BACKGROUND: Symptoms and reflux burden in gastroesophageal reflux disease (GERD) may vary between populations.

AIMS: To evaluate relationships between symptom profiles and objective reflux burden in patients in two world regions, Asia and the United States.

METHODS: This was a cross-sectional study of patients undergoing pH-impedance monitoring from one Asian and two US centres. Validated patient-reported symptom instruments were prospectively collected. Symptom characteristics were compared against objective reflux burden (acid exposure time, AET; total reflux episodes, TRE; mean nocturnal baseline impedance, MNBI) from pH-impedance monitoring between the two populations.

RESULTS: Of 1099 patients, 162 were in Asia (age 47.4 ± 1.1 years, 36.4% female, body mass index, BMI 24.2 ± 0.4 kg/m2) and 937 in the United States (53.1 ± 1.3 years, 67.7% female, BMI 30.1 ± 0.3 kg/m2). Regurgitation dominated in Asia (59.9% vs. 50.3% heartburn in the United States), with higher TRE (55.4 ± 2.4 vs. 46.4 ± 1.2, p < 0.001). Despite this, reflux burden was lower in Asia (mean AET 2.19% ± 0.4% vs. 3.53% ± 0.2%; pathologic AET 11.1% vs. 20.5%; MNBI 2472 ± 62 Ω vs. 1745 ± 81 Ω; conclusive GERD per Lyon 2.0: 13% vs. 25.7%) (all p < 0.001), with higher symptom burden (GERDQ 8.97 ± 0.2 vs. 8.44 ± 0.1, p < 0.05; global symptom severity, GSS: 65.1 ± 1.8 vs. 48.1 ± 1.1, p = 0.001). Changing the AET threshold to 4% increased diagnostic yield by 21% among Asians (p = 0.035 vs. US). On multivariable linear regression, Asian patients (β = 19.3, p < 0.0001), higher AET (β = 1.02, p = 0.0004), higher reflux episodes (β = 0.11, p = 0.0029), lower BMI (β = -0.37, p = 0.0046) and female sex (β = 8.14, p = 0.0007) were independent predictors for higher GSS.

CONCLUSIONS: Compared to US patients, GERD profiles in Asian patients associate with higher symptom reporting despite lower objective reflux burden.

GOALS: To identify clinical features associated with geographic residency in patients with eosinophilic esophagitis (EoE).

BACKGROUND: Prior studies on the geographic distribution of eosinophilic esophagitis (EoE) have focused on disease prevalence. Geographic and environmental factors may impact the clinical characteristics and phenotypes of EoE, although data remain limited.

STUDY: This was a cross-sectional study of consecutive patients residing in Massachusetts with newly diagnosed EoE (≥15 eosinophils/hpf). Patients' residency settings were classified as urban or nonurban based on the 2020 US Census and residential zip codes. Clinical, endoscopic, and histologic variables were recorded. EoE patients in urban versus nonurban settings were compared using the student t test or the Fisher exact test for univariate analyses. Multivariable logistic regression was performed to identify the independent association between urban residency and comorbid atopic conditions, the inflammatory endotype, and the fibrostenotic endotype.

RESULTS: Six hundred eighty-three EoE patients were included, with 136 (20.0%) urban and 547 (80%) nonurban residents. Urban patients had higher rates of atopy (63.2% vs. 51.8%, P=0.02), severe food/environmental allergies (17.7% vs. 8.3%, P=0.002), and inflammatory findings endoscopic (43.4% vs. 27.8%, P=0.0006). On multivariable analysis, atopy (OR=1.57, CI: 1.02-2.40, P=0.04), severe food/environmental allergies (OR=1.99, CI: 1.09-3.63, P=0.02), and inflammatory findings (OR=1.90, CI: 1.22-2.94, P=0.004) remained independently associated with urban residency.

CONCLUSIONS: Urban residency is independently associated with severe food/environmental allergies and inflammatory endoscopic findings at EoE diagnosis, suggesting increased allergic phenotype and active inflammation at presentation. Allergen exposure, particularly indoors, and social determinants may be contributory factors. Environmental considerations, such as geographic residency, may impact EoE disease presentation, activity, and outcome.

BACKGROUND: Foregut disorders, including gastroesophageal reflux disease (GERD), esophageal motility disorders, and obesity, represent a significant and growing clinical and economic burden. The evolution of nuanced diagnostics (e.g., impedance planimetry) and advanced endoscopic therapeutics (e.g., per-oral endoscopic myotomy [POEM], transoral incisionless fundoplication, endobariatrics) has created a training gap not addressed by standard gastroenterology or advanced endoscopy fellowships. Specialized expertise in managing these complex foregut disorders is a critical area of clinical need.

METHODS: The American Foregut Society (AFS) Education Committee developed a core curriculum for a one-year advanced fellowship program focused on foregut disorders. This advanced program is designed for graduates of three-year accredited gastroenterology fellowship training programs. We define a competency-based assessment framework based on domain-specific Entrustable Professional Activities (EPAs) that integrate the six Accreditation Council for Graduate Medical Education (ACGME) Core Competencies.

RESULTS: The Advanced GI Foregut Fellowship curriculum is comprised of three domains: esophageal motility; reflux, mucosal disease, and cancer; and, obesity and metabolic disorders. Fellows will be expected to achieve Level 4 (practice-ready) entrustment in at least two of these domains. Each domain features training to independent proficiency in patient evaluation, diagnostic testing, and therapeutic intervention.

CONCLUSION: The AFS-sponsored Advanced GI Foregut Fellowship is proposed as a pilot program to formally train gastroenterologists to lead interdisciplinary foregut centers. We describe the curriculum, a novel GME assessment framework, and a strategy for implementation and evaluation. The pilot program will be used to determine appropriate training threshold volumes required to achieve competence.

BACKGROUND: The therapeutic hierarchy of current pharmacologic options for eosinophilic esophagitis (EoE) has not been established. We performed a network meta-analysis to evaluate the comparative efficacy of pharmacological therapies for EoE.

METHODS: PubMed, Scopus, Web of Science, and the Cochrane Library were searched from inception to May 25, 2025, for randomised controlled trials (RCTs) ≥12 weeks in duration comparing corticosteroids, biologics, or proton pump inhibitors with placebo or active comparators in participants aged ≥12 years. Key outcomes included changes in dysphagia from baseline and histological remission (≤6 eosinophils/high-power field) at 12, 24, and 48 weeks. Treatments were ranked using the surface under the cumulative ranking curve (SUCRA). Certainty of evidence was assessed using the GRADE framework.

RESULTS: Thirteen RCTs were included. For dysphagia improvement compared with placebo and active comparators, dupilumab 300 mg and cendakimab 360 mg demonstrated moderate-to-high-certainty benefit at 12 and 24 weeks, while budesonide oral suspension (BOS) 2 mg demonstrated moderate-to-high-certainty benefit at 12 weeks; no 24-week data were available for BOS. At 48 weeks, budesonide orodispersible tablets (BOT) 0.5 and 1 mg demonstrated high-certainty benefits for dysphagia improvement compared with placebo and active comparators. SUCRA ranked dupilumab highest for dysphagia improvement at 12 and 24 weeks (92% and 97%), and BOT 1 mg highest at 48 weeks (96%). For histological remission, all agents except etrasimod showed moderate-certainty benefits versus placebo across time points. SUCRA ranked BOS 2 mg highest at 12 weeks (78%), benralizumab 30 mg at 24 weeks (80%), and BOT 1 mg at 48 weeks (79%).

CONCLUSION: All evaluated therapies except etrasimod achieved histologic remission, while only dupilumab, cendakimab, BOS, and BOT were associated with symptomatic improvement in EoE, highlighting dissociations between histologic and symptomatic responses. Most corticosteroid trials were short-term and lacked direct comparisons with biologics. Robust head-to-head trials are needed to define optimal treatment strategies, assess long-term outcomes, and clarify the role of symptom, endoscopic, and histologic endpoints in therapeutic decision-making.

Recent advances in the diagnosis and management of reflux disease were the central focus of the inaugural Gatherings in Esophagology (GiE), which convened experts across gastroenterology, surgery, otolaryngology, pulmonology, and basic research. The sessions highlighted innovations in reflux monitoring-including high-resolution manometry, wireless pH monitoring, and novel salivary biomarkers-while critically evaluating their diagnostic accuracy and clinical utility. Presentations explored the limitations of traditional proton-pump inhibitor therapy, the emergence of potassium-competitive acid blockers as a new class of acid suppressants, and the evolving role of adjunctive treatments such as mucosal protectants, reflux reducers, and neuromodulators for refractory symptoms. The discourse extended to advanced interventional procedures, including transoral incisionless fundoplication, magnetic sphincter augmentation, and the RefluxStop device, with discussion of patient selection, efficacy, and complication management. Discussants emphasized the pathophysiology and management of extraesophageal manifestations of reflux, the interplay between reflux and pulmonary disease, and the diagnostic challenges in pediatric populations. The meeting also addressed the integration of behavioral therapies, the role of the microbiome, and the application of artificial intelligence in reflux diagnostics. Collectively, these insights underscore a shift toward precision medicine in reflux disease, emphasizing individualized diagnostic strategies and tailored therapeutic approaches to improve patient outcomes.

Large animal models, while valuable, are expensive, time-consuming, and limited to discrete interventional or terminal timepoints, while existing benchtop models do not offer an accurate representation of the esophageal environment. Moreover, current pre-clinical models cannot effectively simulate swallowing dysfunction (dysphagia), restricting progress in understanding motility disorders like achalasia and hindering evidence-based dietary recommendations. In response, we present RoboGullet, a biomimetic soft-robotic model with independent localized longitudinal and circumferential muscle actuation, enabling, for the first time, simulation of both normal and diseased esophageal motility. We further enhance realism with a biohybrid variant, RoboGullet + , incorporating porcine esophageal mucosa/submucosa. We demonstrate this platform's versatility through three key applications: assessing stent migration, simulating achalasia I-III within clinical diagnostic criteria, and analyzing bolus swallowing. Our findings reveal that: (1) stent migration increases over fivefold when incorporating longitudinal muscle movement versus isolated circumferential; (2) using a viscous non-Newtonian bolus improves high-resolution manometry diagnostic sensitivity of Achalasia III through increasing the Distal Latency diagnostic metric by 20.83%; and (3) stirring Greek-style yoghurt (common non-Newtonian dietary recommendation) significantly improves bolus transit versus unstirred for Achalasia Types I-II patients. This establishes RoboGullet+ as a powerful translational tool, advancing our understanding of esophageal motility and its therapeutic interventions.

BACKGROUND: Since gastroesophageal reflux disease (GERD) manifests typical and atypical symptoms of varying frequency and severity, the dominant symptom needs identification and quantification.

GOALS: We aimed to compare 5-point Likert scales assessing symptom burden to validated GERD questionnaires and outcomes following GERD management.

STUDY: We retrospectively analyzed pooled data from patients undergoing pH-impedance testing for reflux symptoms from 2 centers. Preprocedure questionnaires assessed symptom severity and frequency on 5-point Likert scales (0=not severe, infrequent; 4=extremely severe, multiple daily episodes); the product for the highest scoring symptom constituted the dominant symptom intensity (DSI). DSI was compared against validated instruments [global symptom severity (GSS), GERD questionnaire (GERDQ) and reflux symptom index (RSI)], and pH-impedance parameters per Lyon Consensus 2.0. DSI change after GERD management was compared against GSS and satisfaction with therapy.

RESULTS: Among 808 patients (mean age: 53.8±1.44 y, 65.2% female). DSI significantly correlated with GSS (R=0.682), GERDQ (R=0.414), RSI (R=0.577), acid exposure time (AET) (R=0.175), total reflux episodes (R=0.194) and mean nocturnal baseline impedance (R=-0.157) (P<0.0001 for each comparison). On ROC analyses, DSI (AUROC=0.60) was noninferior to GSS, GERDQ, and RSI in predicting pathologic AET and total reflux episodes, and conclusive GERD. Percentage DSI improvement after antireflux treatment significantly correlated with GSS change (R=0.632, P<0.0001) and treatment satisfaction (R=0.513, P<0.0001) and was an independent predictor of GSS change (β=0.302, P<0.0001), and satisfaction with therapy (β=0.833, P=0.011) on multivariable regression.

CONCLUSIONS: DSI correlates with validated reflux questionnaires and discriminates abnormal from normal reflux burden. DSI change reflects reflux treatment outcome and satisfaction.