting of the Dysphagia Symptom Questionnaire (DSQ) score and the QoL-specific EoE (EoE-QoL-A) questionnaire score. Correlation analysis examined the relationship between the DSQ and EoE-QoL-A scores. Differences in baseline variables were assessed. Univariate logistic regression assessed the association of variables with disease activity and QoL.

RESULTS

Fifty-four participants responded, and four were excluded due to incomplete surveys. The majority (76%) were male, and the median age was 47 years (IQR 42-58). The median DSQ was 49 (IQR 0-60), and the median EoE-QoL-A score was 68 (IQR 48-80). A reduced EoE-QoL-A score was associated with active disease (OR = 0.96,95% CI 0.926-0.995). Significant associations were found between disease activity and overall EoE-QoL-A score (r = -0.37, p < 0.01) as well as the sub-categories eating and diet (r = -0.54, p < 0.001), social (r = 0.30, p < 0.05), and emotional impact (r = -0.44, p < 0.01). The EOE-QoL-A score was higher in those on PPI (75 vs. 60, p = 0.02).

CONCLUSION

This study identified a decreased quality of life (QoL) in individuals with EoE in New Zealand, aligning with international literature. The increased DSQ scores suggest a possible gap in current management approaches. The correlation between the DSQ and QoL highlights the need for improved care models of care for EoE.

Approach to esophageal absent contractility: can we do better?

Absent contractility (AC), a motility disorder characterized by the absence of esophageal contractions while maintaining normal lower esophageal sphincter relaxation, is recognized as a distinctive major disorder of peristalsis on esophageal high-resolution manometry that warrants comprehensive understanding. This unique motility disorder often co-occurs with connective tissue, rheumatologic or autoimmune diseases, with scleroderma being the classic example. Symptoms of gastroesophageal reflux are common. AC can profoundly impact patients' lives and result in a spectrum of complications, including erosive esophagitis, esophageal candidiasis, Barrett's esophagus, and malnutrition. To address the intricate complexities of AC and its multifaceted complications, a multidisciplinary approach is paramount. This approach considers the distinct clinical presentation and underlying rheumatologic conditions of the individual patient, recognizing the inherent diversity within this disorder. While medical management of gastroesophageal reflux remains the cornerstone of AC treatment, emerging surgical and endoscopic interventions offer additional therapeutic options for those grappling with this challenging condition. This comprehensive review provides an in-depth evaluation of recent advances in our understanding of AC and its management. It endeavors to offer valuable insights into therapeutic strategies for AC and its associated issues.

The Impact of Caustic Ingestion on Nutritional Status: Case Report

Introduction

Caustic injuries remain a major public health concern. Nutritional status plays a pivotal role in determining the outcome. Unfortunately, nutritional care guidelines are not widely implemented in clinical practice, and decisions are often based on prior experience and local policies.

Case Presentation

We present the case of an 83-year-old man who accidentally ingested alkali, resulting in severe caustic injury and subsequent complications that further deteriorated his nutritional status. The management of esophageal strictures necessitated constant adjustments to the nutritional strategies employed. The clinical evaluation revealed protein and energy malnutrition, accompanied by type 2 intestinal failure. However, with individually tailored parenteral nutritional therapy, a significant improvement in the patient's nutritional status was observed.

Conclusion

Recognizing that caustic injuries increase metabolic demands, a comprehensive and active nutritional assessment is crucial, focusing on the need for adequate energy, high protein intake, and an appropriate feeding route. In cases of acute or prolonged type 2 intestinal failure with insufficient oral or enteral nutrition, parenteral feeding should be the primary therapy. Effective management of caustic injuries requires a multidisciplinary and multicenter approach, integrating nutritional evaluation, including body composition measurements, into the clinical algorithm. Early initiation of nutritional therapy is vital to prevent chronic intestinal failure.

Recent Trends in the Management of Eosinophilic Esophagitis: A Systematic Review

Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition characterized by inflammation and eosinophilic accumulation of the esophagus, resulting in dysphagia and food impaction. While the exact etiology of EoE remains unclear, it is believed to be triggered by food allergens and dynamic environmental factors, resulting in various clinical manifestations, from inflammation to fibrosis. Although clinical presentation varies with age, the number of eosinophils in esophagogastroduodenal endoscopy remains the diagnostic gold standard. While diet elimination, proton pump inhibitors (PPIs), topical corticosteroids, and biological therapy are promising treatment options for EoE, there are insufficient data to determine the optimal therapeutic treatment approach. Combination therapies - the use of dietary therapies in conjunction with other treatment modalities, such as PPIs, topical corticosteroids, or biologic agents - have also emerged as a potential management strategy for EoE. In this systematic review, we attempt to highlight the recent advances in EoE therapies and provide updated guidance to their management. From 2017 to 2022, we conducted a comprehensive electronic search of PubMed (MEDLINE) using specific keywords related to our objective and eventually included a total of 44 articles.

Pathogenesis, clinical manifestations, diagnosis, and treatment progress of achalasia of cardia

Achalasia cardia, type of esophageal dynamic disorder, is a relatively rare primary motor esophageal disease characterized by the functional loss of plexus ganglion cells in the distal esophagus and lower esophageal sphincter. Loss of function of the distal and lower esophageal sphincter ganglion cells is the main cause of achalasia cardia, and is more likely to occur in the elderly. Histological changes in the esophageal mucosa are considered pathogenic; however, studies have found that inflammation and genetic changes at the molecular level may also cause achalasia cardia, resulting in dysphagia, reflux, aspiration, retrosternal pain, and weight loss. Currently, the treatment options for achalasia focus on reducing the resting pressure of the lower esophageal sphincter, helping to empty the esophagus and relieve symptoms. Treatment measures include botulinum toxin injection, inflatable dilation, stent insertion, and surgical myotomy (open or laparoscopic). Surgical procedures are often subject to controversy owing to concerns about safety and effectiveness, particularly in older patients. Herein, we review clinical epidemiological and experimental data to determine the prevalence, pathogenesis, clinical presentation, diagnostic criteria, and treatment options for achalasia to support its clinical management.