At the Center for Gastrointestinal Motility at Brigham and Women’s Hospital (BWH), gastroenterologists are establishing new recommendations and protocols for the evaluation and care of patients with esophageal and motility disorders, including high-risk patients.
“We collaborate with specialists in many other disciplines, including pulmonology, otolaryngology, rheumatology, allergy and immunology, thoracic and general surgery, and nutrition, to deliver advanced care for patients with motility issues and significant co-morbid conditions, as well as develop approaches to evaluate and treat patients with new motility conditions that are becoming more prevalent,” said Robert Burakoff, MD, MPH, Clinical Chief of the Division of Gastroenterology, Hepatology, and Endoscopy at BWH.
Specialists in the Center recently led a retrospective cohort study of lung transplantation recipients who underwent pretransplant esophageal multichannel intraluminal impedance and pH testing (MII-pH) between 2007 and 2012. The study found that measures on MII-pH including prolonged bolus clearance, increased total distal reflux episodes, and increased total proximal reflux episodes were significantly associated with decreased time to early allograft injury and early acute rejection following lung transplantation (J Heart Lung Transpl 2015 Jan; 34(1): 26-35 DOI: http://dx.doi.org/10.1016/ j.healun.2014.09.005). Another study led by Center specialists determined that anti-reflux surgery before and soon after lung transplantation was associated with decreased early rejection compared to surgery later following transplantation (J Gastrointest Surgery 2015; in press.). Advanced anti-reflux procedures performed by surgeons at BWH include fundoplication and a new approach that places a rig of magnetic beads around the lower esophageal sphincter.
“There currently is no standard pre-transplant reflux assessment that is universally adopted,” said Walter W. Chan, MD, MPH, Director of the Center for Gastrointestinal Motility and senior author of the paper. “Our findings suggest that combined impedance and pH monitoring may be very valuable in pre-transplant evaluation and that aggressive early reflux therapy should be considered in patients with significant pre-transplant reflux.”
The Center is among few in the nation to offer specialized evaluation and management for adult patients with eosinophilic esophagitis, bringing together experts from gastroenterology, allergy and immunology, nutrition, and pathology to provide collaborative and coordinated care and establish a standardized practice protocol. The team recently published results of a study examining clinical predictors of response to proton pump inhibitor (PPI) therapy in patients with eosinophilic esophagitis (Gastroenterology 2013;144(5):S-495-6.) The study concluded that a history of abdominal pain and ulcers on EGD were associated with positive response to PPI therapy, while a history of dysphagia was a predictor for negative response to PPI therapy. The team also found that endoscopic features of eosinophilic esophagitis are associated with a history of food impaction (Gastrointest Endosc. 2013;77(5), Supplement May 2013.) and that higher mast cell densities were found in eosinophilic esophagitis, suggesting that mast cells may play an important role in the pathogenesis of the disease (Gastroenterology 2014;146(5):S-669.).
Supported by a grant from the American College of Gastroenterology, additional research in the Center is examining the factors associated with treatment outcome, underlying pathophysiology of the disease, and new diagnostic modalities – such as immunohistochemical staining – in the management of eosinophilic esophagitis. The multidisciplinary approach to evaluation and management of this increasingly common and complex disorder will also help facilitate efficient and patientcentered care.
“We are seeing more and more adult patients with eosinophilic esophagitis, which can lead to recurrent esophageal strictures, narrowing, and food impaction,” said Dr. Chan. “Our goal is to optimize the care of these patients through an innovative multidisciplinary approach to research, evaluation, and treatment.”
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