So I invite the faculty back for our question and answer. And Srel, I'll start with you. There was a question about patients who have Botox for the treatment of achalasia, and if there's no improvement after that first treatment with Botox, would you abandon it at that point to move towards other therapies like pneumatic dilation and POEM, or would you try Botox again? Yeah, that's a good question. You're difficult. If there's no response after Botox, I often wonder, well, is this the right diagnosis? So depending on how their symptoms are and how much dysphagia they're having, I might just watch them over time and then repeat the manometry. And in this instance, you know, what does the manometry show? What does the barium esophagram show? Are there some indications of achalasia, but not a whole picture? Yeah, always hesitant to, if Botox doesn't work, to move on to a more permanent option. Great, thank you. And sticking with you for a minute, there's also a question about pH testing, either 24-hour or Bravo. Can you speak to the differences between the two? When would you use the 24-hour versus the Bravo and vice versa? So if I have a patient in the clinic that have, you know, symptoms that I don't think is GERD-related, you know, oftentimes they come in with a cough or some atypical symptoms, and my question is, well, did this patient have GERD, then I would take them off the PPI for 10 days, do a Bravo to really see do they have abnormal GERD or not. On the other hand, if there are patients that have ongoing symptoms despite PPI, I would do a manometry with a pH impedance study on the therapy to really help sort out, are these ongoing symptoms related to GERD, or do they have a hypersensitivity that they have developed? Thank you so much for that. Dr. Call, during the GERD presentation, I'm talking about empiric therapy for GERD. The recommendation was to trial a PPI first, and then if there's no response, discontinue the PPI and do an EGD. The question is, would you wait after discontinuing the PPI for a period of time before you do the EGD, or could it be done simultaneously if the schedule worked out that way? I think in general, there's no such recommendation to wait for a particular time. I think endoscopy can be done at any time after that because you're looking for the reasons for the non-response or partial response, or if there is any alarm symptoms. So that's not a problem, but we know that typically it will take some time for any endoscopic procedure nowadays to be scheduled. So whatever the natural sequence of events is, we go with that. Thank you, and I'll open this up to anybody. There's a couple of questions. I'll kind of try to combine them here. For patients who have GERD symptoms, they're doing well on PPI, should they be kept on PPIs lifelong, and what are those long-term concerns about PPI use? Cyril, do you want to tackle that one first? So the two main things I focus on for the long-term PPI side effects, I say, well, we worry about if people are traveling internationally, they're going to eat food that's not well prepared, they can get gastroenteritis, and I'm concerned about folks that are given antibiotics when I had those PPI for C. diff. Otherwise, you know, there's no cause and effect really found on those retrospective studies, but there are 50,000 people that they reviewed were on PPIs. Maybe they had more heart disease, diabetes, and so we really don't have a cause and effect here between PPIs and long-term side effects. I talk about alternatives, what are the potential side effects of a a nuisance complication, for instance, what is the, what are the, what are the potential risks of not treating the reflux? We think about peptic stricture, we think about Barrett's, but that can be a talk really on its own, and it's a, it's a hot topic. Completely agree. Dr. Callan, these patients who have been on a PPI, assuming that there is no Barrett's esophagus or red flag symptoms, they seem to be doing well. Any advice on how to try to taper people off PPIs before you commit them to that long-term therapy? Yeah, I think it's, this is again, as Sarah mentioned, it's a hot topic, it's a frequently recurring topic. You know, I've tried all kinds of combinations. I have reassured, number one, have reassured patients that, you know, if they are symptomatic and completely symptom-free on PPI and they go about their life and they're happy, you know, for the foreseeable future, they can continue taking it because they are PPI dependent, and that reassured them that, you know, the previous concerns around it are mostly dispelled. There remain a few concerns, such as those that Sarah mentioned, and around magnesium levels and, you know, all of that, but I think in general, you know, try to counsel them that, you know, if you need it, it's probably best to take it. Now, if somebody, number two, if somebody's insistent that they would like to trial an off-PPI regimen, you know, I think we can focus on H2 blockers as a surrogate with aggressive lifestyle modification, so that's an option for some people, and then we revisit that in a three to six-month time period and see how they've done, and the patient will be their best reporter in terms of how things have gone. Number three, I have also tried in some patients doing what we call alternate day PPI therapy. Now, this is not in any of the guidelines, but since the question was asked, how do I handle this? I've tried that, do a Tuesday-Thursday-Saturday regimen. I've included Saturday because we all party on Saturday, but some people have found that useful. I don't know to what degree that continues and whether they completely fall off or go back on a daily. There's no trial that we've done on this, but there's a variety of approaches we've used, and I have to say again that I think if you introduce the concept of lifestyle modification, especially weight loss, reducing central obesity, taking away alcohol and smoking to whatever extent you can, I think that you gain further traction and the importance and dependency of the PPI might be able to be modified to a great extent. Thank you. I'll add, and again, like Dr. Call said, no scientific evidence, but sometimes I will also alternate with famotidine. So try that H2RA in between the PPI, do that for a couple of weeks. If they're doing well, then I might stop the PPI and just do H2RA daily. So a bunch of things that I think we can try to see if we can get them off, but ultimately if their symptoms warrant it and they're well controlled on it, then I try to do the lowest effective dose. Caitlin, I'm going to come to you. A couple of questions for you. The first is, do you follow the same preoperative workup for endobariatrics as insurance requires for the surgical sleeve and bypass? And what's your peer coverage look like? Yeah. So as far as preoperative workup, like I mentioned, we want to make sure that they have truly attempted and failed these lifestyle therapies. And that's where us having another clinic that focuses just on lifestyle medications, pharmacotherapy, and the weight loss piece has been really helpful for our practice. So they've come into us, they've been seeing providers with them, they've failed that. But as far as proving to insurance what they've done, we're really not seeing insurance coverage for these procedures yet. So these are paid out of pocket. And again, it's hard to quote prices, but I would, around $9,000, but again, it's going to be heavily dependent on what facility they're getting it done in, as well as geographic location. Yeah. I'd have to add just a little comment here that, you know, as a chair of the reimbursement committee, I can say that the ASGE has and is going to continue to fight very hard to get reimbursement for not just the bariatric procedures, but several others, including the ESD procedure that I mentioned. So ASGE is at the forefront, along with the other sister societies, to get this squared away for all of us and for this space. And the data is there that it's effective and that they're safe. So hopefully. That is correct. I think the first step in getting a reimbursement code discussion started is to have high quality data. And we have that for many of these procedures. We had that for POEM, and that's how we got POEM reimbursable. We had that for TIFF, we got TIFF reimbursable, but now the next ones are for bariatrics and for endoscopic resection. Great. And Kaylin, sticking with you for a minute, there's also a question about what does long-term follow-up look like? And so are you increasing those visits over time? Do you continue to follow them over years? Yeah. So I think it's patient dependent. With our patients, they're continuing to see in the clinic that they were referring to, the clinic I was referring to, the lifestyle kind of weight loss clinic that we have associated with us. So they go back to them and see that clinic on a regular basis. They will have touch points with either Dr. Sullivan or her outpatient PA at two and four weeks post-procedure. And then it's kind of going to depend on how the patient's doing from there. Like I mentioned, our hope is that we see a lot of resolution in the accommodative symptoms. Of course, with the balloons, they're going to have to come back with us at six or eight months for removal, but it's going to depend on how the patients are managing their symptoms. But we do have them linked in with a separate clinic. There really isn't any good published data on what it should be or how frequently they should be established. Thank you. There's a couple of questions about the potassium competitive acid blockers and how we think that might change our treatment in GERD. Anybody want to speak to that? I said I'll let you take that first. I was just typing a response on it as well. Yeah, I don't have any experience. I'm very close to switching to that, but no experience so far. Yeah, I was just going to add, I think it's very early right now, and these just got approved in the U.S. very, very recently, actually just around the turn of the year over the holidays. And I think a couple of points, I think obviously cost will be a consideration, right? So anything new and fancy that's patented and you know, pretends to be the next big thing will likely have a price tag with it, but we'll see how that goes. The second point I think came out from the data on these was that the speed of healing erosive esophagitis seemed to be much faster compared to the standard therapy. So I think for particular cases, you know, it's likely to find a space, and I think as it gets more prevalent and the pricing is adjusted and we find those populations that benefit from it the most, that we'll see a trend of this kind of evolving. But you know, we have to realize that PPIs are highly effective therapies for those patients in whom the diagnosis is correct. And outside of anatomical constraints, lifestyle modifications that are not, you know, modified, PPIs are very effective. Actually, the rates of fundoplication surgery went down over the last few decades so much compared to back in the day when these agents were not around. So remains to be seen, but in my mind, I think the competitive acid blockers, potassium competitive acid blockers will find a space initially and then will evolve, you know, as we see its benefits. There's a great question that's asking about polone and whether this is becoming more common in the outpatient setting. And then if I'm understanding it correctly, it's asking about potential contraindications to it. And so I don't know, Dr. Kahl, if you or maybe Dr. Tawani want to speak to that one. Let me take that first. Yeah. I actually have no experience with polone personally, so I will have to defer. Yeah, so polone is now established. Polone is now established firmly in most communities. And yes, it, you know, typically the emphasis here is that it would be primarily an outpatient procedure. I can tell you that many practices are still observing these patients overnight. And some do stay, you know, for sometimes two nights or three, depending on the situation that you're dealing with. And that situation may not always be primarily a medical situation, maybe other issues that are there, but there are also some centers that have successfully and safely and effectively done this completely as an outpatient procedure, but then their experience and their, you know, approach to doing that is very, very specific and protocolized, and they're very good at what they're doing, and they have proven that it can be done completely as an outpatient without the overnight stay. That's one big box. The second box is that in some situations, as you know, now we have a reimbursable code for this. In the time that we didn't have a reimbursable code using the unlisted procedure code, sometimes the overnight stay actually added increased compensation for the facility. Not that that was done for that reason, but that was a side benefit of that as well. So there are some financial considerations, obviously, there are logistical considerations. Some of these patients are older, they have nobody around in the middle of the night if something happens, you know, the experience level of the endoscopist plays into it. So there's a variety of factors, but for the most part, it is expected and accepted that an overnight stay is kind of built into this procedure for now. Thank you. I don't want to burden you again, but anybody else in faculty, feel free to jump into this one. It's kind of a two-part question. The first one is for patients who have pH studies, and they're found to be positive, what are the thoughts on the possible causes of symptoms for those that are negative? So percentage that are found to be positive, and then of those that are negative, what do we think that those kind of atypical GERD type of symptoms could be caused from? Yes, I think the first part is, you know, I've seen some Bravo studies that we have sent patients to undergo with a negative study, and some actually have reflux esophagitis. Percentage-wise, I don't know. You know, other causes of symptoms in a negative Bravo, you think about, you know, is there, have they developed this hypersensitivity syndrome where they just really feel and on high alert, where they feel more than they should. So we see quite a bit of esophageal hypersensitivity, and that's often a good idea to do a Bravo off of medicine to see, really, do they have abnormal reflux? And when they push the button for symptom correlation, you'll be looking for, is there a correlation between their symptoms when they push the button, then that can help you kind of sort through that. But we don't have an option to really test the sensitivity of the esophagus. We really rule out abnormalities first. Yeah, I find these classifications to be challenging. You know, sometimes we'll try the tricyclic antidepressants and see if we can get some improvement in their symptoms at that point, but it really does become a bit of a challenge at that level. Anybody else have any comments towards that? Oh, I think, I think the pH studies, the impedance studies are very useful. They are not as often employed and used as I would like them to be. I do see that, you know, there are, especially in the post-COVID time, challenges around, you know, maintaining a high volume and efficient ancillary testing lab. In many places, staffing is an issue, turnover is an issue. These do require people to be trained in these procedures. And then, of course, the concept of patient compliance, especially with the overnight catheter stuff. But whenever indicated, they provide useful information and include or exclude certain disease diagnoses that you are contemplating. And once you have the information from these, I think it's important to keep an eye out for the other possibilities, such as I mentioned, including this motility, including other things that are at play. And so just being objective about the data and presenting that to the patient is the purpose of these studies. Hopefully they'll be done more often as we continue to emerge from COVID. There's a question here, Sarah, about metaplasia versus dysplasia that we said we'll answer live. The question is, metaplasia versus dysplasia, can you differentiate and discuss each as a risk for developing cancer? So I think it's well understood that metaplasia itself, let's say genetically, is less of a risk for cancer. And particularly in Barrett's, as I showed in one of the slides, Barrett's itself is a specialized type of metaplasia, and therefore is a precancerous condition with a relatively low risk of, let's say, 0.2% to 0.3% of development to cancer per year. But dysplasia, depending on which dysplasia you're looking at, so if you're looking at low-grade dysplasia, the risk is a little bit higher at 0.7% per year, but still not that high. But if you're looking at high-grade dysplasia, then the risk is tenfold more, that is 7% a year, or even higher in certain states. So there's a significant difference between metaplasia and dysplasia, especially in Barrett's, but also generally speaking. Yeah, there's another question about a patient who has LA-grade D esophagitis and has multiple bleeding esophageal ulcers, was worked up for iron deficiency anemia. Sounds like the bleeding was probably coming from those ulcers. Not a candidate for TIF, because of a large hiatal hernia, and the question is, what are some of the things that could be done to help to stop that bleeding definitively? Right, that's an interesting question. I noted that. I think we've seen this, as I mentioned, difficult under challenging scenarios in Barrett's treatment, or even esophageal ulcers without Barrett's esophagus. We have to really figure out what the cause of these ulcers are. The ulceration in the esophagus that is related to reflux disease should be medically manageable. If you have high-dose aggressive PPI therapy, remove some of the inciting factors that are there. But in some patients, if there is a significant anatomical issue, such as a large hiatal hernia, or severe dysmotility, or some underlying systemic illness that's creating these issues, then you have to address that, obviously. But if you have a straightforward acid reflux or erosive esophagitis-related ulceration, that should be handled medically, unless there is any indications for surgery. There are other types of esophageal ulcers that occur that are infectious in nature, such as those that are associated with CMV and herpes and such, and idiopathic ulcerations that occur in other disease states. Those are more difficult to manage, and obviously those are individuals with other issues, and then you have to address those. So it's not clear to me what the source of these ulcerations is in that patient, but in general, esophageal ulcerations should be manageable by PPI therapy and life-cell modification if no other inciting factors are present systemically. Sumit, I don't know if anybody else wants to comment on that or add. I would just add to, oh, sorry, considering other reasons for esophageal ulcers, you know, pill esophagitis or pill ulcers, if you can identify on the review of the medications if there is an inciting medication to make sure to consider discontinuation or alternative formulation. We see this most commonly with Alendronate or Fosamax. Now there's reasonable alternatives to change to. Go ahead, Cyril. No, that was the same I was going to ask. Great. Another question is for patients who come in on PPI therapy, they've been on it for many years, probably put on it by their primary care at some point, they may even be referred for other reasons, but when they come, you kind of see they're on a PPI, they have no complaint, no symptoms, never had an EGD, and the person asking it is just wondering thoughts on leaving them on long-term PPI without having an EGD, and they specify particularly in that older population. I'll say that when I see these patients, I do look at their medications first. Are they on Fosamax or some other medication that maybe was causing some dyspeptic symptoms? I asked them about their history, and if I can't identify any contraindication, I often will try to taper them off of it, but I'm curious what the other faculty think. I agree, Sarah. I think it is important to try to get a sense as to the history as to why that patient was started in the first place. A lot of these patients can't recall because they've been on it so many years, and so there's no obvious major risk factor in terms of NSAIDs, antiplatelet agents, other things, and I would consider trying to carefully stop the medication. This is Jill. HEA wrote a great article, I believe it was last year or the year before, on guidelines to deprescribing proton pump inhibitors. It's interesting. They really put a lot of responsibility back on the primary care provider to do that exact discrimination of work to see if they really needed to be on the proton pump inhibitor. I think, unfortunately or fortunately, those patients, once we write a prescription for them, then we're locked into them and they'll be coming back to see us each time for that refill. It's a great reference. I'll go ahead and find it and put it in the Q&A section so people have that for reference. Thanks, Jill. Yes, that's an excellent resource. Thank you, Jill. I think we have time for two more questions. The first one is, for patients who have gastric erosions and gastric ulcers, how long would we continue them on PPI? So it's important, we talked to trainees about it as well, is that gastric erosions are less serious of an inflammation, let's put it that way for lack of a better word. Erosions are more superficial, they tend to heal quicker, they are usually related to NSAID use or some other stress that's temporary and is relatively easier to manage. Ulcers, on the other hand, are deeper, tend to be more resistant to treatment in the short term compared to erosions, are more likely to bleed, are definitely more likely to perforate if they're large enough, and also have this relatively low percentage but real risk of them being malignant. So for those reasons, we take ulcers a little bit more seriously. And there is a built-in guideline to follow up on gastric ulcers even in the Western world at an 8 to 10-week mark to make sure that they are healing or have healed. But there's no such guideline for erosions appropriately, right? So gastric ulcers, a little bit longer treatment, again goes back to what's the underlying etiology, and a considerable percentage of these are related to H. pylori, and H. pylori testing is recommended in the setting of gastric ulcers. The association is less than it is with duodenal ulcers, but it's still a pretty significant association with H. pylori, NSAIDs are big culprits, and there are other causes as well. So hopefully that answers that question. In general, for erosions, I would say a six-week period would be more than enough. For ulcers, it could be anywhere between 8 to 10 weeks or longer, and I would say that the endoscopy will direct that as well, as well as what else is happening with the patient's other issues that may have contributed to that ulcer. Thank you. And the last question before we break for lunch, is there a certain age when a patient presents with new onset GERD symptoms that warrants an immediate EGD? Cyril, do you want to take it? Yes, I'm going to take that one. Yeah, I'm not sure the age is that much other than other warning signs for EGD. And in regards to the H2 blockers, you know, in my various practice, I use it frequently, especially when they are undergoing ablation at bedtime, and then give them a five-day drug holiday per month. But then beyond that, I'm not sure there's much of a role for H2 blocker, unless you take it from there, Vivek. Yeah, I think for age, I think for some reason, 45 seems to be a cutoff for bad things to happen in life, right? So I think it's the 21-year-old coming with acid reflux after a pizza party is a different situation than a 79-year-old coming with reflux-type dyspepsia and mild dysphagia. So I think it's a lot of clinical judgment goes into this as well, right? So I don't know that the guidelines say a particular age to jump at EGD or not. But it's a good question, and I think we kind of addressed this, you know, just looking at the patient, what the story is. But if you go back to the algorithm, I think most uncomplicated GERD would warrant a PPI trial, and then a re-evaluation short-term, whether there's a need for endoscopy. Yeah, I think that's where that history really comes in. Can you identify a trigger on it? Are there any red flags? Do they have acute anemia? Is anything else going on that's helping us to kind of think through that a little bit? Thank you all. These were really wonderful questions. We appreciate all the engagement.

gastroesophageal reflux disease

GERD management

Botox for achalasia

pH testing methods

long-term PPI use

potassium-competitive acid blockers