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Gomez Cifuentes JD, Thota PN, Lopez R. Lower prevalence of gastroesophageal reflux disease in patients with noncardiac chest pain on opiates: a cross-sectional study. Dis Esophagus 2020; 33:doaa068. [PMID: 32543668 DOI: 10.1093/dote/doaa068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 12/11/2022]
Affiliation(s)
| | - P N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - R Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
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Cifuentes JDG, Thota PN, Lopez R. Lower prevalence of gastroesophageal reflux disease in patients with noncardiac chest pain on opiates: a cross-sectional study. Dis Esophagus 2018; 31:5006249. [PMID: 29846541 DOI: 10.1093/dote/doy053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/01/2018] [Indexed: 12/11/2022]
Abstract
Opiates can cause heartburn and spastic esophageal dysmotility but their role in noncardiac chest pain (NCCP) is not known. Our aim was to characterize opiate effects on esophageal function using esophageal pH monitoring and high-resolution manometry (HREM) in these patients.We performed a cross sectional study of opiate users with NCCP who underwent HREM and esophageal pH study from 2010 to 2017 using opiate nonusers as a comparison group. Demographic data, symptoms, opiate use, endoscopic findings, esophageal pH study parameters, and HREM data were abstracted.Thirty three patients with NCCP on opiates were compared to 144 opiate non-users. Compared to opiate nonusers, opiate users had lower total acid exposure (2.3% vs. 3%, P = 0.012), lower upright acid exposure (1.2% vs. 3.1%, P = 0.032) and lower DeMeester score (6.5 vs. 12.7, P = 0.016). Opiate users also had higher lower esophageal sphincter integrated relaxation pressure (LES-IRP) (7.0 mm Hg [2.2, 11.7] vs. 3.7 mm Hg [1.1, 6.2] P = 0.011) and greater mean distal contractile integral (DCI) (2575 mm.Hg.s.cm [1134, 4466] vs. 1409 mm.Hg.s.cm [796, 3003] P = 0.03) than opiate non-users. The prevalence of hypertensive motility disorders (15.2% vs. 11.1%) and achalasia (12.1% vs. 2.1%) was higher in opiate users (P = 0.039) but did not reach significance on multivariate analysis.In patients presenting with NCCP, opiate users had lower esophageal acid exposure compared to opiate nonusers. This might be due to higher LES pressures preventing reflux and higher DCI leading to more rapid acid esophageal clearance.
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Affiliation(s)
| | - P N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - R Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
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Sarvepalli S, Garg SK, Sarvepalli SS, Parikh MP, Wadhwa V, Jang S, Thota PN, Sanaka MR. Inpatient burden of esophageal cancer and analysis of factors affecting in-hospital mortality and length of stay. Dis Esophagus 2018; 31:4956135. [PMID: 29617798 PMCID: PMC7055505 DOI: 10.1093/dote/doy022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/16/2018] [Indexed: 12/11/2022]
Abstract
Esophageal cancer (EC) continues to be a major source of morbidity and mortality in the United States. However, there has been a relative dearth of research into hospital utilization in patients with EC. This study examines temporal trends in hospital admissions, length of stay (LOS), mortality, and costs associated with EC. In addition, we also analyzed factors associated with inpatient mortality and LOS. We interrogated National Inpatient Sample (NIS), a large registry of inpatient data, to retrieve information about various demographic and factors associated with hospital stay in patients who were admitted for EC between the years 1998 and 2013 in the United States. After examining trends over time, multivariate analysis was performed to identify factors associated with LOS and mortality. During 1998-2013, 538,776 hospital stays with principal diagnosis of EC were reviewed. Number of hospital stays and inpatient charges increased by 397 per year (±67.8; P < 0.0001) and $3,033 per patient per year (±135; <0.0001) respectively. Mortality and LOS decreased by 0.23% per year (±0.03; P < 0.0001) and 0.07 days per year (±0.006; P < 0.0001) respectively. Multiple factors associated with LOS and mortality were outlined. Despite overall increase in hospital utilization with respect to number of admissions and inpatient charges, inpatient mortality and LOS associated with EC declined. Factors associated with inpatient mortality and LOS may help drive clinical decision-making and influence healthcare or hospital policy.
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Affiliation(s)
- S Sarvepalli
- Department of Hospital Medicine, Medicine Institute,Address correspondence to: Shashank Sarvepalli, Department of Hospital Medicine, M75 9500 Euclid Ave, Cleveland, OH 44195, USA.
| | - S K Garg
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - S S Sarvepalli
- College of Liberal Arts and Science, Wayne State University, Detroit, Michigan
| | - M P Parikh
- Department of Hospital Medicine, Medicine Institute
| | - V Wadhwa
- Department of Gastroenterology and Hepatology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Weston, Florida, USA
| | - S Jang
- Department of Gastroenterology and Hepatology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - P N Thota
- Department of Gastroenterology and Hepatology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - M R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Chan MQ, Blum AE, Chandar AK, Emmons AMLK, Shindo Y, Brock W, Falk GW, Canto MI, Wang JS, Iyer PG, Shaheen NJ, Grady WM, Abrams JA, Thota PN, Guda KK, Chak A. Association of sporadic and familial Barrett's esophagus with breast cancer. Dis Esophagus 2018; 31:doy007. [PMID: 29528378 PMCID: PMC6005759 DOI: 10.1093/dote/doy007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC). Based on striking aggregation of breast cancer and BE/EAC within families as well as shared risk factors and molecular mechanisms of carcinogenesis, we hypothesized that BE may be associated with breast cancer. Pedigree analysis of families identified prospectively at multiple academic centers as part of the Familial Barrett's Esophagus Consortium (FBEC) was reviewed and families with aggregation of BE/EAC and breast cancer are reported. Additionally, using a matched case-control study design, we compared newly diagnosed BE cases in Caucasian females with breast cancer (cases) to Caucasian females without breast cancer (controls) who had undergone upper endoscopy (EGD). Two familial pedigrees, meeting a stringent inclusion criterion, manifested familial aggregation of BE/EAC and breast cancer in an autosomal dominant inheritance pattern with incomplete penetrance. From January 2008 to October 2016, 2812 breast cancer patient charts were identified, of which 213 were Caucasian females who underwent EGD. Six of 213 (2.82%) patients with breast cancer had pathology-confirmed BE, compared to 1 of 241 (0.41%) controls (P-value < 0.05). Selected families with BE/EAC show segregation of breast cancer. A breast cancer diagnosis is marginally associated with BE. We postulate a common susceptibility between BE/EAC and breast cancer.
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Affiliation(s)
- M Q Chan
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - A E Blum
- University Hospitals Cleveland Medical Center, Cleveland, Ohio,Louis Stokes VA Medical Center, Cleveland, Ohio
| | - A K Chandar
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Y Shindo
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - W Brock
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - G W Falk
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - M I Canto
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J S Wang
- Washington University School of Medicine, St. Louis, Missouri
| | - P G Iyer
- Mayo Clinic, Rochester, Minnesota
| | - N J Shaheen
- University of North Carolina, Chapel Hill, North Carolina
| | - W M Grady
- University of Washington Medical Center, Seattle, Washington
| | - J A Abrams
- Columbia University Medical Center, New York, New York
| | - P N Thota
- Cleveland Clinic Foundation, Cleveland, Ohio
| | - K K Guda
- Case Comprehensive Cancer Center, Cleveland, Ohio
| | - A Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio,Case Comprehensive Cancer Center, Cleveland, Ohio,Address correspondence to: Amitabh Chak, Professor of Medicine, Director,
Clinical Research, Division of Gastroenterology, Wearn 242, University Hospitals Cleveland
Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Aggarwal N, Lopez R, Gabbard S, Wadhwa N, Devaki P, Thota PN. Spectrum of esophageal dysmotility in systemic sclerosis on high-resolution esophageal manometry as defined by Chicago classification. Dis Esophagus 2017; 30:1-6. [PMID: 28881879 DOI: 10.1093/dote/dox067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 05/19/2017] [Indexed: 12/11/2022]
Abstract
The classic manometric findings in systemic sclerosis are aperistalsis of the esophageal body with hypotensive lower esophageal sphincter. These changes contribute to gastroesophageal reflux disease in these patients. With widespread use of high-resolution esophageal manometry, diverse abnormalities are seen. The aim of this study is to characterize esophageal dysmotility in patients with systemic sclerosis undergoing high-resolution esophageal manometry and compare demographic features and diagnostic test results among patients with varying degrees of esophageal dysmotility. Patients with systemic sclerosis who underwent high-resolution esophageal manometry between January 2008 and October 2014 at our institution were identified. High-resolution esophageal manometry studies were reinterpreted using the Chicago Classification, v3.0 criteria. We also reviewed the patient charts for demographic data, indications for manometry, esophagogastroduodenoscopy findings, pH studies, medication use, and autoantibody panel. The cohort consisted of 122 patients with a mean age of 53.3 ± 15.3 years. High-resolution esophageal manometry was normal in 23, showed ineffective esophageal motility in 22, absent contractility in 73, and one case each of type II achalasia, esophagogastric junction outflow obstruction, hypercontractile esophagus, and distal esophageal spasm. Patients with absent contractility were younger and more likely to have erosive esophagitis, hiatal hernia, and esophageal strictures than patients with ineffective esophageal motility or normal manometry. There were no statistically significant differences in the groups based on autoantibodies or indications for manometry. Diverse esophageal motility abnormalities were noted in systemic sclerosis with ineffective esophageal motility or absent contractility observed in over three-fourth of the patients. Patients with absent contractility were younger and had more severe reflux. The severity of gastroesophageal reflux disease related endoscopic findings correlated with the degree of esophageal dysmotility on high-resolution esophageal manometry.
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Affiliation(s)
- N Aggarwal
- Departments of Gastroenterology and Hepatology
| | - R Lopez
- Biostatistics, Cleveland Clinic, Cleveland, Ohio, USA
| | - S Gabbard
- Departments of Gastroenterology and Hepatology
| | - N Wadhwa
- Departments of Gastroenterology and Hepatology
| | - P Devaki
- Departments of Gastroenterology and Hepatology
| | - P N Thota
- Departments of Gastroenterology and Hepatology
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Rouphael C, Arora Z, Thota PN, Lopez R, Santisi J, Funk C, Cline M. Role of wireless motility capsule in the assessment and management of gastrointestinal dysmotility in patients with diabetes mellitus. Neurogastroenterol Motil 2017; 29. [PMID: 28444862 DOI: 10.1111/nmo.13087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/13/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Gastrointestinal (GI) dysmotility is common in diabetic patients. Wireless Motility Capsule (WMC) provides the transit profile of the entire GI tract in a single study. Factors affecting GI dysmotility and utility of WMC study are not clearly established in diabetic patients. Our aims were to study the pattern of GI dysmotility using WMC and evaluate the effect of glycemic control and presence of diabetic microvascular complications on motility impairment in diabetic patients. We also assessed the impact of WMC findings on clinical management. METHODS Retrospective chart review of all diabetic patients who underwent WMC testing at our institution from 2010 to 2015 was performed. Demographics, hemoglobinA1c levels, microvascular complications, and WMC findings were obtained. Impact of WMC on clinical management was assessed. KEY RESULTS A total of 100 patients were included. Mean age was 45±19 years and 76% were female. Seventy-two percentage had abnormal WMC testing, of which 29 (40%) had multiregional dysmotility. There were no significant differences in demographics, diabetic microvascular complications or hemoglobinA1c levels among patients with normal and abnormal WMC testing or among patients with isolated vs multiregional dysmotility. Information about subsequent clinical management was available for 47 patients. WMC testing was abnormal in 33 (70%) patients and treatment changes based on WMC results were made in 24 patients (73%). CONCLUSIONS & INFERENCES There was no association between hemoglobinA1c levels, microvascular complications and pattern of GI dysmotility in diabetic patients undergoing WMC. WMC testing lead to management changes in approximately 75% of diabetic patients with GI dysmotility.
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Affiliation(s)
- C Rouphael
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Z Arora
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - P N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - R Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - J Santisi
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - C Funk
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - M Cline
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
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Rouphael C, Thota PN, Cline M. Reply to multiregional dysmotility in diabetes mellitus assessed using the wireless motility capsule. Neurogastroenterol Motil 2017; 29. [PMID: 28782195 DOI: 10.1111/nmo.13147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 05/30/2017] [Indexed: 02/08/2023]
Affiliation(s)
- C Rouphael
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - P N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - M Cline
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
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Allampati S, Lopez R, Thota PN, Ray M, Birgisson S, Gabbard SL. Use of a positional therapy device significantly improves nocturnal gastroesophageal reflux symptoms. Dis Esophagus 2017; 30:1-7. [PMID: 27629558 DOI: 10.1111/dote.12495] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to measure the efficacy of a positional therapy device (PTD) at reducing proton pump inhibitor (PPI) refractory nocturnal GERD symptoms. Among patients with GERD, nocturnal symptoms are very common. A recent study demonstrated a decrease in nocturnal acid exposure and reflux episodes in healthy volunteers who slept using a PTD. This is a single-center prospective trial involving patients on anti-secretory medications with continued nocturnal heartburn and regurgitation. Patients completed the Nocturnal GERD Symptom Severity and Impact Questionnaire (N-GSSIQ) and GERD health-related quality of life questionnaire (GERD-HRQL) at enrollment. Patients were instructed to sleep on the PTD for at least 6 hours a night during the two week study period; subjects continued their baseline anti-secretory medication dose. After 2 weeks, the questionnaires were repeated. A total of 27 patients (16 females and 11 males; age 57.8 ± 15.1) were recruited. After 2 weeks of PTD use, N-GSSIQ scores significantly improved from baseline, with a mean total score improvement of 39.5 (mean 57.7 [pre] vs. 18.2 [post], P < 0.001). Significant improvement from baseline was also observed for the GERD-HRQL questionnaire (29.8 vs. 16.7, P < 0.001). No adverse events were reported. At 3 months after the trial period, 91% of the subjects continued to use the PTD on a nightly basis. Use of the PTD significantly decreased nocturnal GERD symptoms and improved GERD-HRQL. The PTD was well tolerated during the study period and for 3 months after enrollment.
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Affiliation(s)
- S Allampati
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - R Lopez
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - P N Thota
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - M Ray
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - S Birgisson
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - S L Gabbard
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
Relationships of timed barium esophagram (TBE) findings to achalasia types defined by high-resolution manometry (HRM) have not been elucidated. Therefore, we correlated preoperative TBE and HRM measurements in achalasia types and related these to patient symptoms and prior treatments. From 2006 to 2013, 248 achalasia patients underwent TBE and HRM before Heller myotomy. TBE height and width were recorded at 1 and 5 minutes; HRM measured lower esophageal sphincter mean basal pressure, integrated relaxation pressure (IRP), and mean esophageal body contraction amplitude. Achalasia was classified into types I (25%), II (65%), and III (9.7%). TBE height at 5 minutes was higher for I (median 8 cm; interquartile range 6-12) and II (8 cm; 8-11) than for III (1 cm; 0-7). TBE width at 5 minutes was widest (3 cm; 2-4), narrower in II (2 cm; 2-3), and narrowest in I (1 cm; 0-2), P < 0.001. Volume remaining at 1 and 5 minutes was lower in III (1 m(2) ; 0-16) than I (42 m(2) ; 17-106) and II (39 m(2) ; 15-60), highlighting poorer emptying of I and II. Increasing TBE width correlated with deteriorating morphology and function from III to II to I. Symptoms poorly correlated with TBE and HRM. Prior treatment was associated with less regurgitation, faster emptying, and lower IRP. Although TBE and HRM are correlated in many respects, the wide range of their measurements observed in this study reveals a spectrum of morphology and dysfunction in achalasia that is best characterized by the combination of these studies.
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Affiliation(s)
- A Zanoni
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio, USA
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Thota PN, Zuccaro G, Vargo JJ, Conwell DL, Dumot JA, Xu M. A randomized prospective trial comparing unsedated esophagoscopy via transnasal and transoral routes using a 4-mm video endoscope with conventional endoscopy with sedation. Endoscopy 2005; 37:559-65. [PMID: 15933930 DOI: 10.1055/s-2005-861476] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND STUDY AIMS Unsedated upper endoscopy is an attractive alternative to conventional sedated endoscopy because it can reduce the cost, complications, and recovery time of the procedure. However, it has not gained widespread acceptance in the United States. A prototype 4-mm-diameter video esophagoscope is available. Our aims were to compare unsedated esophagoscopy using this 4-mm esophagoscope with conventional sedated endoscopy with regard to diagnostic accuracy and patient tolerance, to determine the optimal intubation route (transnasal vs. transoral), and to identify the predictors of tolerance of unsedated endoscopy. PATIENTS AND METHODS Outpatients presenting for conventional endoscopy were randomized to undergo unsedated esophagoscopy by either the transnasal or the transoral route, followed by conventional endoscopy. The diagnostic findings, optical quality, and patient tolerance scores were assessed. RESULTS A total of 137 patients were approached and 90 (65.6 %) were randomized to undergo esophagoscopy by the transnasal route (n = 44) or by the transoral route (n = 46) before undergoing conventional esophagoscopy. Patient tolerance of unsedated esophagoscopy was comparable to that of conventional endoscopy. The transnasal route was better tolerated than the transoral route, except with respect to pain, and 93.2 % in transnasal group and 91.3 % in transoral group were willing to have the procedure again. The diagnostic accuracy of endoscopy using the 4-mm video endoscope was similar to that of standard endoscopy. Patients who tolerated the procedure well had lower preprocedure anxiety scores (29 vs. 42.5, P = 0.021) and a higher body mass index (31.5 kg/m2 vs. 28 kg/m2, P = 0.029) than the other patients. CONCLUSIONS Unsedated esophagoscopy with a 4-mm esophagoscope was well tolerated and has a level of diagnostic accuracy comparable to that of conventional endoscopy. Factors associated with good tolerance of unsedated esophagoscopy were low anxiety levels, high body mass index, and use of the transnasal route. Unsedated endoscopy may be offered to a selected group of patients based on these criteria.
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Affiliation(s)
- P N Thota
- Center for Endoscopy and Pancreaticobiliary Disease, Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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