Then and Now: A ‘lifetime’ of advancement in upper GI tract

Fifteen years is a lifetime for the advancement of medical research. This seems particularly true for upper GI tract disorders.

In 2007, eosinophilic esophagitis was a rare disease; limited clinical data were available describing the symptoms, demographic characteristics, and endoscopic findings. Treatment was guided mostly by uncontrolled patient series for topical steroids and comprehensive diet exclusion therapy. Today, the molecular, genetic, and evolving microbiome’s contributions to EoE are being elucidated. EoE is recognized as one of the most common diseases in our practice, and rigorously performed controlled trials of steroids and biologics (including Food and Drug Administration–approved dupilumab) guide our treatment. Diet has also become easier with the identification of a single food antigen as the cause in 40% of EoE patients. The most pressing need is for a test that’s reliable and less invasive than endoscopy to assess and monitor treatment.

Barrett’s esophagus was of great concern 15 years ago and has surged in importance because of the increasing incidence of Barrett’s and esophageal adenocarcinoma, likely emphasized by the obesity epidemic. Sadly, survival with esophageal adenocarcinoma has changed little because most patients present with advanced stages. Multiple studies are questioning guideline recommendations because of their low yield and high expense. Fortunately, a range of easier screening tools is being tested, including sponge on string devices, video capsules, transnasal endoscopy, and the electronic “nose.” These can provide more widespread screening in broader populations of patients at risk who may lack heartburn or classic demographics. In 2007 there was little endoscopic therapy; now, the gastroenterologist has a robust armamentarium with multiple methods for mucosal ablation and resection achieving cure and sparing the patient an esophagectomy. Tissue biomarkers continue to be elucidated and are being applied to clinical practice.

For esophageal motility disorders, manometric data were obtained through a primitive water-infused system. With high-resolution manometry, the Chicago Classification, and impedance planimetry, our ability to precisely define, understand, and treat these disorders has been greatly enhanced.

In prior decades, the association of H. pylori to gastric cancer was noted but landmark trials and meta-analyses have strongly linked eradication of H. pylori with reduction in gastric cancer. These include broad population studies from Taiwan and the U.S. Veterans Health Administration, as well as a Cochrane review. These data have reinforced the need to search for and eradicate H. pylori infection. Although antibiotic resistance is rampant, newer antibiotic combinations including nitazoxanide, levofloxacin, rifabutin, and tinidazole have been proven effective. Potassium-competitive acid blockers may also augment effective eradication.

Endoscopy itself is one of the greatest areas of advancement in upper GI disease since 2007. What was once limited to biopsy, removal of polyps, and control of gastrointestinal bleeding, now has a breathtaking range of diagnostic and therapeutic capabilities. Who could imagine being able to perform bariatric procedures, create a gastrojejunostomy, treat a Zenker’s diverticulum, or drain extraluminal abscesses through an endoscope? With description of the technique of submucosal tunneling, endoscopic mucosal resection has been extended to submucosal dissection for more advanced cancers and benign tumors. This technique has also revolutionized the treatment of achalasia with peroral endoscopic myotomy, a procedure found equivalent to laparoscopic myotomy in controlled trials. Finally, artificial intelligence has taken endoscopic imaging by storm, and the accuracy with which we will diagnose premalignant lesions of the esophagus and stomach should significantly increase our abilities to prevent and treat early cancers.

Dr. Katzka is professor of medicine at Columbia University, New York. He reports consulting for Takeda and Celgene.

This article was updated July 7, 2022.

Fifteen years is a lifetime for the advancement of medical research. This seems particularly true for upper GI tract disorders.

In 2007, eosinophilic esophagitis was a rare disease; limited clinical data were available describing the symptoms, demographic characteristics, and endoscopic findings. Treatment was guided mostly by uncontrolled patient series for topical steroids and comprehensive diet exclusion therapy. Today, the molecular, genetic, and evolving microbiome’s contributions to EoE are being elucidated. EoE is recognized as one of the most common diseases in our practice, and rigorously performed controlled trials of steroids and biologics (including Food and Drug Administration–approved dupilumab) guide our treatment. Diet has also become easier with the identification of a single food antigen as the cause in 40% of EoE patients. The most pressing need is for a test that’s reliable and less invasive than endoscopy to assess and monitor treatment.

Barrett’s esophagus was of great concern 15 years ago and has surged in importance because of the increasing incidence of Barrett’s and esophageal adenocarcinoma, likely emphasized by the obesity epidemic. Sadly, survival with esophageal adenocarcinoma has changed little because most patients present with advanced stages. Multiple studies are questioning guideline recommendations because of their low yield and high expense. Fortunately, a range of easier screening tools is being tested, including sponge on string devices, video capsules, transnasal endoscopy, and the electronic “nose.” These can provide more widespread screening in broader populations of patients at risk who may lack heartburn or classic demographics. In 2007 there was little endoscopic therapy; now, the gastroenterologist has a robust armamentarium with multiple methods for mucosal ablation and resection achieving cure and sparing the patient an esophagectomy. Tissue biomarkers continue to be elucidated and are being applied to clinical practice.

For esophageal motility disorders, manometric data were obtained through a primitive water-infused system. With high-resolution manometry, the Chicago Classification, and impedance planimetry, our ability to precisely define, understand, and treat these disorders has been greatly enhanced.

In prior decades, the association of H. pylori to gastric cancer was noted but landmark trials and meta-analyses have strongly linked eradication of H. pylori with reduction in gastric cancer. These include broad population studies from Taiwan and the U.S. Veterans Health Administration, as well as a Cochrane review. These data have reinforced the need to search for and eradicate H. pylori infection. Although antibiotic resistance is rampant, newer antibiotic combinations including nitazoxanide, levofloxacin, rifabutin, and tinidazole have been proven effective. Potassium-competitive acid blockers may also augment effective eradication.

Endoscopy itself is one of the greatest areas of advancement in upper GI disease since 2007. What was once limited to biopsy, removal of polyps, and control of gastrointestinal bleeding, now has a breathtaking range of diagnostic and therapeutic capabilities. Who could imagine being able to perform bariatric procedures, create a gastrojejunostomy, treat a Zenker’s diverticulum, or drain extraluminal abscesses through an endoscope? With description of the technique of submucosal tunneling, endoscopic mucosal resection has been extended to submucosal dissection for more advanced cancers and benign tumors. This technique has also revolutionized the treatment of achalasia with peroral endoscopic myotomy, a procedure found equivalent to laparoscopic myotomy in controlled trials. Finally, artificial intelligence has taken endoscopic imaging by storm, and the accuracy with which we will diagnose premalignant lesions of the esophagus and stomach should significantly increase our abilities to prevent and treat early cancers.

Dr. Katzka is professor of medicine at Columbia University, New York. He reports consulting for Takeda and Celgene.

This article was updated July 7, 2022.

Fifteen years is a lifetime for the advancement of medical research. This seems particularly true for upper GI tract disorders.

In 2007, eosinophilic esophagitis was a rare disease; limited clinical data were available describing the symptoms, demographic characteristics, and endoscopic findings. Treatment was guided mostly by uncontrolled patient series for topical steroids and comprehensive diet exclusion therapy. Today, the molecular, genetic, and evolving microbiome’s contributions to EoE are being elucidated. EoE is recognized as one of the most common diseases in our practice, and rigorously performed controlled trials of steroids and biologics (including Food and Drug Administration–approved dupilumab) guide our treatment. Diet has also become easier with the identification of a single food antigen as the cause in 40% of EoE patients. The most pressing need is for a test that’s reliable and less invasive than endoscopy to assess and monitor treatment.

Barrett’s esophagus was of great concern 15 years ago and has surged in importance because of the increasing incidence of Barrett’s and esophageal adenocarcinoma, likely emphasized by the obesity epidemic. Sadly, survival with esophageal adenocarcinoma has changed little because most patients present with advanced stages. Multiple studies are questioning guideline recommendations because of their low yield and high expense. Fortunately, a range of easier screening tools is being tested, including sponge on string devices, video capsules, transnasal endoscopy, and the electronic “nose.” These can provide more widespread screening in broader populations of patients at risk who may lack heartburn or classic demographics. In 2007 there was little endoscopic therapy; now, the gastroenterologist has a robust armamentarium with multiple methods for mucosal ablation and resection achieving cure and sparing the patient an esophagectomy. Tissue biomarkers continue to be elucidated and are being applied to clinical practice.

For esophageal motility disorders, manometric data were obtained through a primitive water-infused system. With high-resolution manometry, the Chicago Classification, and impedance planimetry, our ability to precisely define, understand, and treat these disorders has been greatly enhanced.

In prior decades, the association of H. pylori to gastric cancer was noted but landmark trials and meta-analyses have strongly linked eradication of H. pylori with reduction in gastric cancer. These include broad population studies from Taiwan and the U.S. Veterans Health Administration, as well as a Cochrane review. These data have reinforced the need to search for and eradicate H. pylori infection. Although antibiotic resistance is rampant, newer antibiotic combinations including nitazoxanide, levofloxacin, rifabutin, and tinidazole have been proven effective. Potassium-competitive acid blockers may also augment effective eradication.

Endoscopy itself is one of the greatest areas of advancement in upper GI disease since 2007. What was once limited to biopsy, removal of polyps, and control of gastrointestinal bleeding, now has a breathtaking range of diagnostic and therapeutic capabilities. Who could imagine being able to perform bariatric procedures, create a gastrojejunostomy, treat a Zenker’s diverticulum, or drain extraluminal abscesses through an endoscope? With description of the technique of submucosal tunneling, endoscopic mucosal resection has been extended to submucosal dissection for more advanced cancers and benign tumors. This technique has also revolutionized the treatment of achalasia with peroral endoscopic myotomy, a procedure found equivalent to laparoscopic myotomy in controlled trials. Finally, artificial intelligence has taken endoscopic imaging by storm, and the accuracy with which we will diagnose premalignant lesions of the esophagus and stomach should significantly increase our abilities to prevent and treat early cancers.

Dr. Katzka is professor of medicine at Columbia University, New York. He reports consulting for Takeda and Celgene.

This article was updated July 7, 2022.