BACKGROUND: Esophageal symptoms are common among elderly patients, although evidence on age-related esophageal dysfunction remains inconsistent. Esophageal contraction reserve measured by response to multiple rapid swallows (MRS) on high-resolution manometry (HRM) provides additional insights beyond conventional HRM metrics. We aimed to evaluate the impact of age on esophageal contraction reserve among symptomatic adults.

METHODS: Adults with esophageal symptoms undergoing HRM and pH-impedance monitoring off acid suppression were included. Patients with prior foregut surgery or major peristaltic disorder were excluded. MRS response was assessed by the ratio of post-MRS distal contractile integral (DCI) to mean DCI from single water swallows, with a ratio > 1 defining a positive response (MRS+).

RESULTS: Among 619 patients (mean 56.5 years, 59.1% female), 372 patients (60.1%) exhibited intact contraction reserve. MRS+ patients were younger (54.3 ± 15.7 vs. 59.8 ± 12.5 years, p < 0.0001) and MRS+ prevalence declined with advancing age groups (< 35 years: 78.8%; 35-50 years: 65.4%; 50-65 years: 59.6%; > 65 years: 51.7%, p-trend = 0.0008). On multivariable logistic regression, age negatively predicted MRS+ (OR: 0.97, CI: 0.96-0.99, p = 0.0004), after adjusting for potential confounders. In separate models constructed with categorized age groups, age > 65 years independently correlated with less MRS+ compared to all younger groups: Age < 35 (OR: 0.23, CI: 0.10-0.53, p = 0.0005), age 35-50 (OR: 0.58, 95% CI: 0.31-0.98, p = 0.045), and age 50-65 (OR: 0.55, 95% CI: 0.33-0.90, p = 0.017).

CONCLUSION: Esophageal contraction reserve measured by MRS during HRM declines with advancing age. Age-related loss of contractile adaptability may contribute to esophageal dysfunction and unexplained symptoms in older adults. Provocative testing with MRS on HRM provides value in evaluating symptomatic elderly patients.

BACKGROUND: The San Diego Consensus for Laryngopharyngeal Symptoms (LPS) and Laryngopharyngeal Reflux Disease (LRPD) offers a modern interdisciplinary paradigm that focuses on symptoms and aligns evaluation with underlying mechanisms of disease.

PURPOSE: This review uses the San Diego Consensus as the framework to discuss who should be tested for reflux, timing and selection of diagnostic testing, and practical diagnostic algorithms in patients with LPS and LPRD. Patient reported outcome measures are useful to characterize LPS, quantify symptom burden and monitor response, but are not specific for a diagnosis of LPRD. Patients presenting with both LPS and typical esophageal symptoms have higher pretest probability of LPRD, and time limited empiric acid suppressive agents and alginates may be appropriate. In contrast, upfront objective testing is recommended in isolated LPS prior to long-term acid suppressive therapy. Laryngoscopy or stroboscopy can identify alternative etiologies of LPS. Esophagoscopy can demonstrate conclusive reflux evidence, but diagnostic yield is low. pH-impedance monitoring, especially with hypopharyngeal sensors, assesses reflux mechanisms when investigating LPS, and can provide numbers of reflux episodes irrespective of acidity as well as proximal extent of these episodes. High-resolution manometry does not provide a diagnosis of LPRD but serves to rule out motility disorders that mimic LPS. Prolonged wireless pH monitoring may be appropriate when typical esophageal reflux symptoms coexist. The evaluation of LPS requires a paradigm shift away from reflexive attribution to reflux and toward a structured diagnostic approach that systematically considers alternative etiologies of LPS.

BACKGROUND: Throat and airway symptoms are common, but only a small proportion are reflux-related. The term "laryngopharyngeal reflux" has variable definitions in the literature and has been used to describe symptomatic patients with or without objective reflux, often leading to prolonged/unnecessary treatment trials.

PURPOSE: The San Diego consensus introduced the term laryngopharyngeal symptoms (LPS) to describe upper aerodigestive symptoms with potential relationship to reflux physiology, including cough, regurgitation, throat pain, throat clearing, excess phlegm, and hoarseness/voice change. This review describes presentation, health care burden and risk stratification of throat and airway symptoms in light of the San Diego consensus definitions and clinical approach. Laryngopharyngeal reflux disease (LPRD) requires objective evidence of pathologic reflux in addition to LPS. Importantly, LPS alone do not predict LPRD. While various validated patient-reported outcome instruments are available, only some are LPS/LPRD-specific, and all lack specificity for making a diagnosis of LPRD. These instruments may have value in tracking symptoms over time and post-treatment. Concurrent typical reflux symptoms may prompt empiric anti-reflux medication trials as initial therapy. Risk stratification scores have been developed for the purpose of directing upfront therapy for high-risk patients and investigation for intermediate/low-risk patients, but their clinical use needs further validation. Objective diagnosis of LPRD provides confidence in escalation of reflux interventions. Life-threatening long-term sequelae are infrequent in LPS/LPRD, although impact on quality of life and healthcare burden can be profound.

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.