Microbiota Detection Patterns Correlate With Presence and Severity of Barrett's Esophagus

Background

The microbiome has been increasingly associated with different disease processes, but its role in esophagus is largely unknown. Our goal was to determine the associations of the esophageal microbiota with Barrett’s esophagus.

Methods

A total of 74 patients were included in this prospective study, including 34 patients with Barrett’s esophagus and 40 patients without Barrett’s esophagus. Esophageal swabs were obtained from the uvula, and mucosal biopsies were obtained from the proximal esophagus and distal esophagus in each patient. The microbiome of each sample was assessed using a customized Esophageal Microbiome qPCR array (EMB). For each clinical sample, we completed a detection/non-detection analysis for each organism in the EMB. The limit of detection (LOD) for each target was established by analysis of plasmid dilutions.

Results

Average age was 60.2 years. There were significantly different microbial detection patterns in patients with Barrett’s esophagus compared to the control population. There were a greater number of organisms which had different likelihoods of detection in the distal esophagus, compared to the proximal esophagus or uvula. In addition, as the length of the Barrett’s column increased, multiple organisms were less likely to be detected. This decreased likelihood occurred only in the distal esophagus. Beside Barrett’s esophagus, no other demographic factors were associated with differences in detection patterns.

Conclusions

Microbial community structures differ between patients with and without Barrett’s esophagus. Certain organisms are less likely to be detected as the severity of Barrett’s esophagus worsens. These results suggest that particular organisms may have a protective effect against the development of Barrett’s esophagus.

Outcomes of delayed endoscopic management for esophageal soft food impactions

BACKGROUND AND AIMS

Food impactions are a common reason for emergent upper endoscopy. Current guidelines call for urgent upper endoscopy (within 24 hours) for food impactions without complete esophageal obstruction and emergent endoscopy (within 6 hours) for those with complete esophageal obstruction. Multiple adverse events can arise from esophageal foreign bodies. Cases with longer delays from symptom onset to presentation have been associated with higher rates of surgical intervention. However, data on esophageal soft food impactions are scant. We set out to determine differences in outcomes for food impactions undergoing intervention within 12 hours versus over 12 hours of symptom onset.

METHODS

A retrospective review of medical records was conducted to identify patients who presented to our hospital with an esophageal soft food impaction and underwent an EGD between January 2010 and January 2018. Patients were divided into 2 groups based on the timing from symptom onset to EGD. An EGD within 12 hours was considered an early intervention and over 12 hours was considered a delayed intervention. Patients who had ingested bones or hard objects were not included. Primary outcomes studied were rates of aspiration, admission, local esophageal adverse events, and 30-day all-cause mortality.

RESULTS

We identified 110 patients with a soft food impaction who underwent an EGD. Forty- two patients had an early intervention and 68 a delayed intervention. There were no differences in basic demographics and comorbidities. Additionally, there were no differences in rates of local esophageal adverse events, aspiration, admission, or 30-day mortality. Multivariate analysis revealed endoscopic accessory use was associated with increased odds of local esophageal adverse events (odds ratio, 6.37; P = .01).

CONCLUSIONS

The overall rates of serious adverse events in esophageal soft food impactions are low. Delayed intervention is not associated with increased adverse events or 30-day mortality compared with early intervention. However, accessory use is associated with higher adverse event rates.

Microflora composition in the gastrointestinal tract in patients with Barrett's esophagus

Background

The incidence of esophageal adenocarcinoma (EAC) has been increasing over the last 40 years. While Barrett's esophagus is a known risk factor for the development of EAC, the role of the microflora in the development of EAC is still largely unknown and is being investigated further by multiple centers. Our goal was to identify trends in microflora composition along various aspects of the upper gastrointestinal tract in patients with Barrett's esophagus.

Methods

After obtaining institutional review board approval, 12 patients agreed to participate in the study. While endoscopy was performed for surveillance Barrett's monitoring, additional biopsies of esophageal mucosa were taken from the (I) proximal esophagus, (II) mid-esophagus, (III) distal esophagus, and (IV) Barrett's esophagus. Additional swabs were also taken from the uvula and the endoscope used during the procedure. The swabs from the uvula and endoscope were obtained prior to the endoscope entering the stomach, to prevent exposing the endoscope to the acidic environment of the stomach. The most common bacterial elements were identified by amplifying sample DNA using a panel of 5 "universal" fusion primer pairs. The 400-500 base pair fragments created an overlap which covered 95% of the bacterial 16s gene.

Results

Throughout the esophagus, 34 bacterial genera were found which had a relative abundance of >1.0. Streptococcal genera were prevalent in all aspects of the esophagus, ranging from 16% to 70% of the bacterial community. Haemophilus genera were uniquely abundant in the Barrett's esophageal tissue but relatively absent elsewhere in the upper gastrointestinal tract. Overall, the percentage of Gram-positive organisms was much higher in the proximal than distal esophagus. The microflora pattern obtained from the uvula and endoscopic swabs did not correlate with any of the tissue biopsies along any aspect of the esophagus.

Conclusions

In patients with Barrett's esophagus, Streptococcal genera are widespread throughout the esophagus. Gram-positive genera tend to decrease as a percentage of overall flora distally. Obtaining a simple swab of the oropharynx or endoscope itself appears to be a poor substitute for tissue biopsy of esophageal mucosa when evaluating microflora patterns.

Accuracy of endoscopic ultrasound in esophageal cancer staging

Since its advent in the 1980s endoscopic ultrasound (EUS) has played an important role in the diagnosis, staging, and therapeutic management of various gastrointestinal malignancies. EUS has emerged as a vital tool in the evaluation of esophageal cancer as it provides a detailed view of the layers of the esophageal wall and surrounding tissues. This permits determination of tumor invasion depth and local lymph node metastases. It is the most sensitive and specific method available for locoregional staging of esophageal cancer. The information obtained via EUS is vital in determining the appropriate diagnosis, prognosis, and treatment options. Thus, this article aims to present a review of the accuracy and utilization of EUS in the staging of esophageal cancer.

Natural history, pathophysiology and evaluation of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common diseases encountered by both internists and gastroenterologists. GERD can cause a wide variety of symptoms ranging from heartburn and regurgitation to more atypical symptoms such as cough, chest pain, and hoarseness. The diagnosis is often times made on the basis of history and clinical symptomatology. The prevalence of GERD is currently estimated to be 8-33% with the incidence of disease only expected to increase over time. Although most cases of GERD can be diagnosed based on symptoms and clinical presentation, the diagnosis of GERD can be challenging when symptoms are atypical. In this review, we provide a comprehensive summary of the epidemiology, pathophysiology, evaluation and diagnosis of gastroesophageal reflux disease.

Acute lymphoblastic leukemia presenting with mesenteric ischemia

Malignancy can induce a hypercoagulable state and lead to an increased risk of thromboembolic events. The pathogenesis of the prothrombotic state in cancer is complicated but is thought to involve several mechanisms. Thrombosis predominantly affects the venous circulation and infrequently the arteries. Arterial occlusion as an initial manifestation of acute leukemia is unusual. This is a case of a 44-year-old male admitted with complete thrombotic occlusion of the superior mesenteric artery and treated with emergent thrombectomy. Hematologic work-up was consistent with a diagnosis of T-cell acute lymphoblastic leukemia. To our knowledge, this is the first case of complete occlusion of the superior mesenteric artery presenting as the initial manifestation of T-cell acute lymphoblastic leukemia.

Patients with cirrhosis who have coronary artery disease treated with cardiac stents have high rates of gastrointestinal bleeding, but no increased mortality

BACKGROUND

Patients with coronary artery disease (CAD) treated with stents require dual antiplatelet therapy (DAPT). For cirrhotics, who often have varices and coagulopathy, it is not clear if the risk of gastrointestinal bleeding (GIB) should preclude use of DAPT.

AIM

To compare GIB and mortality rates in cirrhotics with CAD treated medically or with stents.

METHODS

Using institutional databases, we identified patients with cirrhosis and CAD treated with stents or medical therapy between January 2000-September 2015. Primary outcomes were GIB and mortality.

RESULTS

We identified 148 cirrhotics with CAD; 68 received stents (cases), 80 were treated with medical therapy (controls). Cases and controls had similar demographics, comorbidities, MELD scores and clinical presentation; DAPT was used in 98.5% of cases vs 5% of controls. The incidence of GIB was significantly higher in cases than controls (22.1% vs 5% at 1 year, P=.003; 27.9% vs 5% at 2 years, P=.0002), whereas all-cause mortality was similar (20.6% vs 21.3%). No patient required surgery or angiography for GIB, and no known patients died due to GIB. Multivariate analysis revealed use of a proton pump inhibitor (PPI) was highly protective against GIB (OR=0.26, 95%CI=0.08-0.79).

CONCLUSIONS

CAD treatment with stents in our cirrhotics was associated with a significantly increased risk of GIB, but no adverse effects on survival. Although it remains unclear whether the cardiovascular benefits of stents outweigh the GIB risk, our findings suggest that DAPT should not be withheld from stented cirrhotics for fear of GIB. Moreover, the use of a PPI should be strongly considered.