Society: AGA

Background: Tools predicting incident esophageal adenocarcinoma (EAC) and gastric cardia adenocarcinoma (GCA) that can be automated in electronic health records (EHRs) to guide screening decisions are needed. However, EHRs often have missing data for smoking, body mass index (BMI), and gastroesophageal reflux disease (GERD) which are important factors used by currently validated tools (Trøndelag Health [HUNT] and Kunzmann). We aimed to accurately predict EAC/GCA even with missing data using machine learning.
Methods: We performed retrospective analyses in the Veterans Health Administration (VHA) Corporate Data Warehouse among Veterans with ≥1 encounter between 2005 and 2018. Cases diagnosed with EAC/GCA were identified in the VHA Central Cancer Registry. The index date was the date of diagnosis for cases and randomly selected for controls. We collected prescriptions, laboratory results, and International Classification of Diseases diagnoses 1 to 5 years prior to index. We randomly divided the cohort into training (50%), preliminary validation (25%), and testing (25%). In the preliminary validation set, simple random sampling imputation and extreme gradient boosting machine learning were most accurate. In the test set, we compared the final model, the Kettles Esophageal and Cardia Adenocarcinoma predictioN (K-ECAN) Tool, to HUNT, Kunzmann, and published guidelines. To simulate a non-VHA population, we randomly under-sampled males. We ranked the proportion of the total gain in the loss function and the mean Shapley Additive Explanations for each variable.
Results: We identified 8,430 cases of EAC, 2,965 of GCA, and 10,256,887 controls. The mean age was 59.6 years, 92% were male, 80% white, and mean BMI 29.3 kg/m². In the test set, K-ECAN was well calibrated (Figure 1) and had better discrimination (area under the receiver operating characteristics curve [AUC] = 0.77) than HUNT (AUC = 0.68), Kunzmann (AUC = 0.64), or guidelines (Figure 2). Using only data from 4-5 years prior to index slightly diminished its accuracy (AUC = 0.75). Under-sampling men to simulate a non-VHA population, the AUCs of HUNT and Kunzmann improved, but K-ECAN was still most accurate (AUC = 0.85, Figure 2). The most important variables influencing K-ECAN included 4 known risk factors (age, race, sex, BMI) and 9 novel (COPD, greater Hct, lower HDL, greater LDL, lower serum CO₂, lower Na, lower BUN, lower ALT, and greater WBC). While GERD was strongly associated with EAC, it only contributed a small proportion of gain in information.
Conclusions: We developed and internally validated a novel prediction tool for incident EAC/GCA using EHR data. K-ECAN identifies individuals who are at increased risk for EAC/GCA ≥ 3 years in advance and is more accurate than published guidelines. Further work is needed to validate K-ECAN outside VHA and to assess how best to implement it within EHRs.

<b>Figure 1. Calibration Plot</b><br /> Predicted and observed risks are the cumulative incidences per 100,000 individuals in the testing set over the 14 years of ascertainment. Each dot represents 2% of the testing set (51,398 individuals).

Figure 1. Calibration Plot
Predicted and observed risks are the cumulative incidences per 100,000 individuals in the testing set over the 14 years of ascertainment. Each dot represents 2% of the testing set (51,398 individuals).

<b>Figure 2. Receiver Operating Characteristic Curves.</b><br /> <b>Panel A: Entire Testing Set. </b>AUCs [95% CIs] are displayed in parentheses.<br /> <b>Panel B: Simulated non-VHA Population</b><br /> Because Kunzmann and HUNT were both developed in populations that were roughly 50% male and both rely heavily on sex for classifying risk, this analysis simulated a non-VHA population by using all available female controls and cancer cases and under-sampled men by including a random selection of an equal number of male controls as female controls and a random sample of male cancer cases to match the expected odds ratio of male sex of 8.33 in the US population.<br /> ACG: American College of Gastroenterology, ACP: American College of Physicians, AGA: American Gastroenterological Association, ASGE: American Society for Gastrointestinal Endoscopy, BSG: British Society of Gastroenterology, ESGE: European Society for Gastrointestinal Endoscopy, HUNT: Trøndelag Health, VHA: Veterans Health Administration

Figure 2. Receiver Operating Characteristic Curves.
Panel A: Entire Testing Set. AUCs [95% CIs] are displayed in parentheses.
Panel B: Simulated non-VHA Population
Because Kunzmann and HUNT were both developed in populations that were roughly 50% male and both rely heavily on sex for classifying risk, this analysis simulated a non-VHA population by using all available female controls and cancer cases and under-sampled men by including a random selection of an equal number of male controls as female controls and a random sample of male cancer cases to match the expected odds ratio of male sex of 8.33 in the US population.
ACG: American College of Gastroenterology, ACP: American College of Physicians, AGA: American Gastroenterological Association, ASGE: American Society for Gastrointestinal Endoscopy, BSG: British Society of Gastroenterology, ESGE: European Society for Gastrointestinal Endoscopy, HUNT: Trøndelag Health, VHA: Veterans Health Administration

Introduction: Eosinophilic esophagitis (EoE) is a rare, chronic disease characterized by infiltration of eosinophils (eos) into the esophagus and symptoms related to esophageal dysfunction, such as dysphagia. Benralizumab, an eos-depleting anti-IL-5Rα monoclonal antibody, reduced eos in the esophagus in smaller studies and may be effective in EoE.
Methods: MESSINA (NCT04543409) was a phase 3, randomized (1:1), double-blind, placebo-controlled study evaluating benralizumab 30 mg subcutaneously every 4 weeks. Patients were 12-65 years with symptomatic (i.e., dysphagia) and histologically active EoE (≥15 eos/high-power field [hpf] on ≥2 esophageal levels); stable standard-of-care therapies were allowed. Dual primary endpoints were proportion of patients with histologic remission (≤6 eos/hpf) and change from baseline (CFB) in Dysphagia Symptom Questionnaire (DSQ) score at Week 24. Key secondary endpoints included percentage CFB in peak tissue eos and absolute CFB in Eosinophilic Esophagitis Histology Scoring System (EoE-HSS) grade and stage scores and Endoscopic Reference Score (EREFS). Symptoms were also assessed using the Eosinophilic Esophagitis Daily Dysphagia Diary (EoE-3D) and the Patient Global Impression of Severity (PGI-S). Selected patients underwent a sub-study with additional endoscopies and biopsies at Weeks 4 & 12 to understand the time course and impact of tissue eos depletion.
Results: A total of 210 patients (103 benralizumab; 107 placebo) were randomized and received treatment. Baseline characteristics were balanced between groups. At Week 24, a significantly higher proportion of patients on benralizumab vs placebo achieved histologic remission (87.4% vs 6.5%; p<0.0001); however, there was no difference in CFB in DSQ score between groups (–12.1 vs –15.1; p=0.1770) (Figure 1). Nominal statistical significance was observed for benralizumab vs placebo across the histology-based secondary endpoints (percentage CFB in peak tissue eos and EoE-HSS grade and stage scores) but not in CFB in EREFS at Week 24 (Figure 2). There were no differences between treatment groups for symptoms as measured by the EoE-3D and PGI-S. The rate of adverse events was 64.1% for patients on benralizumab and 61.7% for placebo. Benralizumab was well tolerated with no new safety signals. Additionally, of the 25 sub-study patients (11 benralizumab; 14 placebo), a higher proportion of patients on benralizumab vs placebo achieved histologic remission, and they had a higher percentage CFB in peak tissue eos at Weeks 4 & 12 than placebo, which was maintained to Week 24 (Figure 2).
Conclusions: Benralizumab reduced esophageal eos at 4 weeks and maintained this reduction to 24 weeks without a significant improvement in symptoms for patients with EoE vs placebo, suggesting that eos are not the primary driver of disease activity and symptomology.

Figure 1

Figure 2

Background: Multiple rapid swallows (MRS) has been proposed as a provocative test performed during high resolution manometry (HRM) to assess esophageal peristaltic reserve. Prior studies have shown that the vigor of peristalsis during MRS is inversely correlated with acid exposure time in nonerosive reflux disease, however the association between peristaltic reserve and extraesophageal reflux has not been elucidated.

Aim: To assess the role of esophageal contractile reserve, or MRS response, in the evaluation of patients with laryngopharyngeal reflux (LPR) symptoms.

Methods: Adults who underwent HRM and multichannel-intraluminal impedance-pH testing (MII-pH) off proton pump inhibitors for evaluation of LPR symptoms at a tertiary care center from 6/2019-10/2021 were included. The magnitude of MRS response was calculated by the ratio of MRS DCI post-contractions divided by the mean DCI from a series of single water swallows in supine position (MRS:SS DCI ratio). An intact MRS response was defined as MRS:SS DCI ratio >1. The proportion of reflux episodes reaching proximal extent was defined as the number of proximal reflux episodes divided by total reflux episodes. Univariate analyses were performed using Spearman’s correlation. Multivariate analyses were performed using general linear regression.

Results: 70 patients (68.7% female, mean age 56.9±14.0 years) were enrolled. Intact MRS response significantly correlated with fewer proximal reflux episodes (17.0±13.4 vs 23.0±19.0, p=0.0347) and greater complete bolus transit on HRM with impedance (63.2% vs 41.2%, p=0.0028) compared to absent reserve. The mean MRS DCI was inversely associated with proximal reflux episodes (R=-0.291, p=0.025) and total reflux episodes (R=-0.281, p=0.031). The magnitude of MRS response also inversely correlated with proximal reflux episodes (R=-0.25, p=0.045) and proportion of reflux episodes reaching proximal extent (R=-0.291, p=0.025). On multivariate analyses adjusting for age, sex, body mass index, smoking, and percent of ineffective swallows, an intact MRS response remained independently associated with fewer proximal and total reflux episodes and greater complete bolus clearance (Figure 1A). The mean MRS DCI also independently correlated with fewer proximal and total reflux events, as well as lower proportion of reflux episodes reaching proximal extent (Figure 1B).

Conclusion:
An intact MRS response is independently associated with decreased proximal reflux and greater complete bolus transit. The magnitude of MRS response also correlated with decreased proximal reflux and lower proportion of reflux events reaching the proximal esophagus. Esophageal contractile reserve may contribute to the protective mechanism against proximal migration of refluxate by improved clearance. Provocative measures such as MRS may have relevance in the evaluation of patients with LPR symptoms.

Introduction: We have implicated polyamines and their metabolism during Helicobacter pylori infection in gastric cancer. Notably, the polyamine spermine is back-converted to spermidine (Spd) by spermine oxidase (SMOX) and generates H₂O₂ and the reactive aldehyde acrolein. We have shown that H. pylori infection increases SMOX expression in human and mouse tissues and that infected C57BL/6 Smox^–/– mice exhibit decreases in gastric Spd, gastritis, and β-catenin activation. Our goal was to determine if increased SMOX expression during H. pylori infection leads to gastric cancer development using a molecular approach.
Methods: C57BL/6 Smox^–/– mice were backcrossed to the FVB/N background and then crossed to transgenic FVB/N insulin-gastrin (INS-GAS) mice, which overexpress the human gastrin gene and develop dysplasia and intramucosal carcinoma (IMC) with H. pylori infection. WT and Smox^–/– INS-GAS mice were infected with H. pylori PMSS1 for 8 weeks. Mice were also given 14 mM Spd in their drinking water beginning 1 week after infection. Histology was analyzed by H&E staining. Immunohistochemistry for Ki67 and quantification (10 high power fields/mouse) were used to assess proliferation. Expression of RNA was quantified by real-time PCR. Concentrations of gastric polyamines (nmol/mg protein) and acrolein (pmol/mg protein) were assessed by LC/MS.
Results: We confirmed that Smox was not expressed in the stomachs of INS-GAS mice with Smox deletion (P=0.0059 vs. WT). In addition, spermidine levels in the gastric tissues of Smox^–/– INS-GAS mice were significantly reduced (11.6 ± 0.7; n=5) compared to WT mice (17.2 ± 0.7; P=0.0079). We found a significant reduction in the extent of dysplasia and cancer after 8 weeks in the infected Smox^–/– INS-GAS mice (18.6 ± 3.8%; n=29) compared to the infected WT mice (39.5 ± 6.2%; n=21; P=0.0083). Only 2 out of 29 infected Smox^–/– INS-GAS mice exhibited IMC (6.9%), compared to 11 out of 21 in the infected WT INS-GAS mice (52.4%; P=0.0012). In parallel, acrolein synthesis in infected INS-GAS mice was significantly reduced with Smox deletion (919.6 ± 87.2, n=3 vs. WT 1238 ± 56.3, n=3; P=0.0479). Spd supplementation did not reverse the phenotype seen in the Smox^–/– mice. Since Ki67 is strongly associated with tumor cell growth, we assessed its expression and found that infected Smox^–/– INS-GAS mice displaying LGD exhibited less positive Ki67 epithelial cell nuclear staining (271.9 ± 18.6; n=5) compared to infected WT animals with IMC (380.0 ± 41.2; n=3; P=0.0113).
Conclusion: We observed that the deletion of Smox prevents acrolein synthesis and IMC development in H. pylori-infected INS-GAS mice. We envision novel therapies to alter SMOX-driven dysregulation of polyamine metabolism and thus reduce the burden of chronic gastritis progression to gastric cancer in H. pylori-infected patients.

Background: High-dose dual therapy (HDDT) with amoxicillin and proton-pump inhibitor has been recommended as one of the standard regimens for H. pylori eradication in most treatment guidelines. However, a lower efficacy of HDDT has been reported in some western countries which we speculated to be impacted by high acid food intake (DDW2021). A recent study shows colloid bismuth subcitrate may impede proton entry into H. pylori and increase the efficacy of ampicillin. We, therefore, hypothesize that the addition of colloid bismuth to HDDT (Bis-HDDT) would enhance the efficacy of HDDT and minimize the impact of high acid diet.
Aim: To compare the efficacy, adverse events, and compliance of HDDT, Bis-HDDT, and modified bismuth quadruple therapy (AM-BQT) as first-line regimens for H. pylori eradication.
Methods: A total of 436 patients with H. pylori infection were recruited. All patients underwent endoscopy with biopsy and culture for histological and microbiological evaluations before treatment. Patients were randomized to receive one of these three regimens for 14 days: (A) HDDT (rabeprazole 20 mg qid and amoxicillin 750 mg qid), (B) Bis-HDDT (rabeprazole 20 mg qid + amoxicillin 750 mg qid + tripotassium dicitrate bismuthate 300 mg qid), (C) AM-BQT (rabeprazole 20 mg bid + tripotassium dicitrate bismuthate 600 mg bid + amoxicillin 1000 mg bid + metronidazole 500 mg tid). All patients completed a standardized questionnaire including dietary habits, adverse events, and drug compliance. E-tests were used to determine antibiotics resistance. CYP 2C19 genotypes were analyzed by PCR-RFLP. Four to eight weeks after completing the course of therapy, H. pylori infection status was examined by C¹³-urea breath tests.
Results: The ITT eradication rates were 85.6% (125/146; 95% CI 79.9-91.3) with HDDT, 95.9% (139/145; 92.6-99.1) with Bis-HDDT, and 89.7% (130/145; 84.7-94.6) with AM-BQT, respectively. The PP eradication rates were 88.7% (83.4-93.9), 97.2% (94.4-99.9), and 92.1% (87.7-96.6), respectively. The efficacy was significantly higher in Bis-HDDT compared to HDDT, p<0.01. Adverse event rates were 22%, 28%, and 39%, respectively, and significantly higher in AM-BQT when compared to HDDT (p<0.01). The resistance rates to amoxicillin, metronidazole, clarithromycin, levofloxacin, and tetracycline were 1.2%, 35.8%, 19.8%, 31.2%, and 0.2%, respectively. Resistance to metronidazole and poor compliance were associated with a reduced eradication rate in AM-BQT group while frequent acidic food intake during treatment was associated with therapeutic failure in HDDT group.
Conclusion: Bis-HDDT achieves a higher H. pylori eradication rate compared to HDDT and the enhanced therapeutic efficacy was not impacted by antibiotic resistance or high acid food intake. Our finding supports the use of Bis-HDDT as a potential first-line or rescue therapy for H. pylori infection.

Background: Three days of high-dose intravenous (IV) proton-pump inhibitor (PPI) following endoscopic hemostasis of high-risk peptic ulcer bleeding has been a standard recommendation to prevent rebleeding. However, hospitalization is required for drug administration. The higher potency of acid-suppressive medication, a potassium-competitive acid blocker- Vonoprazan, is a tantalized alternative given its oral preparation and potency. Nonetheless, the effect of Vonoprazan on peptic ulcer rebleeding prevention is yet to be explored.

Objective: This study aimed to compare the efficacy of Vonoprazan and high-dose IV PPI in preventing high-risk peptic ulcer rebleeding after successful endoscopic hemostasis.

Methods: This is a randomized, open-label, multicenter, non-inferiority trial. Patients with high-risk stigmata peptic ulcer bleeding, defined as Forrest classification Ia, Ib, IIa, and IIb, were recruited from 6 secondary- and tertiary-care centers. After completion of endoscopic hemostasis, participants were randomized 1:1 to receive either Vonoprazan (20 mg twice daily orally for 3 days, then 20 mg once daily for 28 days) or PPI (pantoprazole 80 mg IV bolus followed by an 8 mg per hour infusion over 72 hours, then omeprazole 20 mg twice daily for 28 days). The primary outcome was rebleeding within 30 days. Secondary outcomes, including rebleeding within 3 and 7 days, all causes and bleeding-related mortality within 30 days, rate of rescue therapy, blood transfusion, length of hospital stay, and safety, were collected.

Results: 174 patients were recruited, and 166 completed the study. Demographic data, including; age, gender, comorbidity, antithrombotic usage, clinical presentations, the severity of bleeding, endoscopic characteristics, and stage of ulcers, were comparable among the two groups. In the intention-to-treat (ITT) analysis, the rates of 30-day rebleeding in Vonoprazan and PPI groups were 4.5 % (4/88) and 9.3% (8/86), respectively; non-inferiority (within the margin of 10%) of Vonoprazan to PPI was confirmed (risk difference = -4.76; 95% CI = -12.28, 2.77; P = 0.0005). The rebleeding rate at days 3 and 7 of the Vonoprazan group remained non-inferior to the PPI groups (P = 0.0001 and P = 0.0006, respectively). Total blood transfusion and post-endoscopy blood transfusion were lower in the Vonoprazan group [differences of -0.80 unit (95%CI = 0.03-1.56), p=0.042 and -0.56 unit (95%CI = 0.04-1.09), p=0.034, respectively]. The all-cause mortality rate, bleeding-related mortality rate, rescue therapy rate, length of hospital stays, and adverse events were comparable between the two groups.

Conclusion: Vonoprazan was not inferior to PPI in preventing rebleeding within 30 days in patients with high-risk peptic ulcer bleeding after receiving endoscopic hemostasis.

Nonthalee Pausawasdi

Faculty of Medicine Siriraj Hospital, Mahidol University

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