Esophageal dysphagia and reflux symptoms before and after oral IQoro^(R) training

AIM: To examine whether muscle training with an oral IQoroR screen(IQS) improves esophageal dysphagia and reflux symptoms.METHODS: A total of 43 adult patients(21 women a n d 2 2 m e n) w e re c o n s e c u t i ve l y re fe r re d t o a swallowing center for the treatment and investigation of long-lasting nonstenotic esophageal dysphagia. Hiatal hernia was confirmed by radiologic examination in 21 patients before enrollment in the study(group A; median age 52 years, range: 19-85 years). No hiatal hernia was detected by radiologic examination in the remaining 22 patients(group B; median age 57 years,range: 22-85 years). Before and after training with an oral IQS for 6-8 mo, the patients were evaluated using a symptom questionnaire(esophageal dysphagia and acid chest symptoms; score 0-3), visual analogue scale(ability to swallow food: score 0-100), lip force test(≥ 15 N), velopharyngeal closure test(≥ 10 s), orofacial motor tests, and an oral sensory test. Another twelve patients(median age 53 years, range: 22-68 years) with hiatal hernia were evaluated using oral IQS traction maneuvers with pressure recordings of the upper esophageal sphincter and hiatus canal as assessed by high-resolution manometry.RESULTS: Esophageal dysphagia was present in all 43 patients at entry, and 98% of patients showed improvement after IQS training [mean score(range): 2.5(1-3) vs 0.9(0-2), P < 0.001]. Symptoms of reflux were reported before training in 86% of the patients who showed improvement at follow-up [1.7(0-3) vs 0.5(0-2), P < 0.001). The visual analogue scale scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQS training [71(30-100) vs 22(0-50), P < 0.001]. No significant difference in symptom frequency was found between groups A and B before or after IQS training. The lip force test [31 N(12-80 N) vs 54 N(27-116), P < 0.001] and velopharyngeal closure test values [28 s(5-74 s) vs 34 s(13-80 s), P < 0.001] were significantly higher after IQS training. The oral IQS traction results showed an increase in mean pressure in the diaphragmatic hiatus region from 0 mm Hg at rest(range: 0-0 mm HG) to 65 mm Hg(range: 20-100 mm Hg). CONCLUSION: Oral IQS training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence.

Temporal trends in the relative prevalence of dysphagia etiologies from 1999-2009

AIM:To examine the relative prevalence and temporal variation of dysphagia etiologies in patients undergoing upper endoscopy(EGD) over the past decade.METHODS:EGDs with the indication of dysphagia at an urban,university medical center in 1999,2004 and 2009 were retrospectively identified from the electronic medical record.The entire patient chart,including EGD,pathology,manometry,radiographic and clinician reports,was reviewed for demographic and clinical data and to determine the etiology of dysphagia.The number of EGDs in which an esophageal biopsy was performed was also noted.Gastroesophageal reflux disease(GERD) as a cause of dysphagia independent of peptic stricture was defined by symptoms with erosive esophagitis or symptom response to proton pump inhibition(PPI).Cases of eosinophilic esophagitis(EoE) were defined by an appropriate clinical history and histological criteria of ≥ 15 eosinophils per high powered field.PPI-responsive esophageal eosinophilia was not routinely reported prior to 2008.Statistical analysis was performed using one-way analysis of variance to analyze for trends between 1999,2004 and 2009 and a post-hoc Tukey analysis was performed following a significant main effect.RESULTS:A total of 1371 cases(mean age 54 years,43% male) met pre-specified inclusion criteria with 191,504 and 675 cases in 1999,2004 and 2009,respectively.Patients were older in 2004 compared to 2009(mean ± SD,54.0 ± 15.7 years vs 52.3 ± 16.8 years,P = 0.02) and there were more males in 1999 compared to 2004(57.5% vs 40.8%,P = 0.005).Overall,GERD(27.6%) and EoE(7.7%) were the most common identifiable causes of dysphagia.An unspecified diagnosis accounted for 21% of overall cases.There were no significant differences in the relative prevalence of achalasia or other motility disorders,peptic stricture,Schatzki's ring,esophageal cancer or unspecified diagnoses over the 10-year time period.There was,however,a decrease in the relative prevalence of GERD(39.3% vs 24.1%,P < 0.001) and increases in the relative prevalence of EoE(1.6% vs 11.2%,P < 0.001) and oropharyngeal disorders(1.6% vs 4.2%,P = 0.02) from 1999 to 2009.Post-hoc analyses determined that the increase in relative prevalence of EoE was significant between 1999 and 2009 as well as 2004 and 2009(5.4% vs 11.6%,P < 0.001),but not between 1999 and 2004(1.6% P 5.4%,P = 0.21).On the other hand,the decrease in relative prevalence of GERD was significant between 1999 and 2009 and 1999 and 2004(39.3% vs 27.7%,P = 0.006),but not between 2004 and 2009(27.7% vs 24.1%,P = 0.36).There were also significantly more EGDs in which a biopsy was obtained in 1999 compared to 2009(36.7% vs 68.7%,P < 0.001) as well as between 2004 and 2009(37.5% vs 68.7%,P < 0.001).While total EGD volume did increase over the 10-year time period,the percentage of EGDs for the indication of dysphagia remained stable making increasing upper endoscopy an unlikely reason for the observed increased prevalence of EoE.CONCLUSION:EoE has emerged as a dominant cause of dysphagia in adults.Whether this was due to a rise in disease incidence or increased recognition is unclear.

Predictive value of symptoms and demographics in diagnosing malignancy or peptic stricture

AIM:To determine which features of history and demographics predict a diagnosis of malignancy or peptic stricture in patients presenting with dysphagia.METHODS:A prospective case-control study of 2000 consecutive referrals(1031 female,age range:17-103 years) to a rapid access service for dysphagia,based in a teaching hospital within the United Kingdom,over 7 years.The service consists of a nurse-led telephone triage followed by investigation(barium swallow or gastroscopy),if appropriate,within 2 wk.Logistic regression analysis of demographic and clinical variables was performed.This includes age,sex,duration of dysphagia,whether to liquids or solids,and whether there are associated features(reflux,odynophagia,weight loss,regurgitation).We determined odds ratio(OR) for these variables for the diagnoses of malignancy and peptic stricture.We determined the value of the Edinburgh Dysphagia Score(EDS) in predicting cancer in our cohort.Multivariate logistic regression was performed and P < 0.05 considered significant.The local ethics committee confirmed ethics approval was not required(audit).RESULTS:The commonest diagnosis is gastro-esophageal reflux disease(41.3%).Malignancy(11.0%) and peptic stricture(10.0%) were also relatively common.Malignancies were diagnosed by histology(97%) or on radiological criteria,either sequential barium swallows showing progression of disease or unequivocal evidence of malignancy on computed tomography.The majority of malignancies were esophago-gastric in origin but ear,nose and throat tumors,pancreatic cancer and extrinsic compression from lung or mediastinal metastatic cancer were also found.Malignancy was statistically more frequent in older patients(aged >73 years,OR 1.1-3.3,age < 60 years 6.5%,60-73 years 11.2%,> 73 years 11.8%,P < 0.05),males(OR 2.2-4.8,males 14.5%,females 5.6%,P < 0.0005),short duration of dysphagia(≤ 8 wk,OR 4.5-20.7,16.6%,8-26 wk 14.5%,> 26 wk 2.5%,P < 0.0005),progressive symptoms(OR 1.3-2.6:progressive 14.8%,intermittent 9.3%,P < 0.001),with weight loss of ≥ 2 kg(OR 2.5-5.1,weight loss 22.1%,without weight loss 6.4%,P < 0.0005) and without reflux(OR 1.2-2.5,reflux 7.2%,no reflux 15.5%,P < 0.0005).The likelihood of malignancy was greater in those who described true dysphagia(food or drink sticking within 5 s of swallowing than those who did not(15.1%vs 5.2% respectively,P < 0.001).The sensitivity,specificity,positive predictive value and negative predictive value of the EDS were 98.4%,9.3%,11.8% and 98.0% respectively.Three patients with an EDS of 3(high risk EDS ≥ 3.5) had malignancy.Unlike the original validation cohort,there was no difference in likelihood of malignancy based on level of dysphagia(pharyngeal level dysphagia 11.9% vs mid sternal or lower sternal dysphagia 12.4%).Peptic stricture was statistically more frequent in those with longer duration of symptoms(> 6 mo,OR 1.2-2.9,≤ 8 wk 9.8%,8-26 wk 10.6%,> 26 wk 15.7%,P < 0.05) and over 60 s(OR 1.2-3.0,age < 60 years 6.2%,60-73 years 10.2%,> 73 years 10.6%,P < 0.05).CONCLUSION:Malignancy and peptic stricture are frequent findings in those referred with dysphagia.The predictive value for associated features could help determine need for fast track investigation whilst reducing service pressures.