Nigel Trudgill

@FrontGastro_BMJ @HasanHaboubi @Dominic_S_King There are excellent BSG guidelines on Barrett's oesophagus, and manometry and pH monitoring. We are working on eosinophilic oesophagitis guidelines currently. #fgdebate

The #fgdebate has already gone! Dr N Trudgill @NJEMCP, Dr @HasanHaboubi & Dr @Dominic_S_King any concluding remarks?

@FrontGastro_BMJ @HasanHaboubi @Dominic_S_King Thank you for participating in our debate. We hope we have demystified oesophageal manometry and reflux monitoring for you! #fgdebate

@FrontGastro_BMJ pH with impedance can be helpful here to establish aerophagia and supragastric belching if there is doubt. Showing patients their impedance tracings can help as part of the management #fgdebate

How should I approach the patient with excess belching? #fgdebate

@FrontGastro_BMJ This can be demonstrated to a patient by putting e.g. a pen between the teeth and the belching will stop (as air cannot be swallowed). #fgdebate

@leicdan @DrEmmaNash Absolutely agree - very unusual to have persistent GORD on reflux monitoring with taking BD PPI#fgdebate

@DrEmmaNash Sure #fgdebate @NJEMCP will give you the science, but low dose od PPI doesn't fully suppress the acid so if symptoms aren't resolving you don't know if it is because they are getting a homeopathic dose or because it isn't actually reflux. 30mg BD Lansoprazole, 40mg BD Omeprazole

This 👇 such an important step when first seeing patients with GORD symptoms to use a proper full dose of PPI

@ravmis81 We recommend pH/impedance testing not pH testing as more information, more reproducible and can define GORD phenotypes guiding treatment #fgdebate

Is impedance testing useful and for what indication? #fgdebate

@jamesbmaurice Significant co-morbidity and patient wishes more important than age in stopping Barrett's surveillance #fgdebate

at what age would people stop surveillance for #barretts? I think we're often scoping people who are far too old to benefit #fgdebate

@jamesbmaurice Endoscopic therapy for early cancer by EMR if remarkably safe and age should not necessarily be a limit to surveilalnce #fgdebate

@FrontGastro_BMJ Don’t’ forget other measures to try to lower oesophageal cancer risk in Barrett’s – stop smoking, avoid obesity, PPI therapy #fgdebate

How should I approach the patient with Barrett’s oesophagus? #fgdebate

@FrontGastro_BMJ This one question could have it’s own Frontline Debate. Lots of excitement about Barrett’s endotherapy but for me – in one word...Quality! #fgdebate

@jamesbmaurice @Jonathansegal85 All seem to give good long term results and safe just need an expert doing regularly #fgdebate

@NJEMCP @Jonathansegal85 could you give a few brief pros and cons for each, or which patient groups you might encourage towards which treatment? #fgdebate

What’s the data for poem? I know almost nothing about it-can you tell us more? #fgdebate

@jamesbmaurice @Jonathansegal85 Type 3 achalasia POEM best; types 2 and 1 responds well POEM/PD/lap myotomy - PD needs repeat but sedation, POEM ands Lap myotomy GA.

@UKGastroDr Twice daily PPI first, then consider six food elimination diet if dietician or swallowed steroid. Swallowed Steroid prior to dilatation if strictures and maintain.

Can I ask about treatment of eosinophilic oesophagitis? With and without stictures? #fgdebate

@Jonathansegal85 You then have to balance this result with the recent metanalysis which showed POEM to be better at 12-months at relieving dysphagia (93.5% v 91%) but these patients were more likely to have pathologic gastro-oesophageal reflux. #fgdebate

@Jonathansegal85 Also, retreatment with PD was considered a failure, but if it were not, the PD response rate would have improved to 76% #fgdebate

@Jonathansegal85 The PD technique used a lower maximal pressure (8 PSI) compared with a traditional maximum of 12 PSI, which has been demonstrated to be efficacious without an excessive risk for perforation and might have increased response to PD #fgdebate

@Jonathansegal85 The recent RCT comparing POEM with pneumatic dilatation (PD) generated enthusiasm for POEM but there are some factors that are being addressed in the current ongoing RCT. #fgdebate

@FrontGastro_BMJ EGJ outflow obstruction and absent contractility can both be due to achalasia – adjunctive testing during HRM with rapid drink challenge or food can reveal achalasia in these conditions and should be routine. #fgdebate

What is the significance of EGJ outflow obstruction and absent contractility on HRM? #fgdebate

@FrontGastro_BMJ EGJ outflow obstruction may be due to achalasia that does not meet diagnostic criteria, a mechanical cause (may be missed at endoscopy) or opiates. #fgdebate