Video 1.

OBJECTIVES: To determine the ability of the reflux symptom index (RSI) to predict objective impedance and pH-probe testing, and to examine the relationship between disease-specific and general health status in patients diagnosed with laryngopharyngeal reflux (LPR).

METHODS: Adults presenting to a tertiary care academic center with a primary voice complaint completed the RSI and the Patient-Reported Outcomes Measurement Information System 10-item global health instrument (PROMIS). An RSI score ≥13 was considered abnormal. Objective testing for LPR was performed using hypopharyngeal-esophageal multichannel intraluminal impedance catheter with dual pH (HEMII-pH) testing; a positive test was defined as more than one pharyngeal impedance events over 24 hours. Spearman rho analyses were applied, and the sensitivity and specificity of the RSI to detect HEMII-pH findings were determined.

RESULTS: One hundred four patients underwent HEMII-pH testing. Mean scores were 16.7 (95%CI 15.1-18.3) for RSI. Sixty-three (60.6%) patients were diagnosed with LPR by HEMII-pH testing. RSI scores were moderately correlated with PROMIS physical (Spearman rho 0.43, P < 0.0001), social (Spearman rho 0.33, P < 0.0001) and mental health (Spearman rho 0.33, P < 0.0001) scores. The RSI has a sensitivity and specificity of 66.7% and 31.7%, respectively, for detecting pharyngeal events on HEMII-pH testing.

CONCLUSIONS: There is moderate sensitivity and lack of specificity of the RSI for detecting increased pharyngeal reflux events. Reflux-specific and general health status instruments are correlated. Further investigation could assess the diagnostic ability of RSI compared proximal reflux events on HEMII-pH, as well as whether health status instruments can be used to detect clinically meaningful change in the LPR population.

GOAL: The goal of this study was to compare the clinical presentations of esophagogastric junction outflow obstruction (EGJOO) with coexisting abnormal esophageal body motility (EBM) to isolated EGJOO.

BACKGROUND: The clinical significance and management of EGJOO remain debated, as patients may have varied to no symptoms. The effect of coexisting abnormal EBM in EGJOO is unclear. We hypothesized that a concomitant EBM disorder is associated with clinical symptoms of EGJOO.

STUDY: This was a retrospective cohort study of consecutive adults diagnosed with EGJOO on high-resolution impedance-manometry (HRIM) at 2 academic centers in March 2018 to September 2018. Patients with prior treatment for achalasia, foregut surgery, or evidence of obstruction were excluded. Subjects were divided into EGJOO with abnormal EBM per Chicago classification v3.0 and isolated EGJOO. Statistical analyses were performed using Fisher-exact or Student t test (univariate) and logistic or linear regression (multivariate).

RESULTS: Eighty-two patients (72% women, age 61.1±10.7 y) were included. Thirty-one (37.8%) had abnormal EBM, including 16 (19.5%) ineffective esophageal motility and 15 (18.2%) hypercontractile esophagus. Esophageal symptoms (heartburn, regurgitation, chest pain, dysphagia) were more prevalent among those with abnormal EBM (90.3% vs. 64.7%, P=0.01). On logistic regression adjusting for age, gender, body mass index, and opioid use, abnormal EBM remained predictive of esophageal symptoms (adjusted odds ratio [aOR] 7.51, P=0.007). On separate models constructed, HE was associated with chest pain (aOR 7.45, P=0.01) and regurgitation (aOR 4.06, P=0.046), while ineffective esophageal motility was predictive of heartburn (aOR 5.84, P=0.009) and decreased complete bolus transit (β-coefficient -0.177, P=0.04).

CONCLUSION: Coexisting abnormal EBM is associated with esophageal symptoms and bolus transit in patients with EGJOO.

BACKGROUND & AIMS: Chronic liver disease (CLD) represents a major global health burden. We undertook this study to identify the factors associated with adverse outcomes in patients with CLD who acquire the novel coronavirus-2019 (COVID-19).

METHODS: We conducted a multi-center, observational cohort study across 21 institutions in the United States (US) of adult patients with CLD and laboratory-confirmed diagnosis of COVID-19 between March 1, 2020 and May 30, 2020. We performed survival analysis to identify independent predictors of all-cause mortality and COVID-19 related mortality, and multivariate logistic regression to determine the risk of severe COVID-19 in patients with CLD.

RESULTS: Of the 978 patients in our cohort, 867 patients (mean age 56.9 ± 14.5 years, 55% male) met inclusion criteria. The overall all-cause mortality was 14.0% (n = 121), and 61.7% (n = 535) had severe COVID-19. Patients presenting with diarrhea or nausea/vomiting were more likely to have severe COVID-19. The liver-specific factors associated with independent risk of higher overall mortality were alcohol-related liver disease (ALD) (hazard ratio [HR] 2.42, 95% confidence interval [CI] 1.29-4.55), decompensated cirrhosis (HR 2.91 [1.70-5.00]) and hepatocellular carcinoma (HCC) (HR 3.31 [1.53-7.16]). Other factors were increasing age, diabetes, hypertension, chronic obstructive pulmonary disease and current smoker. Hispanic ethnicity (odds ratio [OR] 2.33 [1.47-3.70]) and decompensated cirrhosis (OR 2.50 [1.20-5.21]) were independently associated with risk for severe COVID-19.

CONCLUSIONS: The risk factors which predict higher overall mortality among patients with CLD and COVID-19 are ALD, decompensated cirrhosis and HCC. Hispanic ethnicity and decompensated cirrhosis are associated with severe COVID-19. Our results will enable risk stratification and personalization of the management of patients with CLD and COVID-19. Clinicaltrials.gov number NCT04439084.

Background and study aims  While argon plasma coagulation (APC) is the first-line treatment for gastric antral vascular ectasia (GAVE), endoscopic band ligation (EBL) has shown promising results. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness of EBL for the treatment of GAVE. Methods  Individualized search strategies were developed in accordance with PRISMA and MOOSE guidelines through September 1, 2020. Measured outcomes included endoscopic success (defined as GAVE eradication/improvement), change in hemoglobin, transfusion dependency, number of treatment sessions, adverse events, rebleeding, and bleeding-associated mortality. Outcomes were compared among studies evaluating EBL versus APC. Results  Eleven studies (n = 393; 59.39 % female; mean age 58.65 ± 8.85 years) were included. Endoscopic success was achieved in 87.84 % [(95 % CI, 80.25 to 92.78); I 2  = 11.96 %] with a mean number of 2.50 ± 0.49 treatment sessions and average of 12.40 ± 3.82 bands applied. For 8 studies comparing EBL (n = 143) versus APC (n = 174), there was no difference in baseline patient characteristics. However, endoscopic success was significantly higher for EBL [OR 6.04 (95 % CI 1.97 to 18.56; P  = 0.002], requiring fewer treatment sessions (2.56 ± 0.81 versus 3.78 ± 1.17; P  < 0.001). EBL was also associated with a greater increase in post-procedure hemoglobin [mean difference 0.35 (95 % CI 0.07 to 0.62; P  = 0.0140], greater reduction in transfusions required [mean difference -1.46 (95 % CI -2.80 to -0.12; P  = 0.033], and fewer rebleeding events [OR 0.11 (95 % CI, 0.04 to 0.36); P  < 0.001]. There was no difference in adverse events or bleeding-associated mortality ( P  > 0.050). Conclusions  EBL appears to be safe and effective for treatment of GAVE, with improved outcomes when compared to APC.

BACKGROUND AND AIM: Gastrointestinal (GI) symptoms have been reported with SARS-CoV-2 infection, but data on the prevalence and severity of GI symptoms in patients with cancer are limited. We sought to characterize the GI manifestations of coronavirus disease-19 (COVID-19) in oncology patients.

MATERIALS AND METHODS: We performed a multicenter cohort study of adult patients hospitalized with COVID-19 in 9 Massachusetts medical centers and identified those with an active malignancy. We evaluated the prevalence and severity of GI symptoms among hospitalized COVID-19 patients with cancer.

RESULTS: Of 395 hospitalized patients with COVID-19, 36 (9%) had an active malignancy. Of the 36 cancer patients, 23 (63%) reported ≥1 new GI symptom. The most prevalent symptoms were anorexia (12, 52%), diarrhea (9, 39%), and vomiting (8, 35%). GI symptoms were the initial symptom in 4/36 (11%) patients, were the predominant symptom in 5/36 (14%) patients, and were severe in 4/23 (17%) patients. Four of 5 patients with GI symptoms at presentation reported concurrent fever; notably 1 patient had no fever or respiratory symptoms. Twelve (33%) patients had elevations in liver transaminases at presentation; patients with elevated transaminases were more likely to have associated GI symptoms (83% vs. 54%, P=0.04).

CONCLUSIONS: Acute GI symptoms associated with COVID-19 are highly prevalent in hospitalized cancer patients and can occur as a presenting symptom without respiratory symptoms. Symptoms are severe in a small subset of patients.

BACKGROUND: The effect of immunosuppressive treatment for immune-mediated diseases on risk of the novel coronavirus disease 2019 (COVID-19) has not been established. We aimed to define the effect of targeted biologic and immunomodulator therapy on risk of COVID-19 in a multi-institutional cohort of patients with inflammatory bowel disease (IBD).

METHODS: We identified patients 18 years and older who received care for IBD at Partners Healthcare between January 2019 and April 2020. The primary outcome was development of COVID-19 defined as a positive polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2. Multivariable regression models were used to examine the effect of immunosuppression on risk of COVID-19 and its outcomes.

RESULTS: In a cohort of 5302 IBD patients, 39 (0.7%) developed COVID-19. There was no difference in age, sex, or race between IBD patients with and without COVID-19. The rate of COVID-19 was similar between patients treated with immunosuppression (0.8%) compared with those who were not (0.64%; P = 0.55). After adjusting for age, sex, race, and comorbidities, use of immunosuppressive therapy was not associated with an increased risk of COVID-19 (odds ratio, 1.73; 95% confidence interval, 0.82-3.63). The presence of obesity was associated with a higher risk of COVID-19 (odds ratio, 8.29; 95% confidence interval, 3.72-18.47). There were 7 hospitalizations, 3 intensive care unit stays, and 1 death. Older age and obesity but not immunosuppressive treatment were associated with severe COVID-19 infection.

CONCLUSIONS: The use of systemic immunosuppression was not associated with an increased risk of COVID-19 in a multi-institutional cohort of patients with IBD.