Progress on treating upper GI disorders

Barrett’s esophagus with dysplasia has traditionally been managed surgically and esophagectomy performed in centers of excellence may not be high-risk as previously thought, especially in otherwise fit individuals. They noted that endoscopic ablative techniques have assumed a greater role in managing dysplastic Barrett’s, while endoscopic mucosal resection (EMR) is a safe and effective alternative to surgery for early cancer.

As well as being therapeutic, EMR compliments endoscopic ultrasound in staging cancer. Close follow-up after ablation and EMR remains important, because the long-term impact of endoscopic treatmentS is not yet clearly defined.

Although proton pump inhibitors (PPIs) remain the corner stone of GERD management, not all individuals respond to these medications. The limitations of PPIs and presented available and investigational strategies for prolonging their activity were outlined. They mentioned that investigational drugs designed to specifically address transient LES relaxations will likely compliment acid suppression. The search for safe, effective, and durable endoscopic techniques to manage GERD remains a priority, since long-term acid inhabitation can occasionally have adverse effects.

Eosinophilic esophagitis (EoE) can cause common symptoms. Heightened awareness of the condition, even when endoscopic findings are not present, should prompt esophageal biopsies at several sites.

Whether EoE is a primary allergic condition or requires both acid injury and allergen exposure is unclear, but symptoms can respond to PPIs, desensitization, and/or food avoidance. For those patients whose symptoms do not respond to acid reduction or allergen elimination, topical steroids (or possibly future biologics) may be necessary, but the required duration of such treatment is unclear.

Peptic ulcer disease can be infectious or iatrogenic indicated that it remains an important clinical issue. They discussed factors affecting accuracy of H. pylori testing (e.g., PPIs, GI bleeding) and implications of treatment duration (longer is better) and antibiotic resistance (consider “sequential therapy”) regarding eradication. NSAIDs have a major pathogenic role in complicated ulcer, and users at risk are candidates for safer agents or prophylactic PPI co-therapy. While acknowledged that interaction between PPIs and clopidogrel occurs in vitro, it was pointed out that clinical consequences of this remain controversial.

Injection therapy of ulcers with high-risk stigmata alone is insufficient, but monotherapy with clips or cautery might be adequate. PPI treatment reduces rebleeding risk following endoscopic homeostasis, and generally this involves continues IV infusion, although it was mentioned that oral administration may be sufficient. Despite optimal management, some patients will require repeat endoscopic attempts to control bleeding.