The Chicago Classification of Esophageal Motility Disorders, now in version 3.0, “has been the standard for high-resolution manometry and esophageal pressure topography” for some time, and the upcoming update to version 4.0 should feature “substantial changes that will benefit this motility classification,” John E. Pandolfino, MD, FACG, told the attendees at the virtual American College of Gastroenterology (ACG) clinical meeting and postgraduate course.

Dr Pandolfino is chief of Gastroenterology and Hepatology and Hans Popper Professor of Medicine at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

Part of an expert panel on esophageal disorders, Dr Pandolfino explained that gastroenterologists assessing motility problems “need a lot more information that goes beyond the 10 supine swallows” required by Chicago Classification 3.0, and should include in their examinations “a variety of supplementary provocative maneuvers such as the multiple rapid swallow and the rapid drink challenge, which can be extremely helpful in ruling out obstruction.” Chicago 4.0 is expected to incorporate provocative swallow tests, as well as post-prandial challenges that are helpful in evaluating patients with regurgitation and belching.

In regard to treatment for various types of dysmotility, Dr Pandolfino said the classification of achalasia in Chicago 3.0 “remains very good for diagnostic separation and phenotyping,” and in making treatment decisions. Achalasia subtypes should dictate treatment decisions, with the best treatment being peroral endoscopic myotomy (POEM).

Esophagogastric junction outflow obstruction “should never be diagnosed with manometry alone, and requires complementary tests to rule in overt obstruction.” Patients should only be referred for POEM or other treatment if timed barium esophagram or functional lumen imaging probe finds evidence of definitive obstruction and there is no evidence of mechanical obstruction.

He noted that “hypercontractile swallows are pretty heterogeneous, ranging from the borderline to normal nutcracker-like swallow to the jackhammer repetitive contractile disorder that really suggests a significant abnormality.” He advises always beginning with medical management of these conditions before moving to POEM.

He further observed that weak peristalsis is “a spectrum of disorders that ranges from absent contractility to ineffective esophageal motility and a seemingly borderline motor disorder.” In Chicago 4.0, Dr Pandolfino said, “I think you’ll see a more restrictive definition of ineffective esophageal motility that will have more clinical significance.”

Vani J.A. Konda, MD, FACG, clinical director of the Center for Esophageal Diseases at Baylor University Medical Center in Dallas, Texas, reviewed the causes and treatments for various types of esophageal strictures, ranging from gastroesophageal reflux disease (GERD) to eosinophilic esophagitis (EoE) and surgery.  

“It’s important to evaluate for any evidence of inflammation when you encounter a stricture, and treat as needed with acid suppression,” she said. “Patients with a history of head and neck cancer treated with radiation or surgery need a modified barium swallow to evaluate for concurrent orolaryngeal dysphagia.” Barium swallows are also helpful in mapping out strictures, she added.

Standard dilation—both balloon and bougie—are first-line treatment for strictures, with bougie being the better choice for more complex or longer strictures. “It’s always critical to know where you are and where you’re going, so consider using fluoroscopy,” Dr Konda said.

With refractory strictures, defined as those that cannot reach a diameter of at least 14 mm over 5 sessions at 2-week intervals, and recurrent strictures, in which a diameter of 14 mm is reached but cannot be maintained for 4 weeks, “it’s important to tailor the therapy. One size does not fit all,” Dr Konda said. Options include cold biopsy forceps, steroid injection, incisional therapy, topical mitomycin C, self-dilation, and reconstructive surgery.

The process of managing esophageal strictures is often a matter of “2 steps forward, 1 step back,” she said. “It requires patience. You must realize that you and the patient are in this for the long haul, and will eventually reach the goal.”

Nicholas Shaheen, MD, MPH, MACG, discussed the management of Barrett esophagus with dysplasia or neoplasia. “Generally speaking, there are 3 phases of successful multimodality therapy for Barrett esophagus,” he explained. “What to do before you treat; what to do when you treat; and what you do after you treat.”

Dr Shaheen is the Bozymski-Heizer Distinguished Professor and chief of the division of gastroenterology and hepatology at University of North Carolina at Chapel Hill School of Medicine. He was also named a Master of the ACG at this year’s meeting.

First of all, he said, “Make sure you’re treating what you think you’re treating. By that, I mean you should make sure the pathology has been confirmed by an expert gastrointestinal (GI) pathologist.”

Second, he said, “make sure that you should be treating what you’re treating—that you’re following the best evidence.” Dr Shaheen explained that a study from The Netherlands, in which the results of 293 patients who were diagnosed with low-grade dysplasia (LGD), were re-read by 3 expert GI pathologists. Only 27% were confirmed as LGD; the rest were downgraded to either indefinite for dysplasia or nondysplastic Barrett esophagus (NDBE). Almost none progressed to dysplasia or esophageal adenocarcinoma (EAC). Of those in which dysplasia was confirmed, about one-quarter progressed to high-grade dysplasia (HGD) or EAC.

All of the guidelines of major gastroenterology organizations call for no treatment for NDBE and for treatment of HGD, LGD, and intramucosal adenocarcinoma (IMC).

What should you do when you treat? “All mucosal irregularities need to come out by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD),” Dr Shaheen explained. “Any modality that reliably kills mucosa, combined with vigorous acid suppression, will induce reversion to squamous epithelium.”

Any lesion removed that is more advanced than superficial submucosal invasion (T1b sm1) deserves consideration for surgery,” Dr Shaheen stated. “If you have mucosal disease only, your risk of lymph node involvement is very low, 0% to 3%. On the other hand, if you have mid-submucosal to deep submucosal disease, the rate of lymph node involvement is unacceptably high, at 36% to 54%.”

Radio frequency ablation (RFA) is the most commonly used method for ablation treatment, although argon plasma therapy is also widely used and has been improved, and liquid or balloon-based cryoablation are successful methods as well.

What do you do after treatment? “Everyone who achieves complete eradication deserves endoscopic surveillance,” Dr Shaheen said. “Inadequate acid suppression is associated with a risk of recurrence, so you should ensure adequate acid suppression.”

Endoscopic eradication therapy is the treatment of choice for HGD and IMC, Dr Shaheen said. It is also widely accepted for confirmed LGD. Anything beyond superficial submucosal invasion has a prohibitively high risk of lymph node involvement and should be removed. Finally, he noted, “Several new ablation modalities hold promise, but only RFA has level-1 evidence for success in reducing the incidence of esophageal cancer.”

For EoE, Prasad Iyer, MD, explained, there are 3 primary treatment modalities: diet, drugs, and dilation.

Dr Iyer is a professor of medicine at the Mayo Clinic in Rochester, Minnesota.

The most likely pathogenesis for EoE appears to be food antigens, he explained. Milk, eggs, and wheat may be the primary culprits in causing an eosinophilic inflammatory response in the mucosa, which may lead to fibrosis, remodeling, and stricture formation.

“Elemental diets in pediatric populations with EoE have been highly effective in more than 90% of patients,” he explained. “For adult patients, elimination diets have been devised to identify and eliminate food antigens. Typically we eliminate 4 to 8 food allergens for 8 weeks and then assess the response via endoscopy. If the patient has responded well, we reintroduce each food, followed by endoscopy 6 to 8 weeks later.”

Dr Iyer said, “This process can take several months and require repeated endoscopy. We’re investigating the use of 1-food or 2-food diets now, because most patients have just 1 or 2 food triggers, and the most common culprits are gluten and milk.”

Drugs can also play a role in treating EoE. Proton pump inhibitors (PPIs) have an anti-inflammatory effect, Dr Iyer said. In a large cohort study of PPIs for EoE, 49% of participants showed a clinical response. The highest rates of success were seen with higher doses, but a lower dose can help to maintain remission.

Dr Iyer noted that there are no treatments approved by the US Food and Drug Administration specifically for EoE; however, inhaled fluticasone, approved for allergic rhinitis, and swallowed budesonide, approved for inflammatory bowel disease, have been tested for this indication. “Oral budesonide so far has not proved superior to fluticasone; both are acceptable and the choice is really dictated by patient preference, cost, tolerability, and insurance coverage,” Dr Iyer explained.

Dilation for EoE can create mucosal tears but recent data suggests that dilation, when done carefully, is safe, Dr Iyer stated. He advised restricting dilation to patients with strictures and persistent dysphagia even with anti-inflammatory treatment.

New treatments for EoE are on the horizon, he explained, including some monoclonal antibodies and interleukin inhibitors that are now in development. “It is not yet clear where these will fit in our treatment algorithm, but they may be useful for treatment-refractory cases of EoE.”

—Rebecca Mashaw

Reference:

Pandolfino JE. Esophageal dysmotility: evaluation and treatment; Shaheen, NJ. Multimodel management of BE dysplasia/neoplasia; Konda VJA, Management of esophageal strictures;   Iyer, PG. Eosinophilic esophagitis treatment approaches in 2020. Talks presented at: American College of Gastroenterology 2020 Clinical Meeting and Postgraduate Course. October 24, 2020. Virtual.