Category: 8. Health

Cystectomy is a major surgery that requires the removal of the bladder and the creation of a urinary diversion. It’s a component of treatment for many patients with bladder cancer and may be an option for patients with other conditions, like neurogenic bladder and fistula repair. Now, surgeons at Cleveland Clinic are increasingly using nerve-sparing techniques for cystectomy that preserve sexual function and quality of life without compromising cancer treatment.

“There’s been a shift in the urologic cancer community in terms of prioritizing quality-of-life outcomes without compromising cancer treatment,” says Nima Almassi, MD. “Historically, cystectomy has been performed with a wide resection to maximize oncologic treatment and avoid positive margins and cancer recurrence.”

Prospective studies have shown that patients generally report positive quality-of-life outcomes across most domains following cystectomy, with a few exceptions. Body image, especially for patients who need a stoma, urinary function, and sexual function tend to be areas where patients report a decreased quality of life. For men undergoing cystectomy, a wide (non-nerve sparing) resection will cause severe erectile dysfunction. Nerve-sparing cystectomy represents one method of potentially improving quality of life outcomes for men undergoing surgery.

Postoperative sexual outcomes in men and women

Urologic oncologists like Dr. Almassi say that many patients don’t need to sacrifice their sexual function because of treatment. For male patients undergoing cystectomy, erectile dysfunction (ED) is a very common side effect, but nerve-sparing cystectomy can help temper it.

The Cleveland Clinic team has also been focused on improving the bladder cancer experience in women, which includes evaluating similar nerve-sparing and organ-sparing techniques to preserve reproductive anatomy and obviate surgical menopause and sexual dysfunction. Prospective studies ongoing at Cleveland Clinic have shown that women who undergo vaginal-sparing cystectomy appear to have less prolapse than women, but the data are still early when it comes to sexual function.

Patient selection is key

Patients eligible for this type of surgery have a good baseline ED and are motivated to preserve it. Additionally, they must be free of specific disease characteristics that could complicate oncologic control, such as cancer abutting or involving the neurovascular bundle. Preoperative MRI imaging can guide patient selection.

Similarly, aggressive subtypes of bladder cancer with high risk of being locally advanced may not be suitable for a nerve-sparing surgical approach. “In this case, we would not recommend nerve-sparing out of concern it could compromise cancer control,” says Dr. Almassi.

A positive institutional experience

Nerve-sparing cystectomy requires the surgeon to dissect the neurovascular bundles off the bladder and prostate. “We have found that this has yielded much better erectile function in patients after surgery without compromising oncologic outcomes. For all patients who we’ve deemed eligible for this, we have not had positive surgical margins,” notes Dr. Almassi.

Using validated questionnaires, patients report their erectile function about every three months for a year. The team is finding that around six months postoperatively, most patients experience only mild ED, and that remains consistent. Even three months following the surgery, he says, patients typically are recovering well but are often not yet sexually active at this time.

“Most patients’ erectile function ends up returning to within three points on a 25-point scale from their preoperative baseline, suggesting erectile function can recover to similar levels to what it was before surgery.”

Part of the center’s protocol is starting patients on tadalafil, and they may still be using it when function is assessed postoperatively, Dr. Almassi remarks.

The Cleveland Clinic team opts for a robotic approach, owing to better visualization and access to the neurovascular bundle. However, performing this technique with open surgery is also achievable in experienced hands. “The way the field has transitioned, fewer surgeons in high volume centers perform open cystectomy,” he explains.

A call for screening candidates

“Optimizing quality of life for our patients is a major focus for our group. Studies show that sexual function declines after cystectomy. We have an opportunity to safely personalize a surgical technique in select patients to help preserve functional outcomes,” says Dr. Almassi. “We certainly encourage our colleagues to consider screening patients who may be good candidates.”

Due to time constraints and surging patient volumes, elderly emergency department patients are not routinely screened for delirium. A Cleveland Clinic geriatrician is making a case for why that should change, however, showing that even a 60-second test can accurately detect confused patients who may otherwise slip through the cracks.

Although delirium screenings are routine for older patients being admitted to the hospital or ICU, they are not yet commonplace in emergency departments, explains Saket Saxena, MD, Codirector of the geriatric emergency department at Cleveland Clinic. “Unfortunately, elderly patients who present with acute conditions often wait hours or days to be fully screened for delirium,” he says, “However, we know that recognizing the disorder early can significantly improve patient care.”

Dr. Saxena is the principal author of a recent study that evaluated 4AT, a bedside screening tool for delirium in emergency department patients. The study found that 4AT, which takes around one minute to complete, can detect delirium with a positivity rate of 14%, a number that is consistent with the general population. Interestingly, about 7% of those determined to have delirium did not initially present with a complaint of altered mental status.

Combatting diagnostic challenges

When people imagine delirium, he notes, they often think of patients who are agitated or even aggressive – getting out of bed, struggling or pulling out their lines. However, a significant number of these patients have hypoactive delirium, a condition that prompts a quiet, docile demeanor. Although these patients may not appear obviously confused, they will sleep a lot, eat little and decline to actively participate in conversations or therapies.

“That is the type of delirium that often gets missed when patients are transitioned from emergency to inpatient care,” explains Dr. Saxena.

Although hypoactive delirium can be particularly difficult to identify because it can easily be explained away by simple fatigue or “not being hungry,” the disorder can have a significant impact on patient outcomes.

“Nutritional status cannot be maintained if the patient isn’t eating,” explains Dr. Saxena. “And if the patient isn’t getting out of bed, the chances of debilitation rise; muscular strength is lost, and the risk of blood clots in the legs increases. All of these factors play a role in how these patients perform during hospitalization and beyond.” In fact, studies have found that patients with delirium have a length of stay that’s twice as long as those without, he notes.

Historically, Cleveland Clinic has used the Confusion Assessment Method to screen patients for delirium in the hospital or ICU; however, no method has been used to formally assess delirium in the emergency department. In preparation for the study, Dr. Saxena worked with triage nurses to identify the delirium screening tool they were most comfortable using in an emergency setting. The 4AT method, which was deemed easy to learn and administer, was chosen as the preferred rapid delirium test. Patients were flagged for screening if they were over 65 years old and medically complex, and all patients over age 80 were screened.

Clinical implications

The rapid test begins by asking the person accompanying the patient if they are concerned about or have noticed any changes in the patient’s mental status. If the caregiver answers yes, the assessment is completed by asking the patient “orientation” questions that evaluate their ability to understand today’s date, where they are, and their date of birth and age. Their attention span is measured by asking the patient to name the months of the year backwards.

Any patient who receives a score of four or more is flagged for delirium.

Dr. Saxena said the study demonstrates that while detecting delirium in the acute setting is challenging, it can be done quickly and accurately using a rapid test like the 4AT method. Among Dr. Saxena’s future goals are improving interdepartmental communication about high-risk geriatric patients. “This approach helps ensure continuity of care throughout the hospital stay by making subsequent caregivers aware of any diagnoses – including delirium – that were made in the emergency department.

Despite the rising incidence of rheumatoid arthritis (RA), extra-articular manifestations have become rare in the era of modern treat-to-target therapy. However, they still present clinical challenges — particularly in the case of rheumatoid nodules. In addition to the need to rule out serious differential diagnoses and address potential complications, especially those involving the lungs, these recurrent inflammatory granulomas can affect daily life not only cosmetically but also functionally.

Christopher Edwards, MD, professor of rheumatology at University Hospital Southampton in Southampton, England, discussed the clinical relevance and management of rheumatoid nodules during the 2025 Annual Meeting of the European Alliance of Associations for Rheumatology.

When Edwards began his career in rheumatology, the presence of rheumatoid nodules was considered a key diagnostic criterion for RA. If not found on the hands, clinicians often examined the elbows and Achilles tendons, which are also common sites. Histologically, rheumatoid nodules are granulomatous inflammatory lesions that evolve through multiple stages. While often subcutaneous, they can also be found on the sclera, larynx, heart valves, and — most significantly — in the lungs.

Biopsy When Malignancy Is Suspected

Pulmonary nodules can present diagnostic difficulties. “I’ve seen patients who were initially told they had lung metastases,” Edwards recalled. Waiting for further imaging and biopsy can be highly distressing for patients. Granulomatosis with polyangiitis can also resemble rheumatoid nodules, further complicating the diagnosis.

It is especially important to distinguish these nodules from infections such as tuberculosis. Patients with RA are at increased risk for infection due to both the underlying disease and immunosuppressive treatment. Like tuberculomas, pulmonary rheumatoid nodules can undergo central necrosis when exposed to tumor necrosis factor-alpha inhibitors, leading to cavitation or even pneumothorax. “Any cavity in the lung can become infected,” Edwards cautioned.

Diagnosing Peripheral Nodules

Diagnosing peripheral rheumatoid nodules is usually straightforward. These nodules typically feel rubbery on palpation and are movable relative to the underlying tissue. Important differential diagnoses include gouty tophi, lipomas, epidermoid cysts, infectious granulomas, sarcoidosis, and neoplastic lesions.

Imaging tools such as ultrasound or fine-needle aspiration can help clarify the diagnosis, particularly when gout is suspected. “Biopsy is rarely required — only if there’s concern about a neoplastic or malignant process,” Edwards explained.

Better Disease Control, Fewer Nodules

“In my practice, I see very few nodules these days,” said Edwards. Epidemiological data support this trend: The 10-year cumulative incidence of subcutaneous nodules in RA patients decreased from 30.9% between 1985 and 1999 to 15.8% between 2000 and 2014.

Multiple factors likely contributed to this decline, including the earlier initiation of more effective therapies and a reduction in smoking rates. Smoking remains a major risk factor for nodule development, along with long-standing, severe RA, male sex, and seropositivity for rheumatoid factor or anti-cyclic citrullinated peptide antibodies. “Patients with nodules are almost always seropositive,” Edwards noted.

These findings suggest that maintaining tight control of disease activity is more critical for preventing nodules than concerns about drug-induced nodulosis.

Little Reason to Discontinue Methotrexate

“There was a time when we worried that methotrexate might be causing nodules,” Edwards said, referring to anecdotal reports of increased nodulosis after initiating methotrexate (MTX). “But now we’re using more MTX and seeing fewer nodules.”

He emphasized that the presence of nodules alone should not prompt discontinuation of MTX. “It wasn’t a reason to stop methotrexate back then, and it’s not a reason now — though in some cases, it may justify a more aggressive treatment approach.”

Other medications — particularly tumor necrosis factor inhibitors like etanercept — have also been linked to nodule development, though Edwards suggested this may reflect reporting bias. “It might not be causal,” he said.

Often, treatment isn’t necessary. “Sometimes it’s just a matter of observation,” Edwards noted. Painful or functionally limiting nodules may be managed with local glucocorticoid injections to reduce discomfort and soften the nodules. However, he admitted he had never personally injected a rheumatoid nodule.

He also cautioned against injections over the elbow. “There’s something about the skin and the olecranon bursa that makes infections more likely in that area. I saw one patient who needed plastic surgery after an infection left a significant wound.”

Rheumatoid nodules also have a tendency to recur.

When to Consider Surgery

“Surgery can benefit some patients,” Edwards said. Surgical removal may be warranted for nodules that ulcerate, become infected, or impair function — such as large nodules on the thumb or fingertip that interfere with gripping. “Patients are usually happy to regain function, even if the nodule comes back a couple of years later.” Nodules that are consistently irritated by shoes or clothing straps may also merit removal.

Pulmonary rheumatoid nodules — unlike subcutaneous ones — often contain B cells and typically respond well to rituximab or abatacept. “These lung nodules tend to shrink or stabilize with rituximab, and certainly, no new ones seem to develop,” Edwards noted. Case reports and small series have also documented improvement with Janus kinase inhibitors.

This story was translated from Medscape’s German edition.

Challenges in space exploration are driving new approaches to delivering eye care in the most inaccessible environments, according to Steven Laurie, PhD, senior scientist and technical lead with the Cardiovascular and Vision Laboratory at NASA’s Johnson Space Center in Houston, Texas.

His talk at the Heidelberg 2025 International SPECTRALIS Symposium – And Beyond (ISS) spotlighted how technologies originally designed for spaceflight, like the Heidelberg Spectralis OCT2 and portable Mini OCT, are setting the stage for autonomous medical diagnostics in deep space—and potentially in the most remote regions here on Earth.

Sheryl Stevenson, executive editor with the Eye Care Network, caught up with Laurie to learn how spaceflight is driving innovations in extreme telemedicine—on orbit and beyond.

Sheryl Stevenson: What are the key takeaways from your presentation?

Steven Laurie, PhD: Astronauts onboard the International Space Station (ISS) use the Heidelberg Spectralis OCT2 to image their eyes, and these images have revealed structural changes in the retina and optic nerve head. I will discuss the unique approach NASA has developed to support these data collection activities, including use of remote guidance from Earth. I will end by sharing our experience with a new device Heidelberg Engineering is developing, the Mini OCT, that is smaller in mass and volume than the Spectralis, and that will not require the remote guidance from Earth.

SS: What are the unique ophthalmic challenges that astronauts face during extended space missions, and how is telemedicine being adapted to address them?

SL: In 2011, the first reports were published documenting the development of optic disc edema and choroidal folds in astronauts flying ~6 month missions to the ISS. Soon after, NASA began using the Spectralis OCT2 to track the development of these findings throughout the mission, and this requires real-time video and communication support from experts on the ground to guide crewmembers in the collection of the OCT images. Over the last 10+ years NASA has used telemedicine to support astronauts in collecting OCT images throughout their spaceflight missions, revealing ophthalmic changes in 60% to 70% of crewmembers.

SS: Can you describe the technologies or protocols that enable effective diagnosis and intervention when specialists are millions of miles away?

SL: The ISS orbits ~250 miles above the surface of the Earth, allowing for only ~1-2 second communication delays between experts in mission control, and crewmembers onboard the ISS. We utilize a video feed from within the ISS cabin, 2-way audio, and screen-sharing of the Heidelberg software to collect the OCT images. Images are downlinked and can be reviewed by experts within hours of data collection. Crewmembers receive two 1-hour long training classes on how to use the hardware before their mission. This training utilizes very specific wording and directions to guide crew through acquisition of OCT images.

SS: How might innovations developed for spaceflight telemedicine translate to patient care in remote or underserved areas here on Earth?

SL: The experience that NASA has developed in using remote guidance to collect OCT images on the ISS highlights that remote telemedicine for collecting OCT images is possible and can be utilized to generate high-quality data. While this represents a great opportunity for remote or underserved populations, it still requires the hardware to be in the remote location, and for real-time audio, video, and screen-sharing communication with experts at a different location. The advancements with the new Mini OCT device represents the next frontier for patients to access medical devices in remote locations without requiring the communication pathways or additional technicians to support data collection. This expands the opportunity from telemedicine supported in real-time by clinicians, to autonomous data collection that only requires transmission of the final images to clinicians.

SS: Anything else to add that you feel would be helpful for our audience to know?

SL: As NASA looks toward sending astronauts back to the Moon and on to Mars, the distance from Earth will limit the real-time communication that we enjoy when crew members are on the ISS. Thus, our ability to utilize remote guidance and real-time communication with experts on the ground will no longer be possible. Technology such as the Mini OCT represents one possible solution to this problem, where astronauts can autonomously collect OCT images on themselves, and then have those images sent back to Earth for assessments by clinical experts. We are excited to see the progression of this technology that may benefit astronauts, as well as patients on Earth.

Alexander T. Reddy, MD

Assistant Professor of Medicine
Division of Gastroenterology
Duke University School of Medicine
Durham, North Carolina

Amit Patel, MD, AGAF, FACG

Professor of Medicine
Division of Gastroenterology
Duke University School of Medicine & Durham Veterans Affairs Medical Center
Durham, North Carolina

---

Dysphagia, the sensation of difficulty swallowing, may be experienced by up to 1 in 6 adults in the United States, according to population-based survey data,^1,2 and is frequently encountered in gastroenterology clinical practice. Esophageal dysphagia may stem from various disease states, so discerning among potential etiologies is critical to facilitate effective, patient-tailored management. The initial evaluation of dysphagia should include a careful clinical history and physical exam, followed by consideration of diagnostic investigations, as appropriate.

Clinicians typically should pursue upper endoscopy with consideration of esophageal biopsies as a first step for esophageal-phase dysphagia.³ Additional physiologic testing such as high-resolution esophageal manometry (HRM) with provocative maneuvers,^4,5 functional lumen imaging probe (FLIP) panometry,^6,7 and/or a barium esophagram (typically as a timed upright barium esophagram)⁸ may be used for further assessment based on the clinical context and endoscopic findings. Here, we present 3 hypothetical cases that illustrate practical approaches to clinical presentations of esophageal dysphagia, highlighting the use of modern diagnostic and therapeutic options.

Case 1

A 30-year-old man with a history of asthma was referred for 2 years of intermittent dysphagia to solids. His symptoms occurred several times weekly, particularly with meats, and were localized retrosternally. He had not used any pharmacotherapy to manage his symptoms. His physical exam was unremarkable, and upper endoscopy revealed esophageal edema (decreased vascularity), mild rings, exudates, and longitudinal furrows (Figure 1A; Eosinophilic Esophagitis [EoE] Endoscopic Reference Score [EREFS] of E1R1Ex1F2S0 [edema = 1, rings = 1, exudates = 1, furrows = 2, and strictures = 0]).^9,10 Biopsies from the upper and lower esophagus revealed peak eosinophil counts of 50 and 40 eosinophils per high-power field, respectively.

Diagnosis: EoE

EoE is a chronic allergen-induced, immune- mediated disease of the esophagus resulting in symptoms of esophageal dysfunction, particularly dysphagia in adults.¹¹ The clinicopathologic diagnosis requires compatible esophageal symptoms along with an eosinophil-predominant infiltrate on histologic assessment of endoscopic biopsies, with peak eosinophil counts of at least 15 eosinophils per high-power field.¹¹ Clinicians should exclude alternate etiologies for esophageal eosinophilia (eg, gastroesophageal reflux disease [GERD], medication adverse effects, infection, achalasia, and hypereosinophilic syndrome) before making a diagnosis of EoE.

Scoring tools such as the EREFS at endoscopic evaluation, as above,^9,10 and the Index of Severity for EoE¹² facilitate the standardization and systematic reporting of disease severity. Although the recognition and diagnosis of EoE have increased rapidly in recent decades,¹³ endoscopic findings of EoE may be subtle and/or overlooked, potentially contributing to diagnostic delay.¹⁴ Therefore, at least 2 to 4 esophageal biopsies from at least 2 levels of the esophagus should be pursued in all patents with symptoms suspicious for EoE, including at the time of food impaction.^10,11,15

Management

After a discussion of potential dietary and pharmacologic management options for EoE, the patient opted for 40 mg of omeprazole twice daily. Repeat endoscopy 2 months later demonstrated no improvement either endoscopically (based on EREFS) or histologically (based on peak eosinophil counts on esophageal biopsies).

The patient then opted to switch to swallowed fluticasone (220 mcg at 4 puffs twice daily; total daily dose, 1,760 mcg). Evaluation after 2 months of adherence with fluticasone again demonstrated no significant improvement in his symptoms, EREFS, or peak eosinophil counts on esophageal biopsies. Based on his lack of response with proton pump inhibitor (PPI) and topical corticosteroid therapy, along with shared decision-making regarding his strong preference to avoid dietary elimination approaches, the patient started 300 mg of dupilumab (Dupixent, Regeneron/Sanofi) weekly. When evaluated 3 months after starting dupilumab, the patient reported resolution of dysphagia. His previous endoscopic findings of EoE had normalized, and no eosinophils were present on upper and lower esophageal biopsies (Figure 1B). Given dupilumab’s effectiveness, the patient opted to continue on it as maintenance therapy.

For the management of EoE, clinicians should focus on both inflammatory and potential fibrostenotic aspects to improve patient symptoms and minimize complications such as food impaction, stricture formation, and esophageal perforation.¹¹ Anti-inflammatory treatment options include strategic dietary elimination,¹⁶ PPIs, topical steroids (ie, budesonide or fluticasone formulations), and dupilumab.¹⁷

Dupilumab, approved for EoE by the FDA in May 2022, is a monoclonal antibody that blocks the effects of interleukin (IL)-4 and IL-13 involved in the type 2 inflammatory cascade.¹¹ Given limited head-to-head clinical trial data among the anti-inflammatory options, individual disease characteristics and patient preferences via shared decision-making should guide treatment selection.¹⁸

Strategies for optimizing management include counseling on the risks and benefits of treatment options, consultation with gastroenterology-trained nutritionists when pursuing food elimination diets, and structured, timely assessment of response after initiating therapy. A willingness to pursue alternative therapies if indicated, as demonstrated in this case, is crucial. Beyond its use in patients with EoE who are nonresponsive to or intolerant of other therapies, dupilumab can be considered earlier in the management algorithm when a patient has concomitant atopic conditions that also could be treated with dupilumab.¹⁹ Endoscopic dilation as an adjunct to anti-inflammatory approaches can be safely used to treat fibrostenotic features of EoE, including strictures and luminal narrowing. Finally, maintaining effective dietary or pharmacologic therapy can help prevent histologic inflammation and symptom recurrence.¹¹

Case 2

A 55-year-old woman with a history of hypertension was referred for 2 years of progressively worsening dysphagia to solids and liquids, with regurgitation, which now is happening on a daily basis. One year prior, she was evaluated by an outside provider with an unrevealing upper endoscopy and esophageal biopsies. The patient had been taking omeprazole for several months without symptom benefit. Esophageal HRM was discussed and pursued, which revealed 100% failed peristalsis with panesophageal pressurization on single wet swallows and an elevated median integrated relaxation pressure (IRP) of 30 mm Hg in the primary supine position (Figure 2A).

Diagnosis: Type II Achalasia

Achalasia is an esophageal motility disorder characterized by abnormal esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter, classically defined by an abnormally elevated median IRP on esophageal HRM.^4,20 Thresholds for abnormal IRP vary based on patient position and HRM equipment manufacturer. Threshold values are 15 mm Hg in the supine position and 12 mm Hg in the upright position for Medtronic HRM systems, and 22 mm Hg in the supine position and 15 mm Hg in the upright position for the Diversatek and Laborie HRM systems.^4,21

Achalasia is classified into 3 types based on peristaltic patterns at HRM, which can help guide prognosis and therapeutic interventions: Type I achalasia consists of 100% failed peristalsis without evidence of panesophageal pressurization, type II achalasia demonstrates 100% failed peristalsis with panesophageal pressurization in 20% or more of swallows, and type III achalasia is characterized by premature contraction in 20% or more of swallows without evidence of peristalsis.^4,20 Patients who are initially suspected of having GERD but who do not respond to acid-suppressive therapy should be evaluated for achalasia.^20,22

Management

Due to worsening symptoms, the patient underwent upper endoscopy with FLIP, which revealed an American Foregut Society hiatus grade 1 with no mechanical obstruction. FLIP assessment revealed an esophagogastric junction-distensibility index (EGJ-DI) of 0.6 mm²/mm Hg at a 60-mL fill volume and a maximum EGJ diameter of 8 mm at a 70-mL fill volume, consistent with a reduced EGJ opening (REO), and no esophageal body contractile response (Figure 2B).

After discussion of treatment options based on her symptoms and diagnostic findings, the patient opted for per-oral endoscopic myotomy (POEM). At follow-up, she reported resolution of dysphagia and regurgitation symptoms off omeprazole. Surveillance endoscopy with FLIP and wireless pH monitoring 6 months after POEM revealed no reflux esophagitis, an EGJ-DI of 3 mm²/mm Hg with an EGJ diameter of 18 mm, and physiologic esophageal acid exposure times (AETs) less than 4% on all 4 days of the pH study.

In a workup of suspected achalasia, a high-quality endoscopic exam should exclude the presence of pseudoachalasia or other causes of mechanical obstruction. Particularly in the setting of diagnostic uncertainty (eg, manometric EGJ outflow obstruction, borderline IRP, abnormal provocative maneuvers at HRM), evaluation with FLIP and/or a timed upright barium esophagram can be helpful in evaluation, as well as to increase confidence in an actionable diagnosis.^8,20

FLIP is increasingly recognized as a useful tool for esophageal motility evaluation and should be considered if alternate investigations for dysphagia are inconclusive; it may even be considered as part of index endoscopy when the procedure and expertise are readily available.^7,23 As per new consensus and American Gastroenterological Association Clinical Practice Update guidance, an EGJ-DI less than 2.0 mm²/mm Hg and maximum EGJ diameter less than 12 mm on FLIP are classified as REO (as in this case), while a normal EGJ opening (EGJ-DI =2.0 mm²/mm Hg and maximum EGJ diameter =16 mm) has a high negative predictive value for achalasia spectrum disorders on HRM.^6,7

For the management of achalasia, definitive therapies with well-established clinical benefit include pneumatic dilation, surgical laparoscopic Heller myotomy (LHM) accompanied by partial fundoplication to help prevent GERD, and POEM. All 3 approaches are comparable and may be considered reasonable options for types I and II achalasia, with selection guided by individual patient characteristics, local expertise, discussions of potential risks and outcomes (eg, POEM may be associated with GERD), and shared decision-making.^20,24 POEM is the preferred treatment for type III achalasia, given the potential to tailor the myotomy to the spastic segment of the esophageal body.^20,25,26 A botulinum toxin injection typically should be reserved for patients who are not candidates for the more definitive therapies described above.²⁰ When available, intra-procedural FLIP during myotomy, whether POEM or LHM, may be helpful in tailoring or guiding the adequacy of disruption to the lower esophageal sphincter.²⁶ Finally, patients who undergo POEM should be monitored for GERD, with treatment offered as appropriate.²⁶

Case 3

A 50-year-old man with a history of obesity and diabetes mellitus was referred for endoscopy after experiencing 3 months of dysphagia to solids. He reported long-standing heartburn and regurgitation, for which he took over-the-counter antacids on an as-needed basis. Upper endoscopy revealed Los Angeles Grade D esophagitis with luminal narrowing at the EGJ (Figure 3A). He was started on 40 mg of omeprazole twice daily with plans for repeat upper endoscopy.

Diagnosis: Erosive Esophagitis (EE) And Peptic Stenosis

GERD is a common condition in which refluxate of acidic contents from the stomach into the esophagus results in bothersome symptoms (commonly heartburn, regurgitation, and noncardiac chest pain). While these typical symptoms in the absence of alarm symptoms can prompt a 4- to 8-week trial of PPI therapy with assessment of response,²⁷ GERD can lead to the formation of peptic strictures, mechanical narrowing that can cause dysphagia. Per the updated Lyon Consensus, the presence of LA Grades B/C/D EE, peptic stricture, and/or biopsy-proven Barrett’s esophagus represent conclusive evidence for a diagnosis of GERD (as in this case).²⁸

If these findings are not present on endoscopy, a diagnosis of GERD may be established with ambulatory reflux monitoring, with distal esophageal AETs more than 6% indicating the presence of pathologic GERD.^27,28 If ambulatory reflux monitoring is inconclusive based on AET, then adjunctive evidence such as numbers of reflux episodes, reflux symptom association, and mean nocturnal baseline impedance may support a diagnosis of GERD.^29-31 A personalized approach to management is warranted, with further evaluation and/or escalation of anti-reflux therapy, including invasive anti-reflux interventions, pursued thoughtfully with shared decision-making.^27,32,33

Management

The patient returned for follow-up endoscopy 2 months later on 40 mg of omeprazole twice daily. Although he reported partial improvement in his dysphagia, upper endoscopy demonstrated LA Grade C esophagitis and ongoing luminal narrowing at the EGJ. Given persistent and severe EE and stricture despite adherence with a high dose of omeprazole, the patient was switched to 20 mg of vonoprazan (Voquezna, Phathom) daily. After 1 month of vonoprazan therapy, upper endoscopy revealed resolution of his reflux esophagitis (Figure 3B).

Across 2 endoscopies, the patient’s peptic stricture was successfully dilated to a diameter of 18 mm using through-the-scope balloon dilators (Figure 3C). He reported resolution of his dysphagia and reflux symptoms at follow-up.

In the setting of EE, optimized antisecretory therapy facilitates healing and can be followed by repeat upper endoscopy to document healing and exclude the presence of Barrett’s esophagus.³⁴ High-dose PPIs are most commonly used as first-line therapy for the healing of EE given their effectiveness, accessibility, safety profile, and cost.²⁷ However, potassium-competitive acid blockers (P-CABs) such as vonoprazan, which received FDA approval for EE in November 2023, are a newer class of antisecretory medications that can provide more potent acid inhibition than PPI formulations, with faster onset of action and longer duration of effect and without premeal dosing requirements.^35,36

Although P-CABs currently are less accessible and more costly than PPIs in the United States, they may be superior to PPIs for the healing and maintenance of healing of more severe (LA Grades C/D) EE and may be associated with more rapid healing.^36,37 Beyond representing an effective therapeutic option for patients with more severe EE and those with documented reflux who fail twice-daily PPI therapy (as in this case), the rapid onset of acid inhibition of P-CABs raises their potential utility as on-demand therapy for reflux-related symptoms.^36,38

For peptic strictures, endoscopic dilation, whether employing balloon or bougie techniques, is safe and effective.^39,40

Conclusion

Through these representative hypothetical cases, we have outlined practical approaches to the evaluation of esophageal dysphagia and the basic management of EoE, achalasia, and reflux esophagitis with peptic stenosis, incorporating clinical pearls and more recent esophageal diagnostic and therapeutic advances, such as dupilumab, FLIP, POEM, and vonoprazan. As demonstrated through these cases, we are fortunate as gastroenterology providers to be able to thoughtfully evaluate our patients with dysphagia with the assistance of insightful diagnostic modalities and also, when indicated, treat our patients with a growing arsenal of effective, patient-tailored management options.

References

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On June 3, 2025, the European Parliament hosted a pivotal event that signalled a turning point in the fight against a silent but pervasive public health threat: Steatotic (Fatty) Liver Disease. Titled “Fatty Liver & NCDs: A European Policy Action”, the event brought together patient leaders, medical experts, policymakers, and public health advocates to call for a unified strategy to address liver health as part of Europe’s broader approach to non-communicable diseases (NCDs).

Organised by the European Liver Patients’ Association (ELPA), co-hosted by MEPs Michalis Hadjipantela (Cyprus, EPP) and Irena Joveva (Slovenia, Renew), and attended by several MEPs and assistants, the gathering underscored a growing cross-party consensus: liver disease is not a niche issue. It is a pan- European epidemic linked to cancer, obesity, type 2 diabetes, and cardiovascular conditions—and it demands coordinated, urgent political action. Both MEPs shared a strong message about how, as policymakers, they are responsible for strengthening health systems, promoting liver screening programs, and ensuring no patient is left behind.

The Patient Voice: Front and Centre

The first panel, “The Patient Perspective: Navigating Liver Disease Across Borders,” highlighted lived experiences across Europe and beyond. Representatives from Cyprus, Israel, Denmark, France, Finland, and Spain painted a vivid picture of the daily struggle faced by people affected by liver disease—and the system-wide gaps in care and recognition.

Marko Korenjak, ELPA President, opened the event by framing Steatotic (Fatty) Liver Disease as “a silent epidemic.” Steatotic (Fatty) liver disease (SLD) is one of the most widespread liver conditions in Europe, affecting up to 25% of the adult population. Closely tied to metabolic dysfunction, SLD often begins silently but progresses over time to cirrhosis and, increasingly, liver cancer. Liver cancer is now one of the fastest-growing causes of cancer-related deaths in Europe. He pointedly asked why, despite clear links to major NCDs, liver disease remains marginal in national and EU-level health strategies. This theme was echoed throughout the discussion. Patients aren’t just calling for awareness—they are demanding structural change.

Bridging Silos: An Alliance of Associations

The true innovation of the event lay in its second panel, “Advocacy in Action.” Here, an unprecedented alliance took the stage: the European Liver Patients’ Association (ELPA), the European Coalition for People living with Obesity (ECPO), the International Diabetes Federation Europe (IDFE), and the Global Heart Hub (GHH). Their message was unified and unambiguous: to tackle Steatotic (Fatty) Liver Disease, Europe must abandon siloed disease strategies and adopt integrated approaches that address shared root causes. This is why patient associations were also joined by the European Public Health Alliance (EPHA) and the European Association for the Study of the Liver (EASL) representative.

This patient representative alliance formally launched a Call to Action—first drafted in Lisbon in November 2024 under the initiative Bridging the Gaps—marking a new era in cross-disease advocacy. For the first time, patient associations from different disease areas co-authored a policy vision, elevating liver disease to its rightful place in the NCD agenda.

David Kelly of the Global Heart Hub summarised the spirit of the Call: “This document isn’t just a list of demands. It’s a declaration of unity from communities that share risk factors and solutions. It shows the power of working together.”

Linking Disease to Systems: Public Health over Personal Blame

Much of the discussion focused on breaking the persistent narrative that liver disease is solely the result of poor lifestyle choices. Professor Shira Zelber- Sagi of EASL emphasised the role of commercial and social determinants of health. “This is not just about individuals. It’s about how we build our food systems, cities, and social protections,” she urged governments to act on upstream factors that drive disease.

Alessandro Gallina of EPHA echoed this call, criticising the EU’s limited public health focus during the current legislative term. “We need to respond to NCDs with integrated, system-wide policies,” he stated. “The narrative must shift to systemic responsibility and political will.” He also added the fundamental importance of fully implementing Europe’s Beating Cancer Plan since the link between cancer and many NCD risk factors, such as tobacco use, unhealthy diets, physical inactivity, and alcohol, is well-established.

The Future: Integration and Prevention

When asked about the obstacles to integrated care, Marko Korenjak didn’t hesitate: “The biggest challenge is the silo mentality. Ministries, budgets, disease areas—all fragmented. Integrated prevention means addressing common risk factors and giving patients a voice at every step.”

A consistent theme across all panellists was the need for integrated care. Elisabeth Dupont of IDFE advocated for diabetes screening programs that also test for liver disease, noting the high comorbidity rates. “Screening early allows us to intervene preventatively,” she said.

Vicki Mooney of ECPO highlighted stigma as a barrier to care for people living with obesity and liver disease. “Healthcare professionals often overlook liver symptoms in people with obesity. Worse, patients internalise stigma and delay seeking help. We must train providers to recognise and respect the full picture.”

Looking ahead, several speakers called for standardised EU-wide liver screening protocols, particularly for high-risk groups such as people living with obesity, type 2 diabetes, and cardiovascular disease. In addition, they pointed out how the European Commission consider integrating liver health into the next NCD framework and the forthcoming European Cardiovascular Health Plan.

Beyond the Event: Building a Movement

From the liver community, the call is loud and clear:

• Integrate liver disease into national and EU-level NCD plans.
• Implement and update the Europe’s Beating Cancer Plan.
• Include liver disease as a key component of the upcoming European Cardiovascular Health Plan.
• Develop screening strategies across primary care systems.
• Fund public health interventions that tackle the commercial determinants of health.
• Recognise and resource cross-disease patient alliances.

This was more than just a health event—it marked the beginning of a growing coalition driven by patients, grounded in science, and speaking directly to EU lawmakers. Building on this momentum, ELPA will organise a second event in early December 2025, in the European Parliament, continuing to place liver health at the heart of the broader conversation on chronic disease prevention and health system resilience.

As Marko Korenjak reflected on the Lisbon meeting where the Call to Action was born, he asked: “What happens when different communities realise they’re not alone in their fight? They form a movement. That’s what’s happening now.”

Click here to read ELPA’s Call to Action

The European Liver Patient Association (ELPA) is a member-based, non-profit organisation dedicated to promoting the interests of people affected by liver disease across Europe. ELPA represents liver patients regardless of their origin, lifestyle, or type of liver condition. Through advocacy, education, and collaboration with healthcare professionals, researchers, and policymakers, ELPA works to ensure that patient engagement is meaningful and patients’ voices are central to healthcare decisions. ELPA’s mission is to improve the quality of life for all liver patients by promoting equitable access to prevention, diagnosis, treatment, and care across the continent. For more visit https://elpa.eu/

 

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Eating a protein-rich diet can have several health benefits. If you struggle to get enough protein to meet your body’s needs, incorporating high-protein foods into snacks can help you reach your protein goal. We spoke with registered dietitians to find out why protein is so important—plus, which high-protein foods should make it into your snack rotation.

Benefits of Eating Protein-Rich Snacks

Protein is an essential macronutrient that is important for health and well-being. “Protein plays a key role in the body’s ability to build muscle, repair tissue, regulate hormones and perform other cellular functions like metabolism,” says Cayleigh McKenna, RD, nutrition consultant at Houston Family Nutrition.

Because protein is essential for building and maintaining muscle, physically active people should emphasize protein in their meals and snacks.

Adding protein to snacks can offer several benefits, including long-lasting energy and increased satiety. “Protein-rich snacks can help you feel fuller for longer, promoting a sense of nourishment and satisfaction,” says Andrea Hinojosa, M.S., RD, founder of Honest Health & Wellness. “Many high-protein snacks are also rich in other essential nutrients, contributing to overall health and well-being,” she adds. Eating protein with snacks may also balance blood sugar, improve heart health and reduce cravings later in the day.

The Best High-Protein Foods to Eat as Snacks

1. Greek Yogurt 

Creamy and refreshing, “Greek yogurt is high in protein and can be easily paired with honey and nuts for added flavor and texture,” says Hinojosa. Depending on the brand, you’ll snag about 20 grams of protein per 7-ounce serving.

You can also use Greek yogurt in place of sour cream and mayonnaise in dip recipes for a high-protein swap that’s lower in saturated fat. Strained Greek-style yogurt is also a great way to add protein to fruit smoothies. 

2. Hard-Boiled Eggs

One egg provides a satisfying 6 grams of protein. “They’re portable, easy to prepare and packed with high-quality protein,” says Hinojosa. Enjoy hard-boiled eggs with a handful of nuts or top with hot sauce. Hinojosa also recommends pairing eggs with kimchi to add digestive-friendly probiotics and a spicy kick.

3. Canned Tuna or Salmon

Canned fish is a quick high-protein option for snacks. You can even purchase “canned” fish in travel-friendly pouches, making them the perfect protein-rich snack when you’re on the go. Canned salmon has about 18 grams of protein per 3-ounce serving, while canned tuna has about 22 grams per serving. “They also provide omega-3 fatty acids, beneficial for heart health and brain function,” adds Hinojosa.

Try our Tuna Salad Spread, which combines canned tuna and Greek yogurt for a protein-packed snack. Spread it on whole-grain crackers or toast, or use raw veggies for dipping. 

4. String Cheese 

Another portable and easy option for snacking is string cheese. One stick has about 8 grams of protein. “For high-protein snacks, I love a turkey and cheese roll-up. I use a cheese stick and two slices of deli turkey or chicken and roll it up together. It’s really satisfying,” says Katie Drakeford, M.A., RD, owner of Drakeford Consulting. You can also enjoy string cheese with fresh fruit or a side of nuts.

5. Jerky

Jerky is a great high-protein snack option—and it’s especially handy if you can’t keep things cold. One serving of beef jerky (about 1 ounce) provides about 10 grams of protein, while turkey jerky has 11 grams per serving. Enjoy jerky with fresh fruit like an apple or banana, or with a handful of trail mix for an added boost of healthy fats. 

6. Deli Turkey

Deli turkey is another high-protein snack option. Just one slice of deli turkey has 6 grams of protein. Enjoy a couple of slices on crackers, layer a few slices with cheese on top of cucumber slices or make a grown-up snack box with turkey, cheese, grapes and crackers. 

7. Cottage Cheese

Until it became a social media darling, who knew there were so many ways to incorporate cottage cheese into meals and snacks? And it’s worth it to do so: 1 cup of low-fat cottage cheese has about 24 grams of protein. “A cup of cottage cheese with berries or pineapple is another go-to when looking to up protein intake,” says Drakeford. If you prefer a savory snack, try our Cottage Cheese Snack Jar.

Our Expert Take

Protein is an important part of a healthy diet. Including these dietitian-approved protein-rich snacks in your routine can provide long-lasting energy, increase feelings of fullness and balance blood sugar. Eating protein consistently throughout the day may also help regulate your appetite and reduce cravings.

A recent study has shed new light on how the ketogenic diet impacts men and women differently, especially when it comes to weight loss.

According to researchers, men consistently experience greater fat loss than women under identical keto protocols, with biological sex playing a significant role in how the body responds to this popular dietary approach.

In one 45-day clinical trial reviewed in the study, men on the keto diet lost an average of 11.63% of their body weight, compared to 8.95% in women following the same regimen. The findings point to complex physiological and hormonal differences that affect how men and women burn fat, store energy, and adapt to carb-restricted eating plans like keto.

The ketogenic diet, which is high in fats, moderate in protein, and extremely low in carbohydrates, puts the body into a state of ketosis.

In this state, the liver produces ketone bodies — byproducts of fat metabolism — which the brain and body use as a primary energy source in place of glucose.

This metabolic shift not only reduces fat stores but also suppresses appetite and regulates blood sugar. However, the new research highlights that sex-specific biology significantly influences how effective a ketogenic diet is for weight loss.

One of the key factors is fat distribution. Men typically store fat viscerally while women tend to store fat subcutaneously.

Visceral fat is more readily metabolised during ketosis, giving men a physiological edge when it comes to shedding pounds on a ketogenic diet.

Hormonal differences also play a crucial role. Testosterone enhances fat-burning processes by increasing beta-adrenergic receptor activity, while oestrogen — especially in premenopausal women — can hinder fat breakdown.

Moreover, the menstrual cycle introduces additional metabolic variability for women. During the luteal phase, elevated progesterone levels reduce insulin sensitivity and increase cravings for carbohydrates, making it harder for many women to maintain ketosis.

Another contributing factor is how each sex uses energy. Men are more likely to burn fat for energy, while women often store fat and rely on carbohydrates as a primary fuel source. These metabolic tendencies can make fat loss more challenging for women on a low-carb diet like keto.

Even at the microbiome level, differences emerge. The study found that men generally have higher levels of fat-metabolising gut bacteria, which may enhance the fat-burning effects of the diet.

Interestingly, the review also noted that a ketogenic diet can support muscle growth, but potentially at a cost for women.

Some studies have shown that keto may contribute to increased muscle fatigue in young, healthy females, possibly affecting workout performance and overall weight loss outcomes.

The researchers concluded that the ketogenic diet is most effective for men and postmenopausal women, with more limited success observed in premenopausal women.

They emphasised the need for personalised dietary approaches that take sex, hormones, genetics, and lifestyle factors into account.

The authors also called for more diverse clinical research to validate these findings across different populations, stating that personalised nutrition could be the key to more effective obesity treatment in the future.

Read more in the journal Frontiers in Nutrition.

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