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Endoscopic therapies in proton pump inhibitors (PPI) dependent/refractory gastroesophageal reflux disease (GERD) are increasingly indicated in patients who are not suitable or willing for chronic medical therapy and surgical fundoplication. Currently available endoluminal anti‐reflux procedures include radiofrequency therapy (Stretta), suturing/plication and mucosal ablation/resection techniques at the gastroesophageal junction. Meticulous work up and patient selection results in a favorable outcome with these endoscopic therapies, especially the quality of life and partially the PPI independence. Stretta can be considered in patients with PPI refractory GERD and might have a role in patients with reflux hypersensitivity and functional heartburn. Endoscopic fundoplication using the Esophyx device and the GERD‐X device have strong evidence (multiple randomized controlled trials) in patients with small hiatus hernia and high volume reflux episodes. Mucosal resection/ablation techniques like anti‐reflux mucosectomy and anti‐reflux mucosal ablation have shown promising results but need long term follow‐up studies to prove their efficacy. The subset of PPI dependent GERD population will benefit from endoscopic therapies and the future of endoscopic management of GERD looks promising.

A BSTRACT Introduction: Seizures are one of the most common neurological emergencies encountered in both urban and rural India. There is only limited research work on the etiology of new-onset seizures in adult patients of different age groups presenting to the emergency department, especially from the Indian sub-continent. A new-onset seizure can be the first presentation of stroke, or it may be a symptom of brain infections, metabolic abnormality, brain tumor, systemic disease, or an early phase of epilepsy, which needs scrutiny and appropriate management. A dedicated study of the underlying etiology of new-onset seizures among different age groups and their incidence and prevalence can help in the prognostication and clinical management of these patients. Materials and Methods: This was a prospective observational cross-sectional study conducted in the Emergency Medical Out-patient Department and emergency medical ward of the Post-graduate Institute of medical education and research, Chandigarh. Results: In our research, males out-numbered females. The most common seizure type recorded in our study was generalized tonic-clonic. In the younger age group between 13 and 35 years, infective etiologies were dominant. In the middle age group between 36 and 55 years, cerebrovascular accidents were the dominant etiology, followed by infective causes and metabolic causes. In the older age group above 55 years, the most dominating etiology found was cerebrovascular accident. Almost 72% had abnormal brain imaging. The most common abnormality found was ischemic infarcts. The second most common abnormality detected was a meningeal enhancement. A small percentage of patients had an intra-cranial bleed, and a very small percentage had a subarachnoid hemorrhage. Conclusions: In younger patients, infections such as tubercular and pyogenic meningitis and cerebral malaria are the most common causes of new-onset seizures, followed by malignancy and metabolic causes, in descending order. In the middle age group, stroke is the most common etiology, followed by central nervous system (CNS) infections and metabolic causes, in descending order. In elderly patients, stroke is the leading etiology for new-onset seizures. Physicians working in rural and remote areas routinely face challenges in managing patients with new-onset seizures. Knowledge of different etiologies in different age groups will equip them to make informed decisions regarding investigations and treatment of patients with new-onset seizures. It also encourages them to aggressively search for CNS infections, especially in younger patients.

Patients with achalasia frequently develop gastroesophageal reflux (GER)-related symptoms and complications after per-oral endoscopic myotomy (POEM). Reflux symptoms are thought to be due to GER and the current treatment of post-POEM GER focuses on acid suppression with proton pump inhibitors (PPI). However, reflux symptoms in achalasia patients post-POEM can be due to true reflux, nonreflux esophageal acidification due to stasis or acid fermentation, or esophageal hypersensitivity to chemical or mechanical stimuli. True acidic reflux is not always the cause of reflux symptoms. Twenty-four-hour pH monitoring with impedance is essential to differentiate causes of esophageal acidification. PPI is useful only in true acidic reflux. Detection of acid fermentation requires manual review of a 24-h pH study, as automated review often overestimates acid exposure time due to its inability to differentiate true reflux from fermentation. Stasis of ingested acidic food warrants evaluation of esophageal emptying by timed barium esophagogram. In cases of inadequate emptying, esophagogastric junction (EGJ) distensibility can be evaluated by a functional lumen imaging probe. Impaired distensibility with inadequate esophageal emptying suggests treatment failure and may require retreatment. In treatment-refractory patients, esophageal hypersensitivity should be considered and treated with neuromodulators. Thus, the diagnostic approach to post-POEM reflux symptoms should evolve to identify various patterns of esophageal acidification, esophageal emptying patterns, EGJ distensibility, and hypersensitivity. Consequently, the treatment of GER post-POEM should not be limited to treating esophageal acidification by reflux, but should encompass other causes of acidification and esophageal hypersensitivity.