Sung, Hea Jung; Moon, Sung Jin; Kim, Jin Su; Lim, Chul Hyun; Park, Jae Myung; Lee, In Seok; Kim, Sang Woo; Choi, Myung-Gye
Background/Aims Available data about reflux patterns and symptom determinants in the gastroesophageal reflux disease (GERD) subtypes off proton pump inhibitor (PPI) therapy are lacking. We aimed to evaluate reflux patterns and determinants of symptom perception in patients with GERD off PPI therapy by impedance-pH monitoring. Methods We retrospectively reviewed the impedance-pH data in patients diagnosed as GERD based on results of impedance-pH monitoring, endoscopy and/or typical symptoms. The characteristics of acid and weakly acidic reflux were evaluated. Symptomatic and asymptomatic reflux were compared according to GERD subtypes and individual symptoms. Results Forty-two patients (22 males, mean age 46 years) were diagnosed as GERD (17 erosive reflux disease, 9 pH(+) non-erosive reflux disease [NERD], 9 hypersensitive esophagus and 7 symptomatic NERD). A total of 1,725 reflux episodes were detected (855 acid [50%], 857 weakly acidic [50%] and 13 weakly alkaline reflux [< 1%]). Acid reflux was more frequently symptomatic and bolus clearance was longer compared with weakly acidic reflux. In terms of globus, weakly acidic reflux was more symptomatic. Symptomatic reflux was more frequently acid and mixed reflux; these associations were more pronounced in erosive reflux disease and symptomatic NERD. The perception of regurgitation was related to acid reflux, while that of globus was more related to weakly acidic reflux. Conclusions In patients not taking PPI, acid reflux was more frequently symptomatic and had longer bolus clearance. Symptomatic reflux was more frequently acid and mixed type; however, weakly acidic reflux was associated more with globus. These data suggest a role for impedance-pH data in the evaluation of globus. PMID:22837877
Sung, Hea Jung; Cho, Yu Kyung; Moon, Sung Jin; Kim, Jin Su; Lim, Chul Hyun; Park, Jae Myung; Lee, In Seok; Kim, Sang Woo; Choi, Myung-Gye
Available data about reflux patterns and symptom determinants in the gastroesophageal reflux disease (GERD) subtypes off proton pump inhibitor (PPI) therapy are lacking. We aimed to evaluate reflux patterns and determinants of symptom perception in patients with GERD off PPI therapy by impedance-pH monitoring. We retrospectively reviewed the impedance-pH data in patients diagnosed as GERD based on results of impedance-pH monitoring, endoscopy and/or typical symptoms. The characteristics of acid and weakly acidic reflux were evaluated. Symptomatic and asymptomatic reflux were compared according to GERD subtypes and individual symptoms. Forty-two patients (22 males, mean age 46 years) were diagnosed as GERD (17 erosive reflux disease, 9 pH(+) non-erosive reflux disease [NERD], 9 hypersensitive esophagus and 7 symptomatic NERD). A total of 1,725 reflux episodes were detected (855 acid [50%], 857 weakly acidic [50%] and 13 weakly alkaline reflux [< 1%]). Acid reflux was more frequently symptomatic and bolus clearance was longer compared with weakly acidic reflux. In terms of globus, weakly acidic reflux was more symptomatic. Symptomatic reflux was more frequently acid and mixed reflux; these associations were more pronounced in erosive reflux disease and symptomatic NERD. The perception of regurgitation was related to acid reflux, while that of globus was more related to weakly acidic reflux. In patients not taking PPI, acid reflux was more frequently symptomatic and had longer bolus clearance. Symptomatic reflux was more frequently acid and mixed type; however, weakly acidic reflux was associated more with globus. These data suggest a role for impedance-pH data in the evaluation of globus.
Sano, Hirohito; Iwakiri, Katsuhiko; Kawami, Noriyuki; Tanaka, Yuriko; Sakamoto, Choitsu
The mechanisms that cause acid reflux in patients with non-erosive reflux disease (NERD), including those that determine how acid extends proximally, are not yet clear. Concurrent esophageal manometry and pH monitoring were performed for 3 h after a meal in 13 patients with NERD, 12 with mild reflux esophagitis (RE), and 13 healthy subjects (HS). Transient lower esophageal sphincter (LES) relaxation (TLESR) was the major mechanism of acid reflux in all three groups. LES pressure did not differ between the groups. At 2 cm above the LES, there were no differences between the three groups in the number of TLESR-related acid reflux episodes, rate of TLESRs and rate of acid reflux during TLESR. However, at 7 cm above the LES, the rate of acid reflux during TLESRs was significantly higher in patients with NERD (mean ± SEM 42.3 ± 4.8) than in those with mild RE (28.0 ± 3.8) and HS (10.8 ± 2.5). TLESRs are the sole motor events underlying acid reflux episodes in patients with NERD. Acid extends proximally more readily in patients with NERD than in HS and those with mild RE.
Emerenziani, S; Ribolsi, M; Guarino, M P L; Balestrieri, P; Altomare, A; Rescio, M P; Cicala, M
Non-erosive reflux disease (NERD) patients are more sensitive than erosive esophagitis patients to weakly acidic reflux and to the presence of gas in the refluxate. Intra-esophageal acid perfusion sensitizes esophageal receptors to mechanical and chemical stimuli. To establish whether acid sensitization plays a role in the perception of weakly acidic and mixed reflux episodes, 29 NERD patients, responders and 14 non-responders to proton pump inhibitors (PPIs), underwent pH-impedance monitoring. Non-responders repeated the study while on PPIs. To assess the effect of acid exposure on symptom perception, the time period with pH below 4 was measured in 15- and 30-minute time-windows preceding the onset of each reflux episode. Considering weakly acidic and mixed refluxes, both in responder and non-responder patients (off PPIs), the symptomatic refluxes were preceded by a significantly higher cumulative acid exposure than the asymptomatic refluxes. In all patients, following acid reflux, the percentage of symptomatic weakly acidic reflux episodes was significantly higher than that of asymptomatic refluxes. Non-responder patients, off-treatment, were characterized by a lower proportion of weakly acidic reflux and mixed reflux episodes. In the non-responder patients on PPI, only mixed and weakly symptomatic reflux episodes were preceded by a higher cumulative acid exposure. In NERD patients, spontaneous acid reflux enhances subsequent reflux perception, regardless of acidity or liquid/mixed composition of episodes; in non-responder patients on PPIs, only the perception of mixed and weakly acidic reflux episodes seems to be mediated by a preceding acid exposure. © 2013 John Wiley & Sons Ltd.
Emerenziani, S; Ribolsi, M; Sifrim, D; Blondeau, K; Cicala, M
The mechanisms underlying symptoms in non-erosive reflux disease (NERD) remain to be elucidated. Non-erosive reflux disease patients appear to be more sensitive to intraluminal stimula than erosive patients, the proximal oesophagus being the most sensitive. In order to assess regional oesophageal changes in reflux acidity and sensitivity to reflux, according either to the acidity or the composition of the refluxate, combined multiple pH and multiple pH-impedance (pH-MII) was performed in 16 NERD patients. According to multiple pH-metry, 29% and 12% of reflux events reached the middle and proximal oesophagus respectively, and 35% and 19% according to conventional pH-MII (P < 0.05). The per-individual analysis confirmed the difference between the two techniques. According to combined distal and proximal pH-MII, approximately 30% of distal acid reflux became weakly acidic at the proximal oesophagus. In all patients, the frequency of symptomatic refluxes, both acid and weakly acidic, was significantly higher at the proximal, compared with distal oesophagus (25 +/- 8%vs 11 +/- 2% for acid reflux and 27 +/- 8%vs 8 +/- 2% for weakly acidic reflux; P < 0.05). Compared with multiple pH-metry, pH-MII shows a higher sensitivity in the detection of proximal reflux. As approximately 30% of acid reflux becomes weakly acidic along the oesophageal body, to better characterize proximal reflux, in clinical practice, combined proximal pH-impedance monitoring should be used. In NERD patients, the proximal oesophagus seems to be more sensitive to both acid and weakly acidic reflux.
Mitchell, David R; Derakhshan, Mohammad H; Robertson, Elaine V; McColl, Kenneth E L
Gastroesophageal reflux disease is one of the commonest chronic conditions in the western world and its prevalence is increasing worldwide. The discovery of the acid pocket explained the paradox of acid reflux occurring more frequently in the postprandial period despite intragastric acidity being low due to the buffering effect of the meal. The acid pocket was first described in 2001 when it was detected as an area of low pH immediately distal to the cardia using dual pH electrode pull-through studies 15 minutes after a meal. It was hypothesized that there was a local pocket of acid close to the gastroesophageal junction that escapes the buffering effect of the meal, and that this is the source of postprandial acidic reflux. The presence of the acid pocket has been confirmed in other studies using different techniques including high-resolution pHmetry, Bravo capsule, magnetic resonance imaging, and scintigraphy. This review aims to describe what we know about the acid pocket including its length, volume, fluid constituents, and its relationship to the lower esophageal sphincter and squamocolumnar junction. We will discuss the possible mechanisms that lead to the formation of the acid pocket and examine what differences exist in patients who suffer from acid reflux. Treatments for reflux disease that affect the acid pocket will also be discussed.
Hung, Jui-Sheng; Lei, Wei-Yi; Yi, Chih-Hsun; Liu, Tso-Tsai; Chen, Chien-Lin
This study was conducted to investigate whether there is a direct association between subjective sleep quality and esophageal acid reflux in patients with gastroesophageal reflux disease. We enrolled patients with classic reflux symptoms for endoscopy and ambulatory pH monitoring. The severity of esophageal mucosal injury was assessed by upper endoscopy. Distal esophageal acid exposure was determined by ambulatory 24-hour pH monitoring. Sleep disturbance was assessed by using the Pittsburgh Sleep Quality Index. In total, 103 patients (53 patients without sleep dysfunction and 50 patients with sleep dysfunction) were studied. Erosive esophagitis was found more in patients with sleep disturbance than in those without sleep disturbance (45% versus 31%, P = 0.04). Abnormal esophageal pH was found more in patients with dysfunction (22%) than in patients without sleep dysfunction (5.7%, P = 0.03). Recumbent acid contact time (%) was greater in patients with sleep disturbance than in those without sleep disturbance (3.7 ± 2.4 versus 1.9 ± 0.9, P = 0.04). Sleep quality score positively correlated with acid contact time (r = 0.32, P = 0.02), prolonged reflux events (r = 0.45, P = 0.008) and longer reflux event (r = 0.28, P = 0.03) during recumbent period. Patients with gastroesophageal reflux disease along with sleep dysfunction are characterized with greater nocturnal acid reflux and more erosive esophagitis. Our study suggests that increased nocturnal acid reflux may play a role in inducing sleep disturbance in patients with gastroesophageal reflux disease. Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.
Kahrilas, Peter J; McColl, Kenneth; Fox, Mark; O'Rourke, Lisa; Sifrim, Daniel; Smout, Andre J P M; Boeckxstaens, Guy
The nadir esophageal pH of reflux observed during pH monitoring in the postprandial period is often more acidic than the concomitant intragastric pH. This paradox prompted the discovery of the "acid pocket", an area of unbuffered gastric acid that accumulates in the proximal stomach after meals and serves as the reservoir for acid reflux in healthy individuals and gastroesophageal reflux disease (GERD) patients. However, there are differentiating features between these populations in the size and position of the acid pocket, with GERD patients predisposed to upward migration of the proximal margin onto the esophageal mucosa, particularly when supine. This upward migration of acid, sometimes referred to as an "acid film", likely contributes to mucosal pathology in the region of the squamocolumnar junction. Furthermore, movement of the acid pocket itself to a supradiaphragmatic location with hiatus hernia increases the propensity for acid reflux by all conventional mechanisms. Consequently, the acid pocket is an attractive target for GERD therapy. It may be targeted in a global way with proton pump inhibitors that attenuate acid pocket development, or with alginate/antacid combinations that colocalize with the acid pocket and displace it distally, thereby demonstrating the potential for selective targeting of the acid pocket in GERD.
Yi, Zhi-hui; Feng, Li; Wen, Mao-yao; Liu, Jian-rong; Yang, Li
To investigate the association between esophageal motility and acid reflux in patients with gastroesophageal reflux disease (GERD). A total of 94 patients with typical reflux symptoms such as heartburn, regurgitation and chest pain, whose score (Sc) of reflux diagnostic questionnaire (RDQ) was greater than or equal to 12 were enrolled in the study. Each participant was evaluated by upper gastrointestinal endoscopy, high resolution manometry (HRM) of esophagus and 24 h esophageal pH monitoring. The participants were divided into groups of reflux esophagitis (RE) and non-erosive reflux disease (NERD) on the basis of endoscopy findings. The 24 h esophageal pH monitoring categorized participants into physiologic reflux (pH) and pathologic reflux (pH+). The characteristics of esophageal motility and acid reflux were compared between the two groups of participants. Lower but non-significant differences (P > 0.05) were found in pressure of lower esophageal sphincter (LESP), length of lower esophageal sphincter (LESL), esophageal contraction amplitude (CA), distal contractile integral (DCI) and effective peristalsis proportion (EPP) in the participants in the RE group compared with those in the NERD group. Participants in the RE group had significantly higher prevalence of reduced LESP (63.0% vs. 31.7%, P < 0.01) and hiatus hernia (HH) (37.0% vs. 14.3%, P < 0.05) than those in the NERD group, pH+ was more prevalent in the RE group than in the NERD group (63.0% vs. 17.5%, P < 0.01). Indicators of 24 h esophageal pH monitoring were significantly higher in participants in the RE group compared with those in the NERD group (P < 0.05). Participants with pH+ had significantly lower LESP, CA and higher HH and prevalence of reduced LESP compared with those with pH (P < 0.05). LESL, DCI and EPP were lower in those with pH+ compared with those with pH-, but without statistical significance (P > 0.05). RE is closely associated with acid reflux and hiatus hernia. Esophageal
Lishchuk, N B; Simanenkov, V I; Tikhonov, S V
To investigate the clinical and pathogenetic features of the non-acidic types of gastroesophageal reflux disease (GERD) and to evaluate the impact of combined therapy versus monotherapy on the course of this disease. The investigation enrolled 62 patients with non-acidic GERD. The follow-up period was 6 weeks. The patients were divided into 2 groups: 1) weakly acidic gastroesophageal refluxes (GER); 2) weakly alkaline GER. Then each group was distributed, thus making up 4 groups: 1) 19 patients with weakly acidic GER who received monotherapy with rabeprazole 20 mg/day; 2) 21 patients with weakly acidic GER had combined therapy with rabeprazole 20 mg and itopride; 3) 8 patients with weakly alkaline GER who received ursodeoxycholic acid (UDCA) monotherapy; and 4) 14 patients with weakly alkaline GER who had combined therapy with UDCA and itopride, The clinical symptoms of the disease, the endoscopic pattern of the upper gastrointestinal tract (GIT) mucosa, histological changes in the esophageal and gastric mucosa, and the results of 24-hour impedance pH monitoring were assessed over time. During differentiation therapy, the majority of patients reported positive clinical changes and an improved or unchanged endoscopic pattern. Assessment of impedance pH monitoring results revealed decreases in the overall number of GERs, the presence of a bolus in the esophagus, and the number of proximal refluxes. These changes were noted not only in patients taking proton pump inhibitors (PPIs), but also in those treated with UDCA monotherapy or combined PPI and prokinetic therapy. A differentiated approach to non-acidic GER treatment contributes to its efficiency. Adding the prokinetic itomed (itopride hydrochloride) to PPI therapy in a patient with weakly acidic GER enhances the efficiency of treatment, by positively affecting upper GIT motility. The mainstay of therapy for GERD with a predominance of weakly alkaline refluxes is UDCA, the combination of the latter and the
Rohof, Wout O; Bennink, Roel J; Smout, Andre J P M; Thomas, Edward; Boeckxstaens, Guy E
Alginate rafts (polysaccharide polymers that precipitate into a low-density viscous gel when they contact gastric acid) have been reported to form at the acid pocket, an unbuffered pool of acid that floats on top of ingested food and causes postprandial acid reflux. We studied the location of an alginate formulation in relation to the acid pocket and the corresponding effects on reflux parameters and acid pocket positioning in patients with gastroesophageal reflux disease (GERD). We randomly assigned patients with symptomatic GERD and large hiatal hernias to groups who were given either (111)In-labeled alginate-antacid (n = 8, Gaviscon Double Action Liquid) or antacid (n = 8, Antagel) after a standard meal. The relative positions of labeled alginate and acid pocket were analyzed for 2 hours by using scintigraphy; reflux episodes were detected by using high-resolution manometry and pH-impedance monitoring. The alginate-antacid label localized to the acid pocket. The number of acid reflux episodes was significantly reduced in patients receiving alginate-antacid (3.5; range, 0-6.5; P = .03) compared with those receiving antacid (15; range, 5-20), whereas time to acid reflux was significantly increased in patients receiving alginate-antacid (63 minutes; range, 23-92) vs those receiving antacid (14 minutes; range, 9-23; P = .01). The acid pocket was located below the diaphragm in 71% of patients given alginate-antacid vs 21% of those given antacid (P = .08). There was an inverse correlation between a subdiaphragm position of the acid pocket and acid reflux (r = -0.76, P < .001). In a study of 16 patients with GERD, we observed that the alginate-antacid raft localizes to the postprandial acid pocket and displaces it below the diaphragm to reduce postprandial acid reflux. These findings indicate the importance of the acid pocket in GERD pathogenesis and establish alginate-antacid as an appropriate therapy for postprandial acid reflux. Copyright © 2013 AGA Institute
Schijven, Marlies P; Gisbertz, Suzanne S; van Berge Henegouwen, Mark I
Gastro-esophageal reflux disease is a troublesome disease for many patients, severely affecting their quality of life. Choice of treatment depends on a combination of patient characteristics and preferences, esophageal motility and damage of reflux, symptom severity and symptom correlation to acid reflux and physician preferences. Success of treatment depends on tailoring treatment modalities to the individual patient and adequate selection of treatment choice. PubMed, Embase, The Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for systematic reviews with an abstract, publication date within the last five years, in humans only, on key terms (laparosc* OR laparoscopy*) AND (fundoplication OR reflux* OR GORD OR GERD OR nissen OR toupet) NOT (achal* OR pediat*). Last search was performed on July 23nd and in total 54 articles were evaluated as relevant from this search. The laparoscopic Toupet fundoplication is the therapy of choice for normal-weight GERD patients qualifying for laparoscopic surgery. No better pharmaceutical, endoluminal or surgical alternatives are present to date. No firm conclusion can be stated on its cost-effectiveness. Results have to be awaited comparing the laparoscopic 180-degree anterior fundoplication with the Toupet fundoplication to be a possible better surgical alternative. Division of the short gastric vessels is not to be recommended, nor is the use of a bougie or a mesh in the vast majority of GERD patients undergoing surgery. The use of a robot is not recommended. Anti-reflux surgery is to be considered expert surgery, but there is no clear consensus what is to be called an 'expert surgeon'. As for setting, ambulatory settings seem promising although high-level evidence is lacking. Copyright © 2013 Elsevier Ltd. All rights reserved.
de Bortoli, N; Martinucci, I; Savarino, E; Franchi, R; Bertani, L; Russo, S; Ceccarelli, L; Costa, F; Bellini, M; Blandizzi, C; Savarino, V; Marchi, S
Multichannel impedance pH monitoring has shown that weakly acidic refluxes are able to generate heartburn. However, data on the role of different pH values, ranging between 4 and 7, in the generation of them are lacking. The aim of this study was to evaluate whether different pH values of weakly acidic refluxes play a differential role in provoking reflux symptoms in endoscopy-negative patients with physiological esophageal acid exposure time and positive symptom index and symptom association probability for weakly acidic refluxes. One hundred and forty-three consecutive patients with gastroesophageal reflux disease, nonresponders to proton pump inhibitors (PPIs), were allowed a washout from PPIs before undergoing: upper endoscopy, esophageal manometry, and multichannel impedance pH monitoring. In patients with both symptom index and symptom association probability positive for weakly acidic reflux, each weakly acidic reflux was evaluated considering exact pH value, extension, physical characteristics, and correlation with heartburn. Forty-five patients with normal acid exposure time and positive symptom association probability for weakly acidic reflux were identified. The number of refluxes not heartburn related was higher than those heartburn related. In all distal and proximal liquid refluxes, as well as in distal mixed refluxes, the mean pH value of reflux events associated with heartburn was significantly lower than that not associated. This condition was not confirmed for proximal mixed refluxes. Overall, a low pH of weakly acidic reflux represents a determinant factor in provoking heartburn. This observation contributes to better understand the pathophysiology of symptoms generated by weakly acidic refluxes, paving the way toward the search for different therapeutic approaches to this peculiar condition of esophageal hypersensitivity. © 2014 International Society for Diseases of the Esophagus.
Bell, Jane C; Schneuer, Francisco J; Harrison, Christopher; Trevena, Lyndal; Hiscock, Harriet; Elshaug, Adam G; Nassar, Natasha
To evaluate the diagnosis and management of reflux and gastro-oesophageal reflux disease (GORD) in infants aged <1 year presenting to general practitioners (GPs). A nationally representative, prospective, cross-sectional survey of GP activity in Australia, 2006-2016 (Bettering the Evaluation And Care of Health Study). Annually, a random sample of around 1000 GPs recorded details for 100 consecutive visits with consenting, unidentified patients. Diagnoses of reflux and GORD and their management including prescribing of acid-suppressant medicines (proton pump inhibitors (PPIs) and histamine receptor antagonists (H2RAs)) and counselling, advice or education. Of all infants' visits, 512 (2.7%) included a diagnosis of reflux (n=413, 2.2%) or GORD (n=99, 0.5%). From 2006 to 2016, diagnostic rates decreased for reflux and increased for GORD. Prescribing of acid suppressants occurred in 43.6% visits for reflux and 48.5% visits for GORD, similar to rates of counselling, advice or education (reflux: 38.5%, GORD: 43.4% of visits). Prescribing of PPIs increased (statistically significant only for visits for reflux), while prescribing of H2RAs decreased. Overprescribing of acid suppressants to infants may be occurring. In infants, acid-suppressant medicines are no better than placebo and may have significant negative side effects; however, guidelines are inconsistent. Clear, concise and consistent guidance is needed. GPs and parents need to understand what is normal and limitations of medical therapy. We need a greater understanding of the influences on GP prescribing practices, of parents' knowledge and attitudes and of the pressures on parents of infants with these conditions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Serra Pueyo, Jordi
Gastroesophageal reflux disease is a highly frequent disorder classically characterized by the presence of heartburn and/or acid regurgitation that improves with drug therapy that reduces acid content in the stomach. However, especially in patients with non-erosive disease, response to proton pump inhibitors is unsatisfactory in approximately 1 out of 3 patients, and consequently, in these patients, it is important to establish a definitive diagnosis and an alternative therapeutic strategy. In the last few years, advances have been made in knowledge of the physiopathology of reflux, such as identification of the role of the acid pocket in producing reflux, technological advances that allow differentiation among acid reflux, non-acid reflux and slightly acid reflux, and advances in the treatment of reflux with drugs that attempt to act on the barrier function of the esophagogastric junction. Copyright © 2013 Elsevier España, S.L. and AEEH y AEG. All rights reserved.
Kawami, Noriyuki; Hoshino, Shintaro; Hoshikawa, Yoshimasa; Takenouchi, Nana; Umezawa, Mariko; Hanada, Yuriko; Kaise, Mitsuru; Iwakiri, Katsuhiko
The present study examined the pathogenesis of potassium-competitive acid blocker (P-CAB)-resistant non-erosive reflux disease (NERD). Forty-three patients with NERD, who had persistent reflux symptoms despite the administration of P-CAB, were included in this study. After excluding eosinophilic esophagitis and primary esophageal motility disorders, esophageal impedance-pH monitoring was performed. In symptom index (SI)-positive patients, the mechanism of SI-positivity and percent time with intragastric pH > 4 and with esophageal pH < 4 were investigated according to the presence or absence of Helicobacter pylori infection. One (2.3%) of 43 patients had a primary esophageal motility disorder (Jackhammer esophagus). Eighteen (41.9%) and 3 (7%) patients were SI-positive for liquid and gas-only reflux, respectively, and the remaining 21 patients who were SI-negative (48.8%) had functional heartburn. All patients SI-positive for liquid reflux were SI-positive for weakly acidic reflux. Gastric acid was sufficiently suppressed by P-CAB, regardless of the presence or absence of H. pylori infection. The pathogenesis of -P-CAB-resistant NERD was elucidated in 51% of patients. Symptoms in all patients SI-positive for liquid reflux were related to weakly acidic reflux, and symptoms related to acid reflux may be ruled out by the administration of P-CAB. © 2018 S. Karger AG, Basel.
Kostovski, Aco; Zdraveska, Nikolina
The main advantage of multichannel intraluminar impedance (MII) compared with pH monitoring is its ability to detect both acid and non-acid gastroesophageal reflux (GER) and to determine the characteristics of reflux (liquid or gas). To compare the value of pH monitoring and MII for diagnosis of GER in children who present with refractory respiratory symptoms. A prospective study that included 37 patients, aged 4.25 ± 3.15 years, using combined MII-pH monitoring was performed. Patients were referred for investigation because of suspected GER as the etiology of recurrent respiratory diseases, including recurrent obstructive bronchitis, recurrent pneumonia, laryngitis, and chronic cough. We analyzed the percentage of time during which the pH was less than 4, the numeric and percentile values of acid, weak acid, and non-acid reflux episodes, and the values of liquid and mixed reflux. Diagnostic values were determined separately for pH monitoring and MII using Fisher's exact test. Reflux was detected in 31 patients. pH monitoring was positive in 20 patients (% time during which pH <4 was 17.72 ± 12.06) and negative in 17 patients (2.93% ± 1.67). Both pH and MII were positive in 19 patients: in 11 patients, MII was positive and pH was negative, and in 6 patients, both were negative. Fisher's exact test showed significant statistical difference and superiority of MII in diagnosing GER (p = 0.033). Out of 30 patients with MII-positive results, 15 had both acid and weak acid reflux episodes, 3 had only acid reflux, 8 had weak acid reflux, and 3 had non-acid reflux. Sixteen patients had mixed (liquid and gas) reflux, and 14 had both liquid and mixed reflux. This study suggests that significant numbers of GER include weak acid reflux that cannot be detected by pH probes alone. The weak acid reflux could be a trigger for recurrent respiratory symptoms. Combining pH with MII monitoring is a valuable diagnostic method for diagnosing GER in children.
Surdea-Blaga, Teodora; Negrutiu, Dana E; Palage, Mariana; Dumitrascu, Dan L
Gastroesophageal reflux disease is a chronic condition with a high prevalence in western countries. Transient lower esophageal sphincter relaxation episodes and a decreased lower esophageal sphincter pressure are the main mechanisms involved. Currently used drugs are efficient on reflux symptoms, but only as long as they are administered, because they do not modify the reflux barrier. Certain nutrients or foods are generally considered to increase the frequency of gastroesophageal reflux symptoms, therefore physicians recommend changes in diet and some patients avoid bothering foods. This review summarizes current knowledge regarding food and gastroesophageal reflux. For example, fat intake increases the perception of reflux symptoms. Regular coffee and chocolate induce gastroesophageal reflux and increase the lower esophageal exposure to acid. Spicy foods might induce heartburn, but the exact mechanism is not known. Beer and wine induce gastroesophageal reflux, mainly in the first hour after intake. For other foods, like fried food or carbonated beverages data on gastroesophageal reflux is scarce. Similarly, there is few data about the type of diet and gastroesophageal reflux. Mediterranean diet and a very low carbohydrate diet protect against reflux. Regarding diet-related practices, consistent data showed that a "short-meal-to-sleep interval" favors reflux episodes, therefore some authors recommend that dinner should be at least four hours before bedtime. All these recommendations should consider patient's weight, because several meta-analysis showed a positive association between increased body mass index and gastroesophageal reflux disease. Copyright© Bentham Science Publishers; For any queries, please email at firstname.lastname@example.org.
... term maintenance therapy is generally required. Occasionally, a health care plan seeks to limit use of proton pump ... and not the medication. Please consult with your care provider if you have any questions. ... Health Centers Colorectal Cancer Hepatitis C Inflammatory Bowel Disease ...
Zullo, Angelo; Hassan, Cesare; Repici, Alessandro; Bruzzese, Vincenzo
Gastroesophageal reflux disease (GORD) is highly prevalent in the general population. In the last decade, a potential relationship between Helicobacter pylori (H. pylori) eradication and GORD onset has been claimed. The main putative mechanism is the gastric acid hypersecretion that develops after bacterial cure in those patients with corpus-predominant gastritis. We performed a critical reappraisal of the intricate pathogenesis and clinical data available in this field. Oesophagitis onset after H. pylori eradication in duodenal ulcer patients has been ascribed to a gastric acid hypersecretion, which could develop following body gastritis healing. However, the absence of an acid hypersecretive status in these patients is documented by both pathophysiology and clinical studies. Indeed, duodenal ulcer recurrence is virtually abolished following H. pylori eradication. In addition, intra-oesophageal pH recording studies failed to demonstrated increased acid reflux following bacterial eradication. Moreover, oesophageal manometric studies suggest that H. pylori eradication would reduce--rather than favor--acid reflux into the oesophagus. Finally, data of clinical studies would suggest that H. pylori eradication is not significantly associated with either reflux symptoms or erosive oesophagitis onset, some data suggesting also an advantage in curing the infection when oesophagitis is already present. Therefore, the legend of "crazy acid" remains--as all the others--a fascinating, but imaginary tale.
Weigt, J; Malfertheiner, P
Until now, it is uncertain if the so-called pH-only reflux episodes that consist of a pH drop without evidence of retrograde bolus movement in multichannel intraluminal impedance (MII) represent reflux episodes or artifacts. Hiatal hernia (HH) may allow reflux of small volumes to occur that can be detected by pH-metry but not by MII. The aim was to search for a mechanism that can explain pH-only reflux, 20 patients (12 females and 8 males, median age 52 years, interquartile range [IQR]: 40.5-60.75 years) were investigated with MII-pH off PPI. Impedance and pH-metry data were analyzed separately. The differences in detection rate of acid reflux between pH-metry and MII were correlated with the presence of HH. In an in vitro experiment, MII-pH probes were flushed with citric acid in plastic tubes of different size with capillary diameter and diameters of 2.5 mm and 4.5 mm, while recording pH values and impedance. HH was present in six patients and absent in 14 patients. In patients with HH in comparison with patients with absent HH, the difference of acid reflux detection between pH-metry and MII is significantly higher (70%, IQR: 15-88% and 3.6%, IQR: 0-31%, respectively). In vitro all simulated reflux lead to a fall in pH whereas a corresponding decrease in impedance was only recognizable in the 4.5-mm plastic tubes. Acid reflux episodes in patients with HH are more frequently detected by pH-metry than by MII. Small volume reflux that does not lead to a decrease in impedance is the likely explanation for this phenomenon. © 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.
Martinucci, Irene; Savarino, Edoardo; Nacci, Andrea; Romeo, Salvatore Osvaldo; Bellini, Massimo; Savarino, Vincenzo; Fattori, Bruno; Marchi, Santino
Laryngopharyngeal reflux is defined as the reflux of gastric content into larynx and pharynx. A large number of data suggest the growing prevalence of laryngopharyngeal symptoms in patients with gastroesophageal reflux disease. However, laryngopharyngeal reflux is a multifactorial syndrome and gastroesophageal reflux disease is not the only cause involved in its pathogenesis. Current critical issues in diagnosing laryngopharyngeal reflux are many nonspecific laryngeal symptoms and signs, and poor sensitivity and specificity of all currently available diagnostic tests. Although it is a pragmatic clinical strategy to start with empiric trials of proton pump inhibitors, many patients with suspected laryngopharyngeal reflux have persistent symptoms despite maximal acid suppression therapy. Overall, there are scant conflicting results to assess the effect of reflux treatments (including dietary and lifestyle modification, medical treatment, antireflux surgery) on laryngopharyngeal reflux. The present review is aimed at critically discussing the current treatment options in patients with laryngopharyngeal reflux, and provides a perspective on the development of new therapies. PMID:24179671
van Hoeij, Froukje B; Weijenborg, Pim W; van den Bergh Weerman, Marius A; van den Wijngaard, René M J G J; Verheij, J; Smout, André J P M; Bredenoord, Albert J
Acid reflux episodes that extend to the proximal esophagus are more likely to be perceived. This suggests that the proximal esophagus is more sensitive to acid than the distal esophagus, which could be caused by impaired mucosal integrity in the proximal esophagus. Our aim was to explore sensitivity to acid and mucosal integrity in different segments of the esophagus. We used a prospective observational study, including 12 patients with gastroesophageal reflux disease (GERD). After stopping acid secretion-inhibiting medication, two procedures were performed: an acid perfusion test and an upper endoscopy with electrical tissue impedance spectroscopy and esophageal biopsies. Proximal and distal sensitivity to acid and tissue impedance were measured in vivo, and mucosal permeability and epithelial intercellular spaces at different esophageal levels were measured in vitro. Mean lag time to heartburn perception was much shorter after proximal acid perfusion (0.8 min) than after distal acid perfusion (3.9 min) (P = 0.02). Median in vivo tissue impedance was significantly lower in the distal esophagus (4,563 Ω·m) compared with the proximal esophagus (8,170 Ω·m) (P = 0.002). Transepithelial permeability, as measured by the median fluorescein flux was significantly higher in the distal (2,051 nmol·cm(-2)·h(-1)) than in the proximal segment (368 nmol·cm(-2)·h(-1)) (P = 0.033). Intercellular space ratio and maximum heartburn intensity were not significantly different between the proximal and distal esophagus. In GERD patients off acid secretion-inhibiting medication, acid exposure in the proximal segment of the esophagus provokes symptoms earlier than acid exposure in the distal esophagus, whereas mucosal integrity is impaired more in the distal esophagus. These findings indicate that the enhanced sensitivity to proximal reflux episodes is not explained by increased mucosal permeability. Copyright © 2016 the American Physiological Society.
Wu, Jing; Liu, Dong; Feng, Cheng; Luo, Yumei; Nian, Yuanyuan; Wang, Xueqin; Zhang, Jun
Background Postprandial proximal gastric acid pocket (PPGAP) plays important roles in gastroesophageal reflux disease (GERD). In this study, we analyzed the characteristics of PPGAP in GERD. Material/Methods There were 17 normal participants and 20 GERD patients who completed a gastroesophageal reflux disease questionnaire (GerdQ) and underwent a gastroscopy, a high-resolution manometry, an esophageal 24-hour pH monitoring, and a station pull-through pH monitoring to assess their symptomatic degree, endoscopic change, acid exposure, and PPGAP. Results PPGAP was present in all participants. Compared with normal participants, the PPGAP in GERD patients was significantly different, thus the disappearing time was significantly later (p<0.001), the lasting time was significantly longer (p<0.001), the length was significantly longer (p<0.001), and the lowest pH and the mean pH were significantly lower (p<0.001). The length of PPGAP in GERD patients was positively correlated with GerdQ score (p<0.05). The disappearing time, the lasting time, and the length of PPGAP in GERD patients was positively correlated with the DeMeester score (p<0.01). The lowest pH and the mean pH of PPGAP in GERD patients was negatively correlated with the DeMeester score (p<0.001). Conclusions PPGAP was generally present. PPGAP in GERD patients had characteristics of long time period, long length, and high acidity. Its length was positively correlated with subjective symptomatic degree. Its period, length, and acidity were positively correlated with the objective acid exposure. PPGAP seems to be the originator of acid reflux events and plays important roles in GERD. PMID:29309401
Zhong, Chanjuan; Duan, Liping; Wang, Kun; Xu, Zhijie; Ge, Ying; Yang, Changqing; Han, Yajing
The esophageal intraluminal baseline impedance may be used to evaluate the status of mucosa integrity. Esophageal acid exposure decreases the baseline impedance. We aimed to compare baseline impedance in patients with various reflux events and with different acid-related parameters, and investigate the relationships between epithelial histopathologic abnormalities and baseline impedance. A total of 229 GERD patients and 34 controls underwent 24-h multichannel intraluminal impedance and pH monitoring (MII-pH monitoring), gastroendoscopy, and completed a GERD questionnaire (GerdQ). We quantified epithelial intercellular spaces (ICSs) and expression of tight junction (TJ) proteins by histologic techniques. Mean baseline values in reflux esophagitis (RE) (1752 ± 1018 Ω) and non-erosive reflux disease (NERD) (2640 ± 1143 Ω) were significantly lower than in controls (3360 ± 1258 Ω; p < 0.001 and p = 0.001, respectively). Among NERD subgroups, mean baselines in the acid reflux group (2510 ± 1239 Ω) and mixed acid/weakly acidic reflux group (2393 ± 1009 Ω) were much lower than in controls (3360 ± 1258 Ω; p = 0.020 and p < 0.001, respectively). The mean baseline in severe RE patients was significantly lower than in mild RE patients (LA-C/D vs. LA-A/B: 970 ± 505 Ω vs. 1921 ± 1024 Ω, p < 0.001). There was a significant negative correlation between baseline value and acid exposure time (AET) (r = -0.41, p < 0.001), and a weak but significant correlation (r = -0.20, p = 0.007) between baseline value and weakly AET. Negative correlations were observed between ICS and the baseline impedance (r = -0.637, p < 0.001) and claudin-1 and the baseline impedance (r = -0.648, p < 0.001). Patients with dominant acid reflux events and with longer AET have low baseline impedance. Baseline values are correlated with esophageal mucosal histopathologic changes such as dilated ICS and TJ alteration.
Gyawali, C Prakash; Azagury, Dan E; Chan, Walter W; Chandramohan, Servarayan M; Clarke, John O; de Bortoli, Nicola; Figueredo, Edgar; Fox, Mark; Jodorkovsky, Daniela; Lazarescu, Adriana; Malfertheiner, Peter; Martinek, Jan; Murayama, Kenric M; Penagini, Roberto; Savarino, Edoardo; Shetler, Katerina P; Stein, Ellen; Tatum, Roger P; Wu, Justin
Esophageal symptoms can arise from gastroesophageal reflux disease (GERD) as well as other mucosal and motor processes, structural disease, and functional esophageal syndromes. GERD is the most common esophageal disorder, but diagnosis may not be straightforward when symptoms persist despite empiric acid suppressive therapy and when mucosal erosions are not seen on endoscopy (as for nonerosive reflux disease, NERD). Esophageal physiological tests (ambulatory pH or pH-impedance monitoring and manometry) can be of value in defining abnormal reflux burden and reflux-symptom association. NERD diagnosed on the basis of abnormal reflux burden on ambulatory reflux monitoring is associated with similar symptom response from antireflux therapy for erosive esophagitis. Acid suppression is the mainstay of therapy, and antireflux surgery has a definitive role in the management of persisting symptoms attributed to NERD, especially when the esophagogastric junction is compromised. Adjunctive approaches and complementary therapy may be of additional value in management. In this review, we describe the evaluation, diagnosis, differential diagnosis, and management of NERD. © 2018 New York Academy of Sciences.
... Serving Size vs Portion Size Healthy Snacking Bone Health Taking Multivitamins Shortness of Breath and Eating Steroids and Nutrition Proper Hydration Reflux and Lung Disease Sodium Dangers Plant-Based Diets Why Breakfast Matters No Thanks Patients & Visitors Giving ...
... cause heartburn and other symptoms known as gastroesophageal disease (GERD). To alleviate symptoms, dietary changes and medications are prescribed. For a patient who has persistent symptoms despite medical treatment, an anti-reflux operation may be an option.
Meyer, Keith C
Gastroesophageal reflux (GER) can cause respiratory symptoms and may trigger, drive and/or worsen airway disorders, interstitial lung diseases and lung allograft dysfunction. Whether lifestyle changes and acid suppression alone can counter and prevent the adverse effects of GER on the respiratory tract remains unclear. Recent data suggest that antireflux surgery may be more effective in preventing lung disease progression in patients with idiopathic pulmonary fibrosis or lung transplant recipients who have evidence of allograft dysfunction associated with the presence of excessive GER. Additional research and clinical trials are needed to determine the role of GER in various lung disorders and identify which interventions are most efficacious in preventing the respiratory consequences of gastroesophageal reflux disease. In addition, measuring biomarkers that indicate that gastric refluxate has been aspirated into the lower respiratory tract (e.g., pepsin and bile acid concentrations in bronchoalveolar lavage fluid) may prove helpful in both diagnosis and therapeutic decision making.
Weijenborg, Pim W; Smout, André J P M; Verseijden, Caroline; van Veen, Henk A; Verheij, Joanne; de Jonge, Wouter J; Bredenoord, Albert J
Increased esophageal sensitivity and impaired mucosal integrity have both been described in patients with gastroesophageal reflux disease, but the relationship between hypersensitivity and mucosal integrity is unclear. The aim of the present study was to investigate acid sensitivity in patients with erosive and nonerosive reflux disease and control subjects to determine the relation with functional esophageal mucosal integrity changes as well as to investigate cellular mechanisms of impaired mucosal integrity in these patients. In this prospective experimental study, 12 patients with nonerosive reflux disease, 12 patients with esophagitis grade A or B, and 11 healthy control subjects underwent an acid perfusion test and upper endoscopy. Mucosal integrity was measured during endoscopy by electrical tissue impedance spectroscopy and biopsy specimens were analyzed in Ussing chambers for transepithelial electrical resistance, transepithelial permeability and gene expression of tight junction proteins and filaggrin. Patients with nonerosive reflux disease and esophagitis were more sensitive to acid perfusion compared with control subjects, having a shorter time to perception of heartburn and higher perceived intensity of heartburn. In reflux patients, enhanced acid sensitivity was associated with impairment of in vivo and vitro esophageal mucosal integrity. Mucosal integrity was significantly impaired in patients with esophagitis, displaying higher transepithelial permeability and lower extracellular impedance. Although no significant differences in the expression of tight junction proteins were found in biopsies among patient groups, mucosal integrity parameters in reflux patients correlated negatively with the expression of filaggrin. In conclusion, sensitivity to acid is enhanced in patients with gastroesophageal reflux disease, irrespective of the presence of erosions, and is associated with impaired esophageal mucosal integrity. Mucosal integrity of the esophagus
Tack, Jan; Pandolfino, John E
The pathogenesis of gastroesophageal reflux disease (GERD) is complex and involves changes in reflux exposure, epithelial resistance, and visceral sensitivity. The gastric refluxate is a noxious material that injures the esophagus and elicits symptoms. Esophageal exposure to gastric refluxate is the primary determinant of disease severity. This exposure arises via compromise of the anti-reflux barrier and reduced ability of the esophagus to clear and buffer the refluxate, leading to reflux disease. However, complications and symptoms also occur in the context of normal reflux burden, when there is either poor epithelial resistance or increased visceral sensitivity. Reflux therefore develops via alterations in the balance of aggressive and defensive forces. Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.
Anggiansah, R; Sweis, R; Anggiansah, A; Wong, T; Cooper, D; Fox, M
Obese patients have an increased risk of gastro-oesophageal reflux disease; however, the mechanism underlying this association is uncertain. To test the hypothesis that mechanical effects of obesity on oesophageal function increase acid exposure and symptoms. Height, weight and waist circumference (WC) were measured in patients with typical reflux symptoms referred for manometry and 24 h ambulatory pH studies. Symptom severity was assessed by questionnaire. The association between obesity [WC, body mass index (BMI)], oesophageal function, acid exposure and reflux symptoms was assessed. Physiological measurements were obtained from 582 patients (median age 48, 56% female) of whom 406 (70%) completed symptom questionnaires. The prevalence of general obesity was greater in women (BMI ≥ 30 kg/m(2) ; F 23%:M 16%; P = 0.056), however more men had abdominal obesity (WC ≥ 99 cm (M 41%:F 28%; P = 0.001)). Oesophageal acid exposure increased with obesity (WC: R = 0.284, P < 0.001) and was associated also with lower oesophageal sphincter (LOS) pressure, reduced abdominal LOS length and peristaltic dysfunction (all P < 0.001). Univariable regression showed a negative association of WC with both LOS pressure and abdominal LOS length (R = -0.221 and -0.209 respectively; both P < 0.001). However, multivariable analysis demonstrated that the effects of increasing WC on oesophageal function do not explain increased acid reflux in obese patients. Instead, independent effects of obesity and oesophageal dysfunction on acid exposure were present. Reflux symptoms increased with acid exposure (R = 0.300; P < 0.001) and this association explained increased symptom severity in obese patients. Abdominal obesity (waist circumference) is associated with oesophageal dysfunction, increased acid exposure and reflux symptoms; however, this analysis does not support the mechanical hypothesis that the effects of obesity on oesophageal function are the cause of increased acid exposure in obese
Mallet, Anne-Laure; Ropert, Alain; Bouguen, Guillaume; Siproudhis, Laurent; Boutroux, Dominique; Bretagne, Jean-François; Brochard, Charlène
An association between acid gastro-oesophageal reflux disease (GERD) and Jackhammer oesophagus has been suggested. To assess the prevalence and characteristics of acid-GERD in Jackhammer oesophagus and the efficacy of proton pump inhibitors. Data and outcomes of patients with Jackhammer oesophagus were assessed. Two groups were compared: (i) GERD, defined by endoscopic oesophagitis or by an increase in acid exposure time or by an acid-hypersensitive oesophagus and (ii) non-GERD defined by normal oesophageal acid exposure without acid-hypersensitive oesophagus. Among the 1994 high-resolution manometries performed, 44 Jackhammer oesophagus (2.2%) were included (sex ratio M/F: 19/25; median age: 66 [61-75] years). Nineteen patients (43.2%) had GERD, 16 (36.4%) had no GERD and 9 patients (20.4%) were undetermined. Dysphagia was the predominant symptom (37/43 (86%)). After a median follow-up of 25.3 months [9.6-31.4], dysphagia was improved in 22/36 (61.1%) patients. Dysphagia improvement as well as other symptoms improvement was not associated with GERD status or proton-pump inhibitors use. The prevalence of GERD is high among patients with Jackhammer oesophagus. The rates of symptom improvement in Jackhammer oesophagus were high regardless of the use of proton-pump inhibitors treatment or of the presence of GERD. Copyright © 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Bulsiewicz, William J; Shaheen, Nicholas J; Hansen, Mark B; Pruitt, Amy; Orlando, Roy C
Acid-sensing ion channels (ASICs) are esophageal nociceptors that are candidates to mediate heartburn in non-erosive reflux disease (NERD). Amiloride, a diuretic, is known to inhibit ASICs. For this reason, we sought a role for ASICs in mediating heartburn by determining whether amiloride could block heartburn in NERD induced by esophageal acid perfusion. In a randomized double-blind crossover study, we perfused the esophagus with amiloride or (saline) placebo prior to eliciting acid-induced heartburn in patients with a history of proton pump inhibitor-responsive NERD. Those with NERD and positive modified Bernstein test were randomized to perfusion with amiloride, 1 mmol/l, or placebo for 5 min, followed by repeat acid-perfusion. Heartburn severity and time to onset was measured and the process repeated following crossover to the alternative agent. 14 subjects completed the study. Amiloride did not reduce the frequency (100 vs. 100 %) or severity of acid-induced heartburn (Mean 2.50 ± SEM 0.33 vs. 2.64 ± 0.45), respectively. There was a trend towards longer time to onset of heartburn for amiloride versus placebo (Mean 2.93 ± SEM 0.3 vs. 2.36 ± 0.29 min, respectively), though these differences did not reach statistical significance (p > 0.05). Amiloride had no significant effect on acid-induced heartburn frequency or severity in NERD, although there was a trend towards prolonged time to onset of symptoms.
Szczesniak, Michal Marcin; Fuentealba, Sergio Enrique; Cook, Ian J
Sensitization of esophageal chemoreceptors, either directly by intermittent acid exposure or indirectly through esophagitis-associated inflammatory mediators, is likely to be the mechanism underlying the perception of heartburn. To compare basal esophageal sensitivity with electrical stimulation and acid, and to compare the degree of acid-induced sensitization in controls and in patient groups across the entire spectrum of gastroesophageal reflux disease: erosive oesophagitis (EO), nonerosive reflux disease (NERD), and functional heartburn (FH). Esophageal sensory and pain thresholds to electrical stimulation were measured before, 30, and 60 minutes after an intraesophageal infusion of saline or HCl. Patients received a 30-minute infusion of 0.15 M HCl and controls were randomized to receive either HCl (n = 11) or saline (n = 10). After electrical sensory threshold testing, participants received another 30-minute infusion of HCl to determine whether sensitivity to acid is increased by prior acid exposure All patient groups had higher basal sensory thresholds than healthy controls (controls, 13 ± 1.4 mA; FH, 20 ± 5.1 mA; NERD, 21 ± 5.1 mA; EO, 23 ± 5.4 mA; P < 0.05). Acute esophageal acid exposure reduced sensory thresholds to electrical stimulation in FH and NERD patients (P < 0.05). The level of acid sensitivity during the first HCl infusion was comparable between all patient groups and controls. The secondary infusion caused increased discomfort in all participants (P < 0.01). This acid-induced sensitization to HCl was significantly elevated in the patient groups ( P < 0.05). (1) Esophageal acid infusion sensitizes it to subsequent electrical and chemical stimulation. (2) The acid-related sensitization is greater in gastroesophageal reflux disease than in controls and may influence in part symptom perception in this population. (3) Acid-related sensitization within the gastroesophageal reflux disease population is not dependant on mucosal inflammation.
Subramanian, Charumathi Raghu; Triadafilopoulos, George
Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents into the esophagus causes troublesome symptoms, esophageal injury, and/or complications. Use of proton pump inhibitors (PPI) remains the standard therapy for GERD and is effective in most patients. Those whose symptoms are refractory to PPIs should be evaluated further and other treatment options should be considered, according to individual patient characteristics. Response to PPIs could be total (no symptoms), partial (residual breakthrough symptoms), or absent (no change in symptoms). Patients experiencing complete response do not usually need further management. Patients with partial response can be treated surgically or by using emerging endoscopic therapies. Patients who exhibit no response to PPI need further evaluation to rule out other causes. PMID:25274499
Yuan, Yao Zong; Fang, Jing Yuan; Zou, Duo Wu; Levinson, Nigel; Jenner, Bartosz; Wilkinson, Joanne
To assess the efficacy of Gaviscon Double Action (DA) alginate antacid chewable tablets for reducing esophageal acid exposure in Chinese patients with gastroesophageal reflux disease (GERD). Altogether 44 patients reporting moderate to severe heartburn symptoms underwent two pH monitoring visits. The treatment sequence was randomized to patients received DA alginate antacid or placebo at one visit and the alternate treatment 7 days later. After a standardized reflux-provoking meal, patients took four tablets of DA alginate antacid or placebo. Esophageal pH was measured for 4 h post-dosing using an electrode positioned 5 cm above the lower esophageal sphincter. The primary end-point was the percentage of 4-h post-dosing period with pH <4. Secondary end-points were number of acid reflux episodes (pH <4), longest reflux time and DeMeester scores. All 44 patients completed the study and provided data for analysis. With DA alginate antacid, the mean percentage time with pH <4 was 5.1%, significantly less (P = 0.0003) than with placebo (14.8%). DA alginate antacid was statistically significantly superior (P = 0.0290) to placebo (from at least twofold to threefold better) for all other end-points. Two patients reported two mild adverse events (AEs) that resolved within a month of completing the study. No patients had serious and/or severe AEs and none withdrew due to AEs. DA alginate antacid was statistically significantly superior to placebo in reducing post-prandial acid exposure without serious clinically relevant health risks. These findings suggest DA alginate antacid tablets are appropriate for treating acid reflux in Chinese GERD patients with heartburn symptoms. © 2016 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.
Wu, Keng-Liang; Kuo, Chung-Mou; Yao, Chih-Chien; Tai, Wei-Chen; Chuah, Seng-Kee; Lim, Chee-Sang; Chiu, Yi-Chun
Acid changes in gastroesophageal reflux with vary component in the food have less been studied, especially carbohydrate. We plan to clarify the effect of different carbohydrate density on low esophageal acid and reflux symptoms of patients with gastroesophgeal reflux disease. Twelve patients (52 ± 12 years old; five female) with gastroesophageal reflux disease were recruited for the prospective crossover study. Each patient was invited for panendoscope, manometry and 24 h pH monitor. The two formulated liquid meal, test meal A: 500 ml liquid meal (containing 84.8 g carbohydrate) and B: same volume liquid meal (but 178.8 g carbohydrate) were randomized supplied as lunch or dinner. Reflux symptoms were recorded. There are significant statistic differences in more Johnson-DeMeester score (p = 0.019), total reflux time (%) (p = 0.028), number of reflux periods (p = 0.026) and longest reflux (p = 0.015) after high carbohydrate diet than low carbohydrate. Total reflux time and number of long reflux periods more than 5 min are significant more after high carbohydrate diet. More acid reflux symptoms are found after high carbohydrate diet. High carbohydrate diet could induce more acid reflux in low esophagus and more reflux symptoms in patients with gastroesophageal reflux disease. Copyright © 2018. Published by Elsevier B.V.
Woodland, Philip; Al-Zinaty, Mohannad; Yazaki, Etsuro; Sifrim, Daniel
Patients with non-erosive reflux disease (NERD) have impaired oesophageal mucosal integrity (dilated intercellular spaces). Oesophageal mucosal integrity reflects the balance between repeated reflux damage and mucosal recovery. The relationship between mucosal integrity and acid sensitivity is unclear. Oesophageal impedance may be used for in vivo mucosal integrity measurement. We studied acid-induced changes in oesophageal mucosal integrity and acid perception in patients with heartburn. 50 patients with heartburn whithout oesophagitis underwent impedance monitoring before, during and after 10 min oesophageal perfusion with neutral (pH 6.5) and acid solutions (pH 1). Symptoms and impedance were recorded during perfusion. Impedance recovery was assessed for 2 h post-perfusion in ambulatory conditions followed by 24-h impedance-pH study. Reflux monitoring discriminated 20 NERD and 30 functional heartburn (FH) patients. Neutral perfusion caused impedance fall that recovered within 10 min. Acid perfusion caused impedance fall with slow recovery: 6.5 Ω/min (IQR 3.3-12.0 Ω/min). Patients with slow recovery (< 25th percentile) had lower baseline impedance (1273 Ω ± 208 Ω vs. 3220 Ω ± 275 Ω ±, p < 0.01) and more frequent acid sensitivity (10/12 vs. 4/12, p = 0.04) than those with fast (> 75th percentile) recovery. Patients with NERD had lower baseline impedance (1669 ± 182 Ω vs. 2384 ± 211 Ω, p = 0.02) and slower impedance recovery (6.0 ± 0.9 Ω/min vs. 10.7 ± 1.6 Ω/min, p = 0.03) than patients with FH. Impaired mucosal integrity might be the consequence of repeated reflux episodes with slow recovery. Mucosal integrity, recovery capacity and symptom perception are linked. Low basal impedance and slow recovery after acid challenge are associated with increased acid sensitivity.
Scarpellini, E; Boecxstaens, V; Broers, C; Vos, R; Pauwels, A; Tack, J
Postprandial gastroesophageal reflux (PGER) in the distal esophagus (DE) is associated with a gastric juice 'acid pocket' (AP). Baclofen reduces AP extension into the DE in healthy volunteers, in part through increased lower esophageal sphincter (LES) pressure. We aimed to verify whether baclofen also affects postprandial AP location and extent in gastroesophageal reflux disease (GERD) patients. Thirteen treatment-naive heartburn-prevalent GERD patients underwent two AP studies, after pretreatment with baclofen 40 mg or placebo 30 minutes preprandially. We performed pH-probe stepwise pull-throughs (PT) (1 cm/min, LES -10 to +5 cm) before and every 30 minutes from 30 minutes before up to 150 minutes after a test meal. After the meal, both after placebo and baclofen, gastric pH significantly dropped at 30, 60, 90 minutes postprandially (P: nadir pHs of 3.9 ± 0.6, 2.3 ± 0.6, 2.1 ± 0.4; B: nadir pHs of 2.5 ± 0.4, 2.8 ± 0.4, 2.5 ± 0.3; all P < 0.05). After placebo, LES pressure decreased at 60, 90 and 120 minutes postprandially (32.7 ± 6.1 vs. 24.5 ± 3.1, 27.3 ± 5.9, 27.3 ± 6.0 mmHg; analysis of variance [ANOVA], P = 0.037), but this was prevented by baclofen (25.4 ± 3.4 vs. 29.4 ± 2, 32.2 ± 1.4, 35.5 ± 1.7 mmHg, ANOVA, P = not significant (NS)). Baclofen did not significantly decrease the postprandial AP extent above the LES but prevented the postprandial increase in transient lower esophageal sphincter relaxations (TLESRs) (preprandial vs. postprandial, placebo: 1.1 ± 0.3 vs. 3.7 ± 0.7, P < 0.05; baclofen: 1.4 ± 0.4 vs. 2 ± 0.5, P = NS). In GERD patients, baclofen significantly increases postprandial LES pressure, prevents the increase TLESRs but, unlike in healthy volunteers, does not affect AP extension into the DE. © 2015 International Society for Diseases of the Esophagus.
Gyawali, C Prakash; Fass, Ronnie
Management of gastroesophageal reflux disease (GERD) commonly starts with an empiric trial of proton pump inhibitor (PPI) therapy and complementary lifestyle measures, for patients without alarm symptoms. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. Patients with continued symptoms can be evaluated with endoscopy and tests of esophageal physiology, to better determine their disease phenotype and optimize treatment. Laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic therapies can benefit patients with well-characterized GERD. Patients with functional diseases that overlap with or mimic GERD can also be treated with neuromodulators (primarily antidepressants), or psychological interventions (psychotherapy, hypnotherapy, cognitive and behavioral therapy). Future approaches to treatment of GERD include potassium-competitive acid blockers, reflux-reducing agents, bile acid binders, injection of inert substances into the esophagogastric junction, and electrical stimulation of the lower esophageal sphincter. Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.
Asaoka, Daisuke; Nagahara, Akihito; Hojo, Mariko; Matsumoto, Kenshi; Ueyama, Hiroya; Matsumoto, Kohei; Izumi, Kentaro; Takeda, Tsutomu; Komori, Hiroyuki; Akazawa, Yoichi; Shimada, Yuji; Osada, Taro; Watanabe, Sumio
The aim of the present study was to investigate the efficacy of a potassium-competitive acid blocker (PCAB) named vonoprazan (VPZ) for improving symptoms in patients with reflux esophagitis (RE), non-erosive reflux disease (NERD), and functional dyspepsia (FD). A hospital-based, retrospective study of outpatients in our department (Department of Gastroenterology, University of Juntendo, Tokyo, Japan) between March 2015 and August 2016 was performed. The patients who were experiencing heartburn, acid regurgitation, gastric pain, and/or a heavy feeling in the stomach of at least moderate severity at baseline were treated with 20 mg VPZ once daily for 4 weeks. The patients completed the global overall symptom (GOS) scale to determine their symptom severity at baseline and after the 4 week treatment period. The proportions of patients with RE, NERD, and FD achieving improvement of their symptoms, defined as a GOS scale score of 1 ('no problem') or 2 ('minimal problem'), were evaluated. During 4 weeks of VPZ therapy, changes in the gastroesophageal reflux disease (GERD) score, which was defined as the total points for heartburn and acid regurgitation on the GOS scale in patients with RE and NERD, and in the FD score, which was defined as the total points for gastric pain and a heavy feeling in the stomach on the GOS scale in patients with FD, were also evaluated. A total of 88 eligible cases were included in the present study, comprising 20 patients with RE, 25 patients with NERD, and 43 patients with FD. The rates of symptomatic improvement in patients with RE, NERD, and FD were 75.0, 60.0, and 48.8%, respectively. For the patients who were first administered VPZ, the rates of symptomatic improvement were 90.9, 66.7, and 58.8% in patients with RE, NERD, and FD, respectively. For those patients who were resistant to 8 weeks of proton pump inhibitor therapy, the rates of symptomatic improvement were 55.6, 53.8, and 42.3% in patients with RE, NERD, and FD, respectively
Gavini, S; Borges, L F; Finn, R T; Lo, W-K; Goldberg, H J; Burakoff, R; Feldman, N; Chan, W W
Gastroesophageal reflux (GER) has been associated with idiopathic pulmonary fibrosis (IPF). Pathogenesis may be related to chronic micro-aspiration. We aimed to assess objective measures of GER on multichannel intraluminal impedance and pH study (MII-pH) and their relationship with pulmonary function testing (PFT) results, and to compare the performance of pH/acid reflux parameters vs corresponding MII/bolus parameters in predicting pulmonary dysfunction in IPF. This was a retrospective cohort study of IPF patients undergoing prelung transplant evaluation with MII-pH off acid suppression, and having received PFT within 3 months. Patients with prior fundoplication were excluded. Severe pulmonary dysfunction was defined using diffusion capacity of the lung for carbon monoxide (DLCO) ≤40%. Six pH/acid reflux parameters with corresponding MII/bolus reflux measures were specified a priori. Multivariate analyses were applied using forward stepwise logistic regression. Predictive value of each parameter for severe pulmonary dysfunction was calculated by area-under-the-receiver-operating-characteristic-curve or c-statistic. Forty-five subjects (67% M, age 59, 15 mild-moderate vs 30 severe) met criteria for inclusion. Patient demographics and clinical characteristics were similar between pulmonary dysfunction groups. Abnormal total reflux episodes and prolonged bolus clearance time were significantly associated with pulmonary dysfunction severity on univariate and multivariate analyses. No pH parameters were significant. The c-statistic of each pH parameter was lower than its MII counterpart in predicting pulmonary dysfunction. MII/bolus reflux, but not pH/acid reflux, was associated with pulmonary dysfunction in prelung transplant patients with IPF. MII-pH may be more valuable than pH testing alone in characterizing GER in IPF. © 2016 John Wiley & Sons Ltd.
Prichard, David O; Byrne, Anne Marie; Murphy, James O; Reynolds, John V; O'Sullivan, Jacintha; Feighery, Ronan; Doyle, Brendan; Eldin, Osama Sharaf; Finn, Stephen P; Maguire, Aoife; Duff, Deirdre; Kelleher, Dermot P; Long, Aideen
The fundamental mechanisms underlying erosive oesophagitis and subsequent development of Barrett's oesophagus (BO) are poorly understood. Here, we investigated the contribution of specific components of the gastric refluxate on adhesion molecules involved in epithelial barrier maintenance. Cell line models of squamous epithelium (HET-1A) and BO (QH) were used to examine the effects of bile acids on cell adhesion to extracellular matrix proteins (Collagen, laminin, vitronectin, fibronectin) and expression of integrin ligands (α 3 , α 4, α 5 , α 6 and α ν ). Experimental findings were validated in human explant oesophageal biopsies, a rat model of gastroesophageal reflux disease (GORD) and in patient tissue microarrays. The bile acid deoxycholic acid (DCA) specifically reduced adhesion of HET-1A cells to vitronectin and reduced cell-surface expression of integrin-α ν via effects on endocytic recycling processes. Increased expression of integrin-α v was observed in ulcerated tissue in a rat model of GORD and in oesophagitis and Barrett's intestinal metaplasia patient tissue compared to normal squamous epithelium. Increased expression of integrin-α ν was observed in QH BO cells compared to HET-1A cells. QH cells were resistant to DCA-mediated loss of adhesion and reduction in cell-surface expression of integrin-α ν . We demonstrated that a specific component of the gastric refluxate, DCA, affects the epithelial barrier through modulation of integrin α ν expression, providing a novel mechanism for bile acid-mediated erosion of oesophageal squamous epithelium and promotion of BO. Strategies aimed at preventing bile acid-mediated erosion should be considered in the clinical management of patients with GORD. © 2017 The Authors. Journal of Cellular and Molecular Medicine published by John Wiley & Sons Ltd and Foundation for Cellular and Molecular Medicine.
Dziekiewicz, M A; Karolewska-Bochenek, K; Dembiński, Ł; Gawronska, A; Krenke, K; Lange, J; Banasiuk, M; Kuchar, E; Kulus, M; Albrecht, P; Banaszkiewicz, A
Gastroesophageal reflux disease is common in adult patients with interstitial lung disease. However, no data currently exist regarding the prevalence and characteristics of the disease in pediatric patients with interstitial lung disease. The aim of the present study was to prospectively assess the incidence of gastroesophageal reflux disease and characterize its features in children with interstitial lung disease. Gastroesophageal reflux disease was established based on 24 h pH-impedance monitoring (MII-pH). Gastroesophageal reflux episodes (GERs) were classified according to widely recognized criteria as acid, weakly acid, weakly alkaline, or proximal. Eighteen consecutive patients (15 boys, aged 0.2-11.6 years) were enrolled in the study. Gastroesophageal reflux disease was diagnosed in a half (9/18) of children. A thousand GERs were detected by MII-pH (median 53.5; IQR 39.0-75.5). Of these, 585 (58.5 %) episodes were acidic, 407 (40.7 %) were weakly acidic, and eight (0.8 %) were weakly alkaline. There were 637 (63.7 %) proximal GERs. The patients in whom gastroesophageal reflux disease was diagnosed had a significantly higher number of proximal and total GERs. We conclude that the prevalence of gastroesophageal reflux disease in children with interstitial lung disease is high; thus, the disease should be considered regardless of presenting clinical symptoms. A high frequency of non-acid and proximal GERs makes the MII-pH method a preferable choice for the detection of reflux episodes in this patient population.
AIM OF THE REVIEW AND METHODS: This review brings together information on the treatment of gastroesophageal reflux disease. Published manuscripts were identified from Medline. The articles were then screened for relevance prior to inclusion in the review. Up to 40% of people in Western countries are estimated to regularly experience heartburn, the most characteristic symptom of gastroesophageal reflux disease (GERD). Treatment options available for GERD range from over-the-counter (OTC) antacids to proton pump inhibitors (PPIs) and anti-reflux surgery. Many patients self-medicate with OTC medications such as antacids and low-dose histamine H2-receptor antagonists (H2RA) to relieve episodic or food-related symptoms of GERD, and may not seek medical advice unless symptoms persist or worsen. However, GERD is a chronic disease that frequently affects health-related quality of life and, if not properly managed, the complications of GERD may include erosive oesophagitis (EO), Barrett's oesophagus and adenocarcinoma. Adequate control of acid secretion is key to the successful treatment of the condition. OTC medications provide effective symptom relief to about one quarter of patients suffering from GERD. H2RAs can also provide effective symptomatic relief, particularly in patients with milder GERD, but become less-effective over time. PPIs are the agents of choice for the suppression of gastric acid production and have become the mainstay of therapy for acid-related diseases. PPIs produce significantly faster and more complete symptomatic relief, significantly faster and more complete healing of erosive GERD compared with H2RAs and are also significantly more effective at preventing relapse of EO. There are a number of existing guidelines for the treatment of GERD. Recommendation for initial therapy consist of general measures, such as lifestyle advice in combination with antacids and/or alginates. When general measures fail, the next step is empirical therapy. Two
Peptic esophagitis - children; Reflux esophagitis - children; GERD - children; Heartburn - chronic - children; Dyspepsia - GERD - children ... GERD. Certain factors can lead to GERD in children, including: Birth defects, such as hiatal hernia , a ...
... is a condition in which the stomach contents leak backward from the stomach into the esophagus (food ... not close all the way, stomach contents can leak back into the esophagus. This is called reflux ...
Nakagawa, Kenichiro; Koike, Tomoyuki; Iijima, Katsunori; Saito, Masahiro; Kikuchi, Hiroki; Hatta, Waku; Ara, Nobuyuki; Uno, Kaname; Asano, Naoki; Shimosegawa, Tooru
AIM: To clarify the pathogenesis of gastroesophageal reflux disease symptoms in non-erosive reflux disease (NERD) patients. METHODS: Thirty-five NERD patients with persistent symptoms, despite taking rabeprazole 10 mg twice daily for at least 8 wk, were included in this study. All patients underwent 24 h combined impedance - pH on rabeprazole. The symptom index (SI) was considered to be positive if ≥ 50%, and proximal reflux episodes were determined when reflux reached 15 cm above the proximal margin of the lower esophageal sphincter. RESULTS: In 14 (40%) SI-positive patients, with liquid weakly acid reflux, the occurrence rate of reflux symptoms was significantly more frequent in proximal reflux episodes (46.7%) than in distal ones (5.7%) (P < 0.001). With liquid acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (38.5%) and distal ones (20.5%) (NS). With mixed liquid-gas weakly acid reflux, the occurrence rate of reflux symptoms in proximal reflux episodes was significantly more frequent (31.0%) than in distal reflux ones (3.3%) (P < 0.001). With mixed liquid-gas acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (29.4%) and distal ones (14.3%) (NS). CONCLUSION: The proximal extent of weakly acidic liquid and mixed liquid-gas reflux is a major factor associated with reflux perception in SI-positive patients on proton pump inhibitor therapy. PMID:26715820
Nakagawa, Kenichiro; Koike, Tomoyuki; Iijima, Katsunori; Saito, Masahiro; Kikuchi, Hiroki; Hatta, Waku; Ara, Nobuyuki; Uno, Kaname; Asano, Naoki; Shimosegawa, Tooru
To clarify the pathogenesis of gastroesophageal reflux disease symptoms in non-erosive reflux disease (NERD) patients. Thirty-five NERD patients with persistent symptoms, despite taking rabeprazole 10 mg twice daily for at least 8 wk, were included in this study. All patients underwent 24 h combined impedance - pH on rabeprazole. The symptom index (SI) was considered to be positive if ≥ 50%, and proximal reflux episodes were determined when reflux reached 15 cm above the proximal margin of the lower esophageal sphincter. In 14 (40%) SI-positive patients, with liquid weakly acid reflux, the occurrence rate of reflux symptoms was significantly more frequent in proximal reflux episodes (46.7%) than in distal ones (5.7%) (P < 0.001). With liquid acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (38.5%) and distal ones (20.5%) (NS). With mixed liquid-gas weakly acid reflux, the occurrence rate of reflux symptoms in proximal reflux episodes was significantly more frequent (31.0%) than in distal reflux ones (3.3%) (P < 0.001). With mixed liquid-gas acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (29.4%) and distal ones (14.3%) (NS). The proximal extent of weakly acidic liquid and mixed liquid-gas reflux is a major factor associated with reflux perception in SI-positive patients on proton pump inhibitor therapy.
Barnhart, Douglas C
Despite the frequency with which antireflux procedures are performed, decisions about gastroesophageal reflux disease treatment remain challenging. Several factors contribute to the difficulties in managing gastroesophageal reflux. First, the distinction between physiologic and pathologic gastroesophageal reflux (gastroesophageal reflux disease-GERD) is not always clear. Second, measures of the extent of gastroesophageal reflux often poorly correlate to symptoms or other complications attributed to reflux in infants and children. A third challenge is that the outcome of antireflux procedures, predominately fundoplications, are relatively poorly characterized. All of these factors contribute to difficulty in knowing when to recommend antireflux surgery. One of the manifestations of the uncertainties surrounding GERD is the high degree of variability in the utilization of pediatric antireflux procedures throughout the United States. Pediatric surgeons are frequently consulted for GERD and fundoplication, uncertainties notwithstanding. Although retrospective series and anecdotal observations support fundoplication in some patients, there are many important questions for which sufficient high-quality data to provide a clear answer is lacking. In spite of this, surgeons need to provide guidance to patients and families while awaiting the development of improved evidence to aid in these recommendations. The purpose of this article is to define what is known and what is uncertain, with an emphasis on the most recent evidence. Copyright © 2016 Elsevier Inc. All rights reserved.
Troncon, L.E.; Rezende Filho, J.; Iazigi, N.
Increased duodenogastric reflux has been recognized as a cause of gastric mucosa damage. The frequent finding of bile-stained gastric juice and a suggested higher frequency of lesions of the gastric mucosa in patients with Chagas' disease, which is characterized by a marked reduction of myenteric neurons, suggest that impairment of intrinsic innervation of the gut might be associated with increased duodenogastric reflux. Duodenogastric bile reflux was quantified after intravenous injection of 99mtechnetium-HIDA, in 18 patients with chronic Chagas' disease, 12 controls, and 7 patients with Billroth II gastrectomy. All but one of the chagasic patients were submitted to upper digestivemore » tract endoscopy. High reflux values (greater than or equal to 10%) were detected both in chagasic patients and in the controls, but the values for both groups were significantly lower (P less than 0.01) than those obtained for Billroth II patients (median: 55.79%; range: 12.58-87.22%). Reflux values tended to be higher in the Chagas' disease group (median: 8.20%; range: 0.0-29.40%) than in the control group (median: 3.20%; range: 0.0-30.64%), with no statistical difference between the two groups (P greater than 0.10). Chronic gastritis was detected by endoscopy in 12 chagasic patients, benign gastric ulcer in 2 patients, and a pool of bile in the stomach in 11 patients. However, neither the occurrence of gastric lesions nor the finding of bile-stained gastric juice was associated with high reflux values after (99mTc)HIDA injection. This study suggests that lesions of the intramural nervous system of the gut in Chagas' disease do not appear to be associated with abnormally increased duodenogastric reflux.« less
Mendes-Filho, Antonio Moreira; Moraes-Filho, Joaquim Prado Pinto; Nasi, Ary; Eisig, Jaime Natan; Rodrigues, Tomas Navarro; Barbutti, Ricardo Correa; Campos, Josemberg Marins; Chinzon, Decio
Gastroesophageal reflux disease is a worldwide prevalent condition that exhibits a large variety of signs and symptoms of esophageal or extra-esophageal nature and can be related to the esophagic adenocarcinoma. In the last few years, greater importance has been given to the influence of physical exercises on it. Some recent investigations, though showing conflicting results, point to an exacerbation of gastroesophageal reflux during physical exercises. To evaluate the influence of physical activities in patients presenting with erosive and non erosive disease by ergometric stress testing and influence of the lower esophageal sphincter tonus and body mass index during this situation. Twenty-nine patients with erosive disease (group I) and 10 patients with non-erosive disease (group II) were prospectively evaluated. All the patients were submitted to clinical evaluation, followed by upper digestive endoscopy, manometry and 24 h esophageal pH monitoring. An ergometric testing was performed 1 h before removing the esophageal pH probe. During the ergometric stress testing, the following variables were analyzed: test efficacy, maximum oxygen uptake, acid reflux duration, gastroesophageal reflux symptoms, influence of the lower esophageal sphincter tonus and influence of body mass index in the occurrence of gastroesophageal reflux during these physical stress. Maximum oxigen consumption or VO 2 max, showed significant correlation when it was 70% or higher only in the erosive disease group, evaluating the patients with or without acid reflux during the ergometric testing (p=0,032). The other considered variables didn't show significant correlations between gastroesophageal reflux and physical activity (p>0,05). 1) Highly intensive physical activity can predispose the occurrence of gastroesophageal reflux episodes in gastroesophageal reflux disease patients with erosive disease; 2) light or short sessions of physical activity have no influence on reflux, regardless of body
MENDES-FILHO, Antonio Moreira; MORAES-FILHO, Joaquim Prado Pinto; NASI, Ary; EISIG, Jaime Natan; RODRIGUES, Tomas Navarro; BARBUTTI, Ricardo Correa; CAMPOS, Josemberg Marins; CHINZON, Décio
Background Gastroesophageal reflux disease is a worldwide prevalent condition that exhibits a large variety of signs and symptoms of esophageal or extra-esophageal nature and can be related to the esophagic adenocarcinoma. In the last few years, greater importance has been given to the influence of physical exercises on it. Some recent investigations, though showing conflicting results, point to an exacerbation of gastroesophageal reflux during physical exercises. Aim To evaluate the influence of physical activities in patients presenting with erosive and non erosive disease by ergometric stress testing and influence of the lower esophageal sphincter tonus and body mass index during this situation. Methods Twenty-nine patients with erosive disease (group I) and 10 patients with non-erosive disease (group II) were prospectively evaluated. All the patients were submitted to clinical evaluation, followed by upper digestive endoscopy, manometry and 24 h esophageal pH monitoring. An ergometric testing was performed 1 h before removing the esophageal pH probe. During the ergometric stress testing, the following variables were analyzed: test efficacy, maximum oxygen uptake, acid reflux duration, gastroesophageal reflux symptoms, influence of the lower esophageal sphincter tonus and influence of body mass index in the occurrence of gastroesophageal reflux during these physical stress. Results Maximum oxigen consumption or VO 2 max, showed significant correlation when it was 70% or higher only in the erosive disease group, evaluating the patients with or without acid reflux during the ergometric testing (p=0,032). The other considered variables didn't show significant correlations between gastroesophageal reflux and physical activity (p>0,05). Conclusions 1) Highly intensive physical activity can predispose the occurrence of gastroesophageal reflux episodes in gastroesophageal reflux disease patients with erosive disease; 2) light or short sessions of physical activity have
Pacheco-Galván, Adalberto; Hart, Simon P; Morice, Alyn H
Our understanding of the relationship between gastro-oesophageal reflux and respiratory disease has recently undergone important changes. The previous paradigm of airway reflux as synonymous with the classic gastro-oesophageal reflux disease (GORD) causing heartburn has been overturned. Numerous epidemiological studies have shown a highly significant association of the acid, liquid, and gaseous reflux of GORD with conditions such as laryngeal diseases, chronic rhinosinusitis, treatment resistant asthma, COPD and even idiopathic pulmonary fibrosis. However, it has become clear from studies on cough hypersensitivity syndrome that much reflux of importance in the airways has been missed, since it is either non- or weakly acid and gaseous in composition. The evidence for such a relationship relies on the clinical history pointing to symptom associations with known precipitants of reflux. The tools for the diagnosis of extra-oesophageal reflux, in contrast to the oesophageal reflux of GORD, lack sensitivity and reproducibility. Unfortunately, methodology for detecting such reflux is only just becoming available and much additional work is required to properly delineate its role. Copyright © 2011 SEPAR. Published by Elsevier Espana. All rights reserved.
Mancini, Valentina; Ribolsi, Mentore; Gentile, Massimo; de'Angelis, Gianluigi; Bizzarri, Barbara; Lindley, Keith J; Cucchiara, Salvatore; Cicala, Michele; Borrelli, Osvaldo
We sought to compare intercellular space diameter in children with non-erosive and erosive reflux disease, and a control group. We also aimed to characterize the reflux pattern in erosive and non-erosive reflux disease patients, and to explore the relationship between intercellular space diameter values and reflux parameters. Twenty-four children with non-erosive reflux disease, 20 with erosive reflux disease, and 10 controls were prospectively studied. All patients and controls underwent upper endoscopy. Biopsies were taken at 2-3 cm above the Z-line, and intercellular space diameter was measured using transmission electron microscopy. Non-erosive and erosive reflux disease patients underwent impedance-pH monitoring. Mean intercellular space diameter values were significantly higher in both non-erosive (0.9 ± 0.2 μm) and erosive reflux disease (1 ± 0.2 μm) compared to controls (0.5 ± 0.2 μm, p<0.01). No difference was found between the two patient groups. Acid exposure time, the number of acid, weakly acidic and weakly alkaline reflux events did not differ between the two patient groups. No difference was found in the mean intercellular space diameter between non-erosive reflux disease children with and without abnormal acid exposure time (1 ± 0.3 vs. 0.9 ± 0.2 μm). No correlation was found between any reflux parameter and intercellular space diameter values. Dilated intercellular space diameter seems to be a useful and objective marker of oesophageal damage in paediatric gastro-oesophageal reflux disease, regardless of acid exposure. In childhood, different gastro-oesophageal reflux disease phenotypes cannot be discriminated on the basis of reflux pattern. Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Tutuian, Radu; Castell, Donald O
Gastroesophageal reflux disease (GERD) is a chronic condition requiring long-term treatment. Simple lifestyle modifications are the first methods employed by patients and, because of their low cost and simplicity, should be continued even when more potent therapies are initiated. Potent acid-suppressive therapy is currently the most important and successful medical therapy. Whereas healing of the esophageal mucosa is achieved with a single dose of any proton pump inhibitor (PPI) in more than 80% of cases, symptoms are more difficult to control. Patients with persistent symptoms on therapy should be tested (preferably with combined multichannel intraluminal impedance and pH) for association of symptoms with acid, nonacid, or no GER. Long-term follow-up studies indicate that PPIs are efficacious, tolerable, and safe medication. So far, promotility agents have shown limited efficacy, and their side-effect profile outweighs their benefits. Antireflux surgery in carefully selected patients (ie, young, typical GERD symptoms, abnormal pH study, and good response to PPI) is as effective as PPI therapy and should be offered to these patients as an alternative to medication. Still, patients should be informed about the risks of antireflux surgery (ie, risk of postoperative dysphagia; decreased ability to belch, possibly leading to bloating; increased flatulence). Endoscopic antireflux procedures are recommended only in selected patients and given the relative short experience with these techniques, patients treated with endoscopic procedures should be enrolled in a rigorous follow-up program.
Rubesin, Stephen E; Levine, Marc S
This article discusses the extraesophageal manifestations of gastroesophageal reflux disease, focusing primarily on the gamut of pharyngeal abnormalities that can be detected on barium swallows. Abnormalities of pharyngeal swallowing caused by gastroesophageal reflux are illustrated. We particularly emphasize how pharyngoesophageal relationships can guide the radiologist for performing tailored barium swallows to optimally evaluate pharyngeal abnormalities in patients with underlying gastroesophageal reflux disease.
Ahmad, Ijaz; Batch, A J G
Otolaryngological manifestations of acid reflux include a wide range of pharyngeal and laryngeal symptoms; and the constellation of symptoms has been called laryngopharyngeal reflux. This is a prospective study in a cohort of patients with various throat symptoms suggestive of laryngopharyngeal reflux (LPR) who underwent flexible oesophago-gastroscopy, as a principal investigation. The aims were to look at the most reliable symptom(s) and sign(s), the diagnostic role of flexible oesophago-gastroscopy and the treatment response in these patients. The endoscopy score of 0 to 3 was based on endoscopic findings and the treatment response was measured from 0 to 100 per cent improvement of symptoms, as described by the patients. There were a total of 303 patients, 174 females and 129 males with ages ranging from 19 to 88 years. Seventy-five per cent had had symptoms for more than a year. Fifteen per cent were smokers. Globus, voice change, sore throat, dysphagia and cough were the predominant symptoms. Most patients, however, presented with a complex of various other secondary symptoms. The endoscopic findings were abnormal in 98 per cent of patients. Apart from the finding of non-specific hyperaemia, usually of the posterior larynx (13 per cent), lesions of the larynx and vocal folds were surprisingly uncommon. Proton pump inhibitors (PPI) were prescribed in 90 per cent of patients. A total of 233 (76.8 per cent) responded to treatment. The improvement of symptoms ranged from 25 per cent in 36 (23 per cent), 50 per cent in 60 (20 per cent), 75 per cent in 59 (19 per cent) and 100 per cent in 78 (26 per cent) patients. Accumulative analysis of variance showed a significant difference between treatment responders and non-responders (p <0.04). In a logistic regression model patients with globus, voice change and gastric prolapse were more likely to respond to treatment (p <0.04). It can be concluded that voice change, sore throat, globus and cough choking are the most
Badillo, Raul; Francis, Dawn
Gastroesophageal reflux disease (GERD) is a common disease with a prevalence as high as 10%-20% in the western world. The disease can manifest in various symptoms which can be grouped into typical, atypical and extra-esophageal symptoms. Those with the highest specificity for GERD are acid regurgitation and heartburn. In the absence of alarm symptoms, these symptoms can allow one to make a presumptive diagnosis and initiate empiric therapy. In certain situations, further diagnostic testing is needed to confirm the diagnosis as well as to assess for complications or alternate causes for the symptoms. GERD complications include erosive esophagitis, peptic stricture, Barrett’s esophagus, esophageal adenocarcinoma and pulmonary disease. Management of GERD may involve lifestyle modification, medical therapy and surgical therapy. Lifestyle modifications including weight loss and/or head of bed elevation have been shown to improve esophageal pH and/or GERD symptoms. Medical therapy involves acid suppression which can be achieved with antacids, histamine-receptor antagonists or proton-pump inhibitors. Whereas most patients can be effectively managed with medical therapy, others may go on to require anti-reflux surgery after undergoing a proper pre-operative evaluation. The purpose of this review is to discuss the current approach to the diagnosis and treatment of gastroesophageal reflux disease. PMID:25133039
Pathogenesis of Double-Dose Proton Pump Inhibitor-Resistant Non-Erosive Reflux Disease, and Mechanism of Reflux Symptoms and Gastric Acid Secretion-Suppressive Effect in the Presence or Absence of Helicobacter pylori Infection.
Kawami, Noriyuki; Takenouchi, Nana; Umezawa, Mariko; Hoshino, Shintaro; Hanada, Yuriko; Hoshikawa, Yoshimasa; Sano, Hirohito; Hoshihara, Yoshio; Nomura, Tsutomu; Uchida, Eiji; Iwakiri, Katsuhiko
Various mechanisms have been suggested to be responsible for contributing to the occurrence of proton pump inhibitor (PPI)-resistant non-erosive reflux disease (NERD). The aims of this study were to clarify the pathogenesis of PPI-resistant NERD. Fifty-three patients with NERD, who had persistent reflux symptoms despite taking double-dose PPI, were included in this study. After excluding eosinophilic esophagitis (EoE) and primary esophageal motility disorder, esophageal impedance-pH monitoring was carried out. In symptom index (SI)-positive patients, the mechanism of SI positivity and the percent time with intragastric pH >4 were investigated according to the presence or absence of Helicobacter pylori infection. One of the 53 patients had EoE, and 4 had primary esophageal motility disorder. Twenty-three and 2 patients were SI-positive for liquid and gas-only reflux respectively. Of 17 SI-positive, H. pylori-negative patients, 5 were SI-positive for acid reflux, whereas all of the H. pylori-positive patients were SI-positive for non-acid reflux. The percent time with intragastric pH >4 was significantly lower in the H. pylori-negative patients than in the H. pylori-positive patients. The pathogenesis of double-dose PPI-resistant NERD was identified in 57%. In some of H. pylori-negative patients, acid-related symptoms were observed. However, in H. pylori-positive patients, these symptoms were excluded by taking double-dose PPI. © 2017 S. Karger AG, Basel.
Maqbool, Asim; Ryan, Matthew J
This relationship between gastroesophageal reflux and airway disorders is complex, possibly bidirectional, and not clearly defined. The tools used to investigate gastroesophageal reflux are mostly informative about involvement of gastroesophageal reflux within the gastrointestinal tract, although they are often utilized to study the relationship between gastroesophageal reflux and airway issues with are suspected to occur in relation to reflux. These modalities often lack specificity for reflux-related airway disorders. Co-incidence of gastroesophageal reflux and airway disorders does not necessarily infer causality. While much of our focus has been on managing acidity, controlling refluxate is an area that has not been traditionally aggressively pursued. Our management approach is based on some of the evidence presented, but also often from a lack of adequate study to provide further guidance. Copyright © 2018 Mosby, Inc. All rights reserved.
Ness-Jensen, Eivind; Lagergren, Jesper
Gastro-oesophageal reflux disease (GORD) develops when reflux of gastric content causes troublesome symptoms or complications. The main symptoms are heartburn and acid regurgitation and complications include oesophagitis, strictures, Barrett's oesophagus and oesophageal adenocarcinoma. In addition to hereditary influence, GORD is associated with lifestyle factors, mainly obesity. Tobacco smoking is regarded as an aetiological factor of GORD, while alcohol consumption is considered a triggering factor of reflux episodes and not a causal factor. Yet, both tobacco smoking and alcohol consumption can reduce the lower oesophageal sphincter pressure, facilitating reflux. In addition, tobacco smoking reduces the production of saliva rich in bicarbonate, which is important for buffering and clearance of acid in the oesophagus. Alcohol also has a direct noxious effect on the oesophageal mucosa, which predisposes to acidic injury. Tobacco smoking cessation reduces the risk of GORD symptoms and avoidance of alcohol is encouraged in individuals where alcohol consumption triggers reflux. Copyright © 2017 Elsevier Ltd. All rights reserved.
Gyawali, C Prakash
Proton pump inhibitor (PPI) use in gastroesophageal reflux disease (GERD) has been redefined, in light of recent advances highlighting GERD phenotypes that respond to PPIs, and fresh revelations of potential risks of long-term PPI therapy. Erosive esophagitis predicts excellent response to PPI therapy, but non-erosive reflux disease (NERD) with abnormal reflux parameters on ambulatory reflux monitoring also demonstrates a similar response. In contrast, response is suboptimal in the absence of abnormal reflux parameters. In this setting, if an alternate appropriate indication for PPI therapy does not coexist, risks may outweigh benefits of PPI therapy. Adverse events from long-term PPI therapy continue to be reported, most based on association rather than cause-and-effect. Appropriate indications need to be established before embarking on long-term PPI therapy. Future research will define true risks of long-term PPI therapy, and develop alternate management options for acid peptic diseases.
Wang, Hong; Tian, Yuan; Ding, Yan
To study the relationship between esophageal motor functional disorder [decreased lower esophageal sphincter pressure (LESP)and ineffective motility (IEM)] and gastroesophageal reflux disease (GERD). Totally 89 patients with GERD were enrolled in this study. All of them underwent 24-hour pH monitoring with dual-channel probe and stationary esophageal manometry. In addition, 77 of these patients underwent upper endoscopy. IEM and LES, 10 mmHg were common disturbances in patients with GERD (54% and 48%, respectively). The number of the acid reflux events of distal esophagus and prevalence of moderate or severe erosive esophagitis (EE) were significantly higher in patients with low LESP and IEM than patients without low LESP ( P<0.05). The number of the acid reflux events in distal esophagus was significantly correlated with the severity of esophagitis, distal esophagus amplitude, and LESP, while no such correlation was found between IEM and degree of esophageal acid exposure or esophagitis. The pathophysiology of GERD is probably multifactorial. Lower LESP or IEM is not a independent pathophysiological factor for GERD. However,one single factor is insufficient to explain all the pathogenic mechanism of GERD.
Kahrilas, Peter J; Jonsson, Andreas; Denison, Hans; Wernersson, Börje; Hughes, Nesta; Howden, Colin W
Objective Limited data exist on the impact of regurgitation on health-related quality of life (HRQOL) in gastro-oesophageal reflux disease (GORD). We assessed the relationship between regurgitation frequency and HRQOL before and after acid suppression therapy in GORD. Method We used data from two randomised trials of AZD0865 25–75 mg/day vs. esomeprazole 20 or 40 mg/day in non-erosive reflux disease (NERD) (n=1415) or reflux oesophagitis (RO) (n=1460). The Reflux Disease Questionnaire was used to select patients with frequent and intense heartburn for inclusion and to assess treatment response. The Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire was used to assess HRQOL. Results At baseline, 93% of patients in both the NERD and RO groups experienced regurgitation. Mean QOLRAD scores were similar for NERD and RO at baseline and at week 4 and disclosed decremental HRQOL with increasing frequency of regurgitation; a clinically relevant difference of >0.5 in mean QOLRAD scores was seen with regurgitation ≥4 days/week vs. <4 days/week. The prevalence of frequent, persistent regurgitation (≥4 days/week) at week 4 among heartburn responders (≤1 day/week of mild heartburn) was 28% in NERD and 23% in RO. QOLRAD scores were higher amongst heartburn responders. There was a similar pattern of impact related to regurgitation frequency in heartburn responders as in the group as a whole. Conclusion Frequent regurgitation was associated with a clinically relevant, incremental decline in HRQOL beyond that associated with heartburn before and after potent acid suppression, in both NERD and RO. Clinical trial numbers NCT00206284 and NCT00206245. PMID:23831734
Kahrilas, Peter J; Jonsson, Andreas; Denison, Hans; Wernersson, Börje; Hughes, Nesta; Howden, Colin W
Limited data exist on the impact of regurgitation on health-related quality of life (HRQOL) in gastro-oesophageal reflux disease (GORD). We assessed the relationship between regurgitation frequency and HRQOL before and after acid suppression therapy in GORD. We used data from two randomised trials of AZD0865 25-75 mg/day versus esomeprazole 20 or 40 mg/day in non-erosive reflux disease (NERD) (n=1415) or reflux oesophagitis (RO) (n=1460). The Reflux Disease Questionnaire was used to select patients with frequent and intense heartburn for inclusion and to assess treatment response. The Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire was used to assess HRQOL. At baseline, 93% of patients in both the NERD and RO groups experienced regurgitation. Mean QOLRAD scores were similar for NERD and RO at baseline and at week 4 and disclosed decremental HRQOL with increasing frequency of regurgitation; a clinically relevant difference of >0.5 in mean QOLRAD scores was seen with regurgitation ≥4 days/week versus <4 days/week. The prevalence of frequent, persistent regurgitation (≥4 days/week) at week 4 among heartburn responders (≤1 day/week of mild heartburn) was 28% in NERD and 23% in RO. QOLRAD scores were higher among heartburn responders. There was a similar pattern of impact related to regurgitation frequency in heartburn responders compared with the group as a whole. Frequent regurgitation was associated with a clinically relevant, incremental decline in HRQOL beyond that associated with heartburn before and after potent acid suppression in both NERD and RO. NCT00206284 and NCT00206245.
Martinucci, Irene; de Bortoli, Nicola; Giacchino, Maria; Bodini, Giorgia; Marabotto, Elisa; Marchi, Santino; Savarino, Vincenzo; Savarino, Edoardo
Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophageal motility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from non-erosive reflux disease to erosive reflux disease and Barrett's esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.
Bor, Serhat; Valytova, Elen; Yildirim, Esra; Vardar, Rukiye
Background The role of sexual activity on gastroesophageal reflux disease (GERD) is an under-recognized concern of patients, and one rarely assessed by physicians. Objective The objective of this article is to determine the influence of sexual activity on the intraesophageal acid exposure and acid reflux events in GERD patients. Methods Twenty-one patients with the diagnosis of GERD were prospectively enrolled. Intraesophageal pH monitoring was recorded for 48 hours with a Bravo capsule. All patients were instructed to have sexual intercourse or abstain in a random order two hours after the same refluxogenic dinner within two consecutive nights. Patients were requested to have sex in the standard “missionary position” and women were warned to avoid abdominal compression. The patients completed a diary reporting the time of the sexual intercourse and GERD symptoms. The percentage of reflux time and acid reflux events were compared in two ways: within 30 and 60 minutes prior to and after sexual intercourse on the day of sexual intercourse and in the same time frame of the day without sexual intercourse. Results Fifteen of 21 GERD patients were analyzed. The percentage of reflux time and number of acid reflux events did not show a significant difference within the 30- and 60-minute periods prior to and after sexual intercourse on the day of sexual intercourse and on the day without sexual intercourse, as well. Conclusion Sexual activity does not predispose to increased intraesophageal acid exposure and acid reflux events. Larger studies are needed to confirm our findings in patients who define reflux symptoms during sexual intercourse. PMID:25452843
Heidelbaugh, Joel J; Gill, Arvin S; Van Harrison, R; Nostrant, Timothy T
Gastroesophageal reflux disease typically manifests as heartburn and regurgitation, but it may also present with atypical or extraesophageal symptoms, including asthma, chronic cough, laryngitis, hoarseness, chronic sore throat, dental erosions, and noncardiac chest pain. Diagnosing atypical manifestations of gastroesophageal reflux disease is often a challenge because heartburn and regurgitation may be absent, making it difficult to prove a cause-and-effect relationship. Upper endoscopy and 24-hour pH monitoring are insensitive and not useful for many patients as initial diagnostic modalities for evaluation of atypical symptoms. In patients with gastroesophageal reflux disease who have atypical or extraesophageal symptoms, aggressive acid suppression using proton pump inhibitors twice daily before meals for three to four months is the standard treatment, although some studies have failed to show a significant benefit in symptomatic improvement. If these symptoms improve or resolve, patients may step down to a minimal dose of antisecretory therapy over the following three to six months. Surgical intervention via Nissen fundoplication is an option for patients who are unresponsive to aggressive antisecretory therapy. However, long-term studies have shown that some patients still require antisecretory therapy and are more likely to develop dysphagia, rectal flatulence, and the inability to belch or vomit.
Lee, Kwang Jae
The prevalence of gastroesophageal reflux disease (GERD) in South Korea has increased over the past 10 years. Patients with erosive reflux disease (ERD) shows better response to proton pump inhibitors (PPIs) than those with non-erosive reflux disease (NERD). NERD is a heterogeneous condition, showing pathological gastroesophageal reflux or esophageal hypersensitivity to reflux contents. NERD patients with pathological gastroesophageal reflux or hypersensitivity to acid may respond to PPIs. However, many patients with esophageal hypersensitivity to nonacid or functional heartburn do not respond to PPIs. Therefore, careful history and investigations are required when managing patients with refractory GERD who show poor response to conventional dose PPIs. Combined pH-impedance studies and a PPI diagnostic trial are recommended to reveal underlying mechanisms of refractory symptoms. For those with ongoing reflux-related symptoms, split dose administration, change to long-acting PPIs or PPIs less influenced by CYP2C19 genotypes, increasing dose of PPIs, and the addition of alginate preparations, prokinetics, selective serotonin reuptake inhibitors, or tricyclic antidepressants can be considered. Pain modulators, selective serotonin reuptake inhibitors, or tricyclic antidepressants are more likely to be effective for those with reflux-unrelated symptoms. Surgery or endoscopic per oral fundoplication may be effective in selected patients.
Baker, Shannon J; Johnson, Philip J; David, Andrew; Cook, Cristi Reeves
Chronic gastroesophageal reflux disease was diagnosed in a 22-year-old female Tennessee Walking Horse that had signs of bruxism and ptyalism. Esophageal ulceration was detected via endoscopy. Compared with the damage to the proximal portions of the esophagus, the severity of the ulceration increased toward the gastroesophageal junction. Esophageal ulceration attributable to chronic gastric acid reflux is usually secondary to pyloric outflow obstruction in horses. In the horse of this report, there was no evidence of either a chronic pyloric or duodenal obstruction that could have resulted in esophageal ulceration. Esophageal ulceration in this horse was attributed to gastroesophageal reflux disease, a common condition in humans in which the underlying abnormality is functional incompetence of the gastroesophageal junction. Treatment is directed at decreasing gastric acidity and protecting the ulcerated mucosa. In the horse of this report, treatment was unsuccessful and the horse was euthanatized; a physical cause of gastroesophageal reflux disease was not identified during an extensive postmortem examination.
Houghton, Lesley A; Lee, Augustine S; Badri, Huda; DeVault, Kenneth R; Smith, Jaclyn A
Gastro-oesophageal reflux is associated with a wide range of respiratory disorders, including asthma, isolated chronic cough, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease and cystic fibrosis. Reflux can be substantial and reach the proximal margins of the oesophagus in some individuals with specific pulmonary diseases, suggesting that this association is more than a coincidence. Proximal oesophageal reflux in particular has led to concern that microaspiration might have an important, possibly even causal, role in respiratory disease. Interestingly, reflux is not always accompanied by typical reflux symptoms, such as heartburn and/or regurgitation, leading many clinicians to empirically treat for possible gastro-oesophageal reflux. Indeed, costs associated with use of acid suppressants in pulmonary disease far outweigh those in typical GERD, despite little evidence of therapeutic benefit in clinical trials. This Review comprehensively examines the possible mechanisms that might link pulmonary disease and oesophageal reflux, highlighting the gaps in current knowledge and limitations of previous research, and helping to shed light on the frequent failure of antireflux treatments in pulmonary disease.
de Vries, Durk R; van Herwaarden, Margot A; Smout, André J P M; Samsom, Melvin
The roles of intragastric pressure (IGP), intraesophageal pressure (IEP), gastroesophageal pressure gradient (GEPG), and body mass index (BMI) in the pathophysiology of gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are only partly understood. In total, 149 GERD patients underwent stationary esophageal manometry, 24-h pH-metry, and endoscopy. One hundred three patients had HH. Linear regression analysis showed that each kilogram per square meter of BMI caused a 0.047-kPa increase in inspiratory IGP (95% confidence interval [CI] 0.026-0.067) and a 0.031-kPa increase in inspiratory GEPG (95% CI 0.007-0.055). Each kilogram per square meter of BMI caused expiratory IGP to increase with 0.043 kPa (95% CI 0.025-0.060) and expiratory IEP with 0.052 kPa (95% CI 0.027-0.077). Each added year of age caused inspiratory IEP to decrease by 0.008 kPa (95% CI -0.015-0.001) and inspiratory GEPG to increase by 0.008 kPa (95% CI 0.000-0.015). In binary logistic regression analysis, HH was predicted by inspiratory and expiratory IGP (odds ratio [OR] 2.93 and 2.62, respectively), inspiratory and expiratory GEPG (OR 3.19 and 2.68, respectively), and BMI (OR 1.72/5 kg/m(2)). In linear regression analysis, HH caused an average 5.09% increase in supine acid exposure (95% CI 0.96-9.22) and an average 3.46% increase in total acid exposure (95% CI 0.82-6.09). Each added year of age caused an average 0.10% increase in upright acid exposure and a 0.09% increase in total acid exposure (95% CI 0.00-0.20 and 0.00-0.18). BMI predicts IGP, inspiratory GEPG, and expiratory IEP. Age predicts inspiratory IEP and GEPG. Presence of HH is predicted by IGP, GEPG, and BMI. GEPG is not associated with acid exposure.
Avidan, B; Sonnenberg, A; Schnell, T; Sontag, S
BACKGROUND AND AIMS—The pulmonary symptoms of patients with lung disease may be ascribed to gastro-oesophageal reflux although a causal relationship between acid reflux and coughing or wheezing has not been proved. Does cough cause reflux or does reflux cause cough? The aim of this study was to evaluate 24 hour oesophageal pH tracings of asthmatics with gastro-oesophageal reflux to determine the temporal association between acid reflux and coughing or wheezing. METHODS—The oesophageal tracings of 128 asthmatics from the outpatient clinics who underwent oesophagogastroduodenoscopy, oesophageal manometry, and 24 hour oesophageal pH monitoring were analysed. Three possible temporal relationships between the occurrence of acid reflux and the occurrence of coughs or wheezes were evaluated: (1) pulmonary symptoms preceding reflux; (2) reflux preceding pulmonary symptoms; and (3) unrelated occurrence of both events. RESULTS—Of 128 asthmatics, 53 recorded five or more coughs and 19 recorded three or more wheezes during the 24 hour recording period. Mean acid contact time was similar in asthmatics with and without pulmonary symptoms (12.2 (1.2)% v 10.4 (0.6)%). Of all coughs and wheezes, 46% and 48%, respectively, were associated with acid reflux. For the individual asthmatic, the likelihood of reflux induced coughing increased as the number of coughs increased. CONCLUSIONS—Half of all coughs and wheezes in asthmatics are associated with acid reflux into the oesophagus. While an occasional coughing episode can lead to reflux, it is rather the reflux episode in the vast majority of instances that leads to cough. Keywords: asthma; gastro-oesophageal reflux disease; erosive oesophagitis; oesophageal pH monitoring; lung disease; pulmonary symptoms PMID:11709509
Liu, Julia J; Saltzman, John R
Refractory gastro-oesophageal reflux disease (GORD) is described when reflux symptoms have not responded to 4-8 weeks of proton pump inhibitor therapy and occurs in a heterogeneous mixture of patients. The causes of refractory GORD include inadequate acid suppression, non-acid gastro-oesophageal reflux, and non-reflux causes of GORD symptoms including achalasia, gastroparesis and functional heartburn. Upper gastrointestinal tract endoscopy should initially be performed to identify the presence of oesophagitis, and exclude other diagnoses including eosinophilic oesophagitis and peptic ulcer disease. Patients with refractory symptoms but with a normal upper endoscopy are more difficult to diagnose and may require ambulatory pH monitoring, impedance testing, oesophageal motility tests and gastric emptying scans. The primary goal of treatment is symptom reduction and eventual elimination, which can be achieved with proper identification of the underlying cause of the symptoms.
Forcelini, C M; Tomiozzo, J C; Farré, R; Van Oudenhove, L; Callegari-Jacques, S M; Ribeiro, M; Madalosso, B H; Fornari, F
Non-erosive reflux disease (NERD) patients generally present with heartburn as the main symptom. Antidepressants might help to relieve heartburn by acting on the esophagus-brain axis. We aimed to assess the effect of nortriptyline on behavioral and brain responses to painful esophageal acid infusion in NERD patients evaluated with functional magnetic resonance imaging (fMRI). In a randomized double-blind crossover design, 20 NERD patients off proton pump inhibitors (36.1 ± 9.3 years, 75% women) were assigned to 21 days of nortriptyline and placebo, in counterbalanced order, with a 21 days washout period in between both treatment periods. Changes in acid-induced brain response on fMRI and heartburn perception were assessed and at the end of each treatment. Nortriptyline significantly reduced the acid-induced brain response in prefrontal cortex (median [IQR]: -1.9 [-4.5 to -0.1] vs -0.3 [-2.5 to 2.3]; p = 0.050), caudate (-3.0 [-5.1 to -0.01] vs 0.48 [-1.9 to 3.1]; p = 0.029), insula (-2.4 [-4.8 to -0.6] vs -0.2 [-1.5 to 1.5]; p = 0.029), cingulate (-4.2 [-8.8 to -0.1] vs -0.6 [-1.8 to 3.0]; p = 0.017), and hippocampus (-2.7 [-6.0 to 0.5] vs -0.04 [-2.3 to 1.9]; p = 0.006) in comparison with placebo. However, there was no significant difference between nortriptyline and placebo in clinical outcomes and side effects. Nortriptyline decreased the brain response to esophageal acid infusion more markedly than placebo, but without clinical significance. © 2013 John Wiley & Sons Ltd.
Macchini, Francesco; Morandi, Anna; Cognizzoli, Paola; Farris, Giorgio; Gentilino, Valerio; Zanini, Andrea; Leva, Ernesto
To investigate the prevalence and the characteristics of gastroesophageal reflux disease (GERD) in infants with apparent life threatening events (ALTE). Infants with at least one episode of ALTE in absence of predisposing factors were included. All infants underwent a cardiorespiratory recording with simultaneous 24-hour pH-monitoring. Patients were divided into 3 groups according to the severity of GERD: A. Reflux Index (RI) <3%, B. RI = 3-7%, C. RI >7%. Monthly evaluations were performed and the anti-reflux therapy was maintained till normalization of monitoring and clinic. 41 infants were enrolled. GERD was found in 80% of patients (moderate in 54%, severe in 27%). A normalization of the cardiorespiratory tracks was recorded on average after 1 month for group A, 7 months for the group B and 9.5 months for group C. A significant difference was registered between group A and both group B and C (P < 0.0001), as well as between the group B and C (P < 0.05). GERD influences significantly the time of normalization of the cardiorespiratory monitoring in infants with ALTE. GERD diagnosis and treatment are mandatory in these patients. Copyright © 2016. Published by Elsevier B.V.
Wang, Yao-Kuang; Hsu, Wen-Hung; Wang, Sophie S. W.; Lu, Chien-Yu; Kuo, Fu-Chen; Su, Yu-Chung; Yang, Sheau-Fang; Chen, Chiao-Yun; Wu, Deng-Chyang
Gastroesophageal reflux disease (GERD), a common disorder with troublesome symptoms caused by reflux of gastric contents into the esophagus, has adverse impact on quality of life. A variety of medications have been used in GERD treatment, and acid suppression therapy is the mainstay of treatment for GERD. Although proton pump inhibitor is the most potent acid suppressant and provides good efficacy in esophagitis healing and symptom relief, about one-third of patients with GERD still have persistent symptoms with poor response to standard dose PPI. Antacids, alginate, histamine type-2 receptor antagonists, and prokinetic agents are usually used as add-on therapy to PPI in clinical practice. Development of novel therapeutic agents has focused on the underlying mechanisms of GERD, such as transient lower esophageal sphincter relaxation, motility disorder, mucosal protection, and esophageal hypersensitivity. Newer formulations of PPI with faster and longer duration of action and potassium-competitive acid blocker, a newer acid suppressant, have also been investigated in clinical trials. In this review, we summarize the current and developing therapeutic agents for GERD treatment. PMID:23878534
Zentilin, Patrizia; Marabotto, Elisa; Pellegatta, Gaia; Coppo, Claudia; Furnari, Manuele; Savarino, Edoardo; Savarino, Vincenzo
Gastroesophageal reflux disease (GERD) is defined as a condition which develops when the reflux of gastric contents causes troublesome symptoms, impairs quality of life, or leads to mucosal damage or complications. There are two main phenotypic presentations of GERD, the erosive (ERD) and non-erosive reflux disease (NERD), with the latter one representing up to 70% of GERD spectrum. Moreover, patients with GERD can be clinically subdivided into two distinct syndromes: patients with esophageal and extraesophageal symptoms. The diagnosis of NERD should be supported by the evidence that symptoms are due to reflux episodes on the basis of an excess of acid into the esophagus or a positive correlation between symptoms and acid and/or weakly acidic reflux episodes as evidenced by 24-hour impedance-pH monitoring. Patients with normal esophageal acid exposure and no correlation between heartburn and any kind of chemical reflux are considered affected by functional heartburn and do not pertain to the realm of NERD. They do not usually respond to PPI therapy as further empirical criterion and are included in the large group of functional digestive disorders with the expression of altered generation or perception of symptoms at the esophageal level and can often overlap with functional dyspepsia and irritable bowel syndrome.
Levine, Marc S; Carucci, Laura R
Fluoroscopic esophagography is a widely available, safe, and inexpensive test for detecting gastroesophageal reflux disease. In this article, we review the technique for performing a high-quality esophagram, including upright, double-contrast views of the esophagus and cardia with high-density barium; prone, single-contrast views of the esophagus with low-density barium; and evaluation of gastroesophageal reflux. We then discuss the radiographic findings associated with gastroesophageal reflux disease, including esophageal dysmotility, reflux esophagitis, peptic strictures, and Barrett's esophagus. Finally, we consider the differential diagnosis for the various radiographic findings associated with this condition. When carefully performed and interpreted, the esophagram is a useful test for evaluating gastroesophageal reflux disease and its complications.
Martinucci, Irene; de Bortoli, Nicola; Giacchino, Maria; Bodini, Giorgia; Marabotto, Elisa; Marchi, Santino; Savarino, Vincenzo; Savarino, Edoardo
Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophageal motility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from non-erosive reflux disease to erosive reflux disease and Barrett’s esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted. PMID:24868489
Boeckxstaens, Guy; El-Serag, Hashem B; Smout, André J P M; Kahrilas, Peter J
The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future. PMID:24607936
Strugala, Vicki; Avis, Jeanine; Jolliffe, Ian G; Johnstone, Lesley M; Dettmar, Peter W
During a reflux event the oesophagus is exposed to a heterogeneous mixture of gastric juice components. The role of non-acid components of the refluxate in causing damage to the oesophagus is now well established but no therapeutic option exists to address this. The role of Gaviscon Advance (GA), a raft-forming alginate suspension, in protecting the oesophagus from damage by pepsin and bile acids (aggressors) was investigated using a series of in-vitro models. GA was able to dose-dependently inhibit pepsin activity over and above the neutralisation effect of the formulation. This was evident against both protein and collagen substrates using two distinct colorimetric assays. GA was able to retard the diffusion of pepsin and multiple bile acids using a Franz cell model. Using the raft-forming mode of action GA was able to remove both pepsin and multiple bile acids from a simulated reflux event. There was capacity in the GA raft to accommodate aggressors from multiple reflux events. GA can specifically remove both pepsin and bile acids from the refluxate, limit their diffusion and affect enzymatic activity of pepsin. There is a role for GA to reduce the damaging potential of the refluxate and thus protect the oesophagus.
Tavakkoli, Anna; Sayed, Bisma A; Talley, Nicholas J; Moshiree, Baharak
To determine whether an increased number and duration of non-acid reflux events as measured using the multichannel intraluminal impedance pH (MII-pH) is linked to gastroparesis (GP). A case control study was conducted in which 42 patients undergoing clinical evaluation for continued symptoms of gastroesophageal reflux disease (both typical and atypical symptoms) despite acid suppression therapy. MII-pH technology was used over 24 h to detect reflux episodes and record patients' symptoms. Parameters evaluated in patients with documented GP and controls without GP by scintigraphy included total, upright, and supine number of acid and non-acid reflux episodes (pH < 4 and pH > 4, respectively), the duration of acid and non-acid reflux in a 24-h period, and the number of reflux episodes lasting longer than 5 min. No statistical difference was seen between the patients with GP and controls with respect to the total number or duration of acid reflux events, total number and duration of non-acid reflux events or the duration of longest reflux episodes. The number of non-acid reflux episodes with a pH > 7 was higher in subjects with GP than in controls. In addition, acid reflux episodes were more prolonged (lasting longer than 5 min) in the GP patients than in controls; however, these values did not reach statistical significance. Thirty-five patients had recorded symptoms during the 24 h study and of the 35 subjects, only 9% (n = 3) had a positive symptom association probability (SAP) for acid/non-acid reflux and 91% had a negative SAP. The evaluation of patients with a documented history of GP did not show an association between GP and more frequent episodes of non-acid reflux based on MII-pH testing.
Mastracci, L; Fiocca, R; Engström, C; Attwood, S; Ell, C; Galmiche, J P; Hatlebakk, J G; Långström, G; Eklund, S; Lind, T; Lundell, L
Proton pump inhibitors and laparoscopic anti-reflux surgery (LARS) offer long-term symptom control to patients with gastro-oesophageal reflux disease (GERD). To evaluate the process of 'normalisation' of the squamous epithelium morphology of the distal oesophagus on these therapies. In the LOTUS trial, 554 patients with chronic GERD were randomised to receive either esomeprazole (20-40 mg daily) or LARS. After 5 years, 372 patients remained in the study (esomeprazole, 192; LARS, 180). Biopsies were taken at the Z-line and 2 cm above, at baseline, 1, 3 and 5 years. A severity score was calculated based on: papillae elongation, basal cell hyperplasia, intercellular space dilatations and eosinophilic infiltration. The epithelial proliferative activity was assessed by Ki-67 immunohistochemistry. A gradual improvement in all variables over 5 years was noted in both groups, at both the Z-line and 2 cm above. The severity score decreased from baseline at each subsequent time point in both groups (P < 0.001, all comparisons), attaining a normal level by 5 years. Corresponding decreases in Ki-67 expression were observed (P < 0.001, all comparisons). No significant differences were found between esomeprazole treatment and LARS. Neither baseline severity score nor Ki-67 expression predicted the risk of treatment failure. Five years of treatment is generally required before squamous epithelial cell morphology and proliferation are 'normalised' in patients with chronic GERD, despite endoscopic and symptomatic disease control. Control of the acid component of the refluxate seems to play the predominant role in restoring tissue morphology. © 2017 John Wiley & Sons Ltd.
Altomare, Annamaria; Guarino, Michele Pier Luca; Cocca, Silvia; Emerenziani, Sara; Cicala, Michele
Although gastroesophageal reflux disease (GERD) is a common disorder in Western countries, with a significant impact on quality of life and healthcare costs, the mechanisms involved in the pathogenesis of symptoms remain to be fully elucidated. GERD symptoms and complications may result from a multifactorial mechanism, in which acid and acid-pepsin are the important noxious factors involved. Prolonged contact of the esophageal mucosa with the refluxed content, probably caused by a defective anti-reflux barrier and luminal clearance mechanisms, would appear to be responsible for macroscopically detectable injury to the esophageal squamous epithelium. Receptors on acid-sensitive nerve endings may play a role in nociception and esophageal sensitivity, as suggested in animal models of chronic acid exposure. Meanwhile, specific cytokine and chemokine profiles would appear to underlie the various esophageal phenotypes of GERD, explaining, in part, the genesis of esophagitis in a subset of patients. Despite these findings, which show a significant production of inflammatory mediators and neurotransmitters in the pathogenesis of GERD, the relationship between the hypersensitivity and esophageal inflammation is not clear. Moreover, the large majority of GERD patients (up to 70%) do not develop esophageal erosions, a variant of the condition called non-erosive reflux disease. This summary aims to explore the inflammatory pathway involved in GERD pathogenesis, to better understand the possible distinction between erosive and non-erosive reflux disease patients and to provide new therapeutic approaches.
Background Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disease, and the cost of health care and lost productivity due to GERD is extremely high. Recently described side effects of long-term acid suppression have increased the interest in nonpharmacologic methods for alleviating GERD symptoms. We aimed to examine whether GERD patients follow recommended dietary guidelines, and if adherence is associated with the severity and frequency of reflux symptoms. Methods We conducted a population-based cross-sectional study within the Kaiser Permanente Northern California population, comparing 317 GERD patients to 182 asymptomatic population controls. All analyses adjusted for smoking and education. Results GERD patients, even those with moderate to severe symptoms or frequent symptoms, were as likely to consume tomato products and large portion meals as GERD-free controls and were even more likely to consume soft drinks and tea [odds ratio (OR) = 2.01 95% confidence interval (CI) 1.12-3.61; OR = 2.63 95% CI 1.24-5.59, respectively] and eat fried foods and high fat diet. The only reflux-triggering foods GERD patients were less likely to consume were citrus and alcohol [OR = 0.59; 95% CI: 0.35-0.97 for citrus; OR = 0.41 95% CI 0.19-0.87 for 1 + drink/day of alcohol]. The associations were similar when we excluded users of proton pump inhibitors. Conclusions GERD patients consume many putative GERD causing foods as frequently or even more frequently than asymptomatic patients despite reporting symptoms. These findings suggest that, if dietary modification is effective in reducing GERD, substantial opportunities for nonpharmacologic interventions exist for many GERD patients. PMID:25125219
A novel once daily microparticulate dosage form comprising lansoprazole to prevent nocturnal acid breakthrough in the case of gastro-esophageal reflux disease: preparation, pharmacokinetic and pharmacodynamic evaluation.
Alai, Milind; Lin, Wen Jen
The objective of this study was to formulate and evaluate the lansoprazole (LPZ)-loaded microparticles to prevent nocturnal acid breakthrough in the case of gastro-esophageal reflux disease (GERD). The microparticulate delivery system was prepared by solvent evaporation method using Eudragit RS100 as a matrix polymer followed by enteric coated with Eudragit S100 and hydroxypropyl methylcellulose phthalate HP55 using spray drying method. The enteric coated microparticles were stable in gastric pH condition. In vivo pharmacokinetic and pharmacodynamic studies in male Wistar rats demonstrated that enteric coated microparticles sustained release of LPZ and promoted ulcer healing activity. In other words, the microparticulate dosage form provided effective drug concentration for a longer period as compared to conventional extended release dosage form, and showed sufficient anti-acid secretion activity to treat acid related disorders including the enrichment of nocturnal acid breakthrough event based on a once daily administration.
Delavari, Alireza; Moradi, Ghobad; Elahi, Elham; Moradi-Lakeh, Maziar
Gastroesophageal reflux disease is one of the most common disorders of the gastrointestinal tract. The prevalence of this disease ranges from 5% to 20% in Asia, Europe, and North America. The aim of this study was to estimate the burden of gastroesophageal reflux disease in Iran. Burden of gastroesophageal reflux disease in Iran was estimated for one year from 21 March 2006 to 20 March 2007. The definition was adjusted with ICD-code of K21. Incident-based disability-adjusted life year (DALY) was used as the unit of analysis to quantify disease burden. A simplified disease model and DisMod II software were used for modeling. The annual incidence for total population of males and females in Iran was estimated 17.72 and 28.06 per 1000, respectively. The average duration of gastroesophageal reflux disease as a chronic condition was estimated around 10 years in both sexes. Total DALYs for an average of 59 symptomatic days per year was estimated 153,554.3 (60,330.8 for males and 93,223.5 for females). The results of this study showed that reflux imposes high burden and high financial costs on the Iranian population. The burden of this disease in Iran is more similar to that of European countries rather than Asian countries. It is recommended to consider the disease as a public health problem and make decisions and public health plans to reduce the burden and financial costs of the disease in Iran.
Yuan, Yuhong; Hunt, Richard H
Gastroesophageal reflux disease (GERD) is a common chronic disorder often successfully treated, although there are several evolving issues in management. We reviewed the issues related to unmet needs over the past 12 months. A substantial number of patients fail to respond adequately to once or even twice daily proton pump inhibitor (PPI). There is no standard definition of PPI failure in GERD; a universally accepted definition for treatment success is also not available. Differentiation between erosive esophagitis and nonerosive reflux disease can be made but requires endoscopy; but studies still confuse functional heartburn and nonerosive reflux disease, which impacts management. Acid reflux plays an important role in GERD pathogenesis and the precise role of acid requires more studies of differences between erosive esophagitis and nonerosive reflux disease symptom generation and the implication of nocturnal acidification. Several possible mechanisms may explain GERD refractory to PPIs. Management of PPI nonresponders remains a challenge. Objective and precise evaluation of symptoms and treatment response requires study in high-quality trials. New therapeutic approaches are under investigation to answer unmet needs and improve erosive esophagitis healing rates and symptom control.
Sifrim, D; Castell, D; Dent, J; Kahrilas, P J
To date, most concepts on the frequency of gastro-oesophageal reflux episodes and the efficiency of the antireflux barrier have been based on inferences derived from measurement of oesophageal pH. The development of intraluminal impedance monitoring has highlighted the fact that pH monitoring does not detect all gastro-oesophageal reflux events when little or no acid is present in the refluxate, even if special pH tracing analysis criteria are used. In November 2002, a workshop took place at which 11 specialists in the field of gastro-oesophageal reflux disease discussed and criticised all currently available techniques for measurement of reflux. Here, a summary of their conclusions and recommendations of how to achieve the best results from the various techniques now available for reflux measurement is presented. PMID:15194656
Chen, Jiann-Hwa; Wen, Shu-Hui; Hsu, Ching-Sheng; Yi, Chih-Hsun; Liu, Tso-Tsai; Chen, Chien-Lin; Wang, Chia-Chi
Gastroesophageal reflux disease (GERD) is an emerging disease, and can impair quality of life and sleep. This study aimed to investigate whether GERD patients with different timings of reflux symptoms have different clinical characteristics. This study prospectively enrolled individuals who underwent upper gastrointestinal endoscopy during a health checkup. Each participant completed all questionnaires including Reflux Disease Questionnaire, Nighttime GERD questionnaire, Pittsburg Sleep Quality Index, Taiwanese Depression Questionnaire, and State-Trait Anxiety Inventory. Combined reflux was defined as the timing of reflux symptoms occurring at both daytime and nighttime. A total of 2604 participants were enrolled. Of them, 651 symptomatic GERD patients, according to the Reflux Disease Questionnaire score, were recruited for final analysis. Of them, 224 (34.4%) had erosive esophagitis on endoscopy. According to the timing of reflux symptoms, 184 (28.3%) were assigned to the daytime reflux group, 71 (10.9%) to the nighttime reflux group, and 396 (60.8%) to the combined reflux group. In post hoc analysis, the combined reflux group had a significantly higher Reflux Disease Questionnaire score than the daytime reflux group (p < 0.0001). Combined and nighttime reflux groups had higher body mass index and longer duration (> 12 years) of education than the daytime reflux group (p < 0.05). There was no difference in Pittsburg Sleep Quality Index, Taiwanese Depression Questionnaire, and State-Trait Anxiety Inventory scores among three groups. GERD patients with combined daytime and nighttime reflux of have more troublesome symptoms than those with daytime reflux. GERD patients with different timings of reflux symptoms have different clinical characteristics in terms of body mass index and duration of education, but not in terms of esophageal inflammation, quality of sleep, and psychosocial status. Copyright © 2016. Published by Elsevier B.V.
Davenport, Mike; Davenport, Tracy
When a child is sick, parents want answers. They want to know what is wrong, what they can do, and how to get their child healthy--pronto. Regrettably, there are some puzzling illnesses affecting children that are surrounded by mystery. One of them is gastroesophageal reflux (GER), otherwise known as acid reflux--or "reflux" for short. Reflux…
Mikami, Dean J; Murayama, Kenric M
Gastroesophageal reflux disease (GERD) is one of the most common problems treated by primary care physicians. Almost 20% of the population in the United States experiences occasional regurgitation, heartburn, or retrosternal pain because of GERD. Reflux disease is complex, and the physiology and pathogenesis are still incompletely understood. However, abnormalities of any one or a combination of the three physiologic processes, namely, esophageal motility, lower esophageal sphincter function, and gastric motility or emptying, can lead to GERD. There are many diagnostic and therapeutic approaches to GERD today, but more studies are needed to better understand this complex disease process. Copyright © 2015 Elsevier Inc. All rights reserved.
Komura, Makoto; Kanamori, Yutaka; Tanaka, Yujiro; Kodaka, Tetsuro; Sugiyama, Masahiko; Terawaki, Kan; Suzuki, Kan; Iwanaka, Tadashi
The prokinetic agent cisapride is effective for the treatment of gastroesophageal reflux disease (GERD) in infants and children, but is no longer used for this purpose because of safety concerns. Therefore, other pharmacological agents need to be investigated for efficacy in GERD treatment. In this study, we examined the effectiveness and safety of mosapride for the treatment of neurologically impaired children and adolescents with GERD. Mosapride (0.3 mg/kg/day) was administered to 11 neurologically impaired patients with GERD (five male; median age, 12.3 years). Esophageal acid exposure was measured using esophageal pH monitoring before and at >5 days after the start of mosapride treatment. The pressure and length of the lower esophageal sphincter were compared before and after mosapride treatment. In the 11 patients, median reflux index (percentage of the total monitoring period during which recorded pH was <4.0) was 17.5% (range, 4.4-59%) before and 8.2% (range, 2.8-20.7%) after mosapride treatment (P = 0.02). Median esophageal clearance was 1.0 min/reflux (range, 0.5-2.1 min/reflux) before and 0.7 min/reflux (range, 0.4-1.2 min/reflux) after treatment with mosapride (P = 0.02). The median number of reflux episodes before (219) and after (122) drug treatment did not differ significantly. The decreased reflux index in neurologically impaired patients with GERD is due to mosapride, therefore mosapride may be a candidate for GERD treatment. © 2016 Japan Pediatric Society.
Storr, M; Meining, A; Allescher, H D
Gastroesophageal reflux disease (GERD) is one of the most common diagnoses in a gastroenterologist's practice. Gastroesophageal reflux (GER) describes the retrograde movement of gastric contents through the lower oesophageal sphincter (LES) to the oesophagus. GER can occur physiologically and may be accompanied by symptoms. The introduction of endoscopes and ambulatory devices for continuous monitoring of oesophageal pH (24 h pH monitoring) has led to great improvement in the ability to diagnose reflux disease and reflux-associated complications. The development of pathological reflux and GERD can be attributed to many factors. Pathophysiology of GERD includes transient lower oesophageal sphincter relaxations (TLESRs), incompetent LES because of a decreased lower oesophageal sphincter pressure (LESP) and deficient or delayed oesophageal acid clearance. Uncomplicated GERD may be treated by modification of lifestyle and eating habits in an early stage of GERD. The various agents currently used for treatment of GERD include mucoprotective substances, antacids, H2-blockers, prokinetics and proton pump inhibitors (PPIs). Although these drugs are effective, they do not necessarily influence the underlying causes of the disease by improving the oesophageal clearance, increasing the LESP or reducing the frequency of TLESRs. The following article gives an overview regarding current concepts of the pathophysiology and pharmacological treatment of GERD stressing on pharmacoeconomic issues of the treatment and discusses the advantages and disadvantages for step-up and step-down therapy.
Rohof, W O; Bennink, R J; de Ruigh, A A; Hirsch, D P; Zwinderman, A H; Boeckxstaens, G E
The risk for acidic reflux is mainly determined by the position of the gastric acid pocket. It was hypothesised that compounds affecting proximal stomach tone might reduce gastro-oesophageal reflux by changing the acid pocket position. To study the effect of azithromycin (Azi) on acid pocket position and acid exposure in patients with gastro-oesophageal reflux disease (GORD). Nineteen patients with GORD were included, of whom seven had a large hiatal hernia (≥3 cm) (L-HH) and 12 had a small or no hiatal hernia (S-HH). Patients were randomised to Azi 250 mg/day or placebo during 3 days in a crossover manner. On each study day, reflux episodes were detected using concurrent high-resolution manometry and pH-impedance monitoring after a standardised meal. The acid pocket was visualised using scintigraphy, and its position was determined relative to the diaphragm. Azi reduced the number of acid reflux events (placebo 8.0±2.2 vs Azi 5.6±1.8, p<0.01) and postprandial acid exposure (placebo 10.5±3.8% vs Azi 5.9±2.5%, p<0.05) in all patients without affecting the total number of reflux episodes. Acid reflux occurred mainly when the acid pocket was located above, or at the level of, the diaphragm, rather than below the diaphragm. Treatment with Azi reduced hiatal hernia size and resulted in a more distal position of the acid pocket compared with placebo (below the diaphragm 39% vs 29%, p=0.03). Azi reduced the rate of acid reflux episodes in patients with S-HH (38% to 17%) to a greater extent than in patients with L-HH (69% to 62%, p=0.04). Azi reduces acid reflux episodes and oesophageal acid exposure. This effect was associated with a smaller hiatal hernia size and a more distal position of the acid pocket, further indicating the importance of the acid pocket in the pathogenesis of GORD. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1970 NTR1970.
Kavitt, Robert T; Lal, Pooja; Yuksel, Elif Saritas; Ates, Fehmi; Slaughter, James C; Garrett, C Gaelyn; Higginbotham, Tina; Vaezi, Michael F
Current diagnostic tests for gastroesophageal reflux disease (GERD) do not consistently measure chronicity of reflux. Mucosal impedance (MI) is a minimally invasive measurement to assess esophageal conductivity changes due to GERD. We aimed to investigate MI pattern in patients with symptoms of extraesophageal reflux (EER) in a prospective longitudinal cohort study. Patients with potential symptoms of EER undergoing esophagogastroduodenoscopy (EGD) with wireless pH monitoring were studied. Participants included those with erosive esophagitis (E+), normal EGD/abnormal pH (E-/pH+), and normal EGD/normal pH (E-/pH-). MI was measured from the site of injury in patients with E+, as well as at 2, 5, and 10 cm above the squamocolumnar junction (SCJ) in all participants. Forty-one patients with symptoms of EER were studied. MI measurements at 2 cm above the SCJ were significantly (P = 0.04) different among the three groups, with MI lowest for E+ and greatest for E-/pH- patients. Although not statistically significant, there is a graded increase in median (interquartile range) MI axially along the esophagus at 5 cm (P = 0.20) and at 10 cm (P = 0.27) above the SCJ, with those with reflux (E+ and E-/pH+) having a lower MI than those without. Patients with symptoms of EER and evidence of acid reflux have an MI lower than those without at 2 cm above the SCJ, with a trend at 5 cm and 10 cm as well. MI may be a tool to assess presence of GERD in patients presenting with EER symptoms. Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Ingebrigtsen, Truls S; Marott, Jacob L; Vestbo, Jørgen; Nordestgaard, Børge G; Hallas, Jesper; Lange, Peter
We tested the hypothesis that gastro-esophageal reflux disease is a risk factor for exacerbations in individuals with chronic obstructive pulmonary disease (COPD). Among 9622 participants in the Copenhagen City Heart Study, we identified 1259 individuals with COPD and information on gastro-esophageal reflux disease and the regular use of acid inhibitory treatment. These individuals were followed for 5 years with regard to medically treated COPD exacerbations, which we defined as a short course treatment with oral corticosteroids alone or in combination with antibiotics. We applied a multivariable Cox regression analysis with adjustment for well-established risk factors associated with COPD exacerbations or gastro-esophageal reflux disease, including COPD severity, and symptoms. Individuals with COPD and gastro-esophageal reflux disease had more chronic bronchitis (31 vs 21%, P = 0.004), more breathlessness (39 vs 22%, P < 0.001), and more of them had a history of respiratory infections (6.8 vs 1.4%, P < 0.001) than individuals with COPD but without gastro-esophageal reflux disease. Among individuals with COPD and gastro-esophageal reflux disease, those who did not use acid inhibitory treatment regularly had an increased risk of COPD exacerbations during follow-up, hazards ratio (HR): HR = 2.7 (1.3-5.4, P = 0.006). Individuals with gastro-esophageal reflux disease, using acid inhibitory treatment regularly did not have an increased risk of exacerbations, HR = 1.2 (0.6-2.7, P = 0.63). Gastro-esophageal reflux disease was associated with an increased risk of medically treated exacerbations of COPD, but only in those individuals who did not use acid inhibitory treatment regularly. © 2014 Asian Pacific Society of Respirology.
Potassium-competitive acid blocker (P-CAB) is a class of drug that competitively blocks the potassium-binding site of H+, K+-adenosine triphosphate (ATP)ase. Although the history of this class of drugs started over 30 years ago, clinical use of two P-CABs, revaprazan and vonoprazan, were only recently approved in Korea and Japan, respectively. Among them, vonoprazan has several advantages over conventional proton-pump inhibitors (PPIs), including rapid onset of action, long duration of acid suppression, fewer interindividual variations in terms of acid suppression, and minimum dietary influence on its action. These advantages of vonoprazan have been proved in clinical trials conducted for license approvals for several acid-related diseases. In this review article, current evidence of vonoprazan in the management of gastroesophageal reflux disease (GERD) will be summarized. Since the clinical trial data, as well as postmarketed clinical data, have consistently demonstrated superiority of vonoprazan over conventional PPIs in terms of achieving healing of mucosal breaks and maintaining the healing, it may provide an excellent, if not complete, option for fulfilling some of the unmet needs for current GERD therapy. The safety problem of vonoprazan is also discussed, as more pronounced hypergastrinemia inevitably ensues with its use. PMID:29383028
von Renteln, Daniel; Schmidt, Arthur; Riecken, Bettina; Caca, Karel
Endoscopic full-thickness plication allows transmural suturing at the gastroesophageal junction to recreate the antireflux barrier. Multichannel intraluminal impedance monitoring (MII) can be used to detect nonacid or weakly acidic reflux, acidic swallows, and esophageal clearance time. This study used MII to evaluate the outcome of endoscopic full-thickness plication. In this study, 12 subsequent patients requiring maintenance proton pump inhibitor therapy underwent endoscopic full-thickness plication for treatment of gastroesophageal reflux disease. With patients off medication, MII was performed before and 6-months after endoscopic full-thickness plication. The total median number of reflux episodes was significantly reduced from 105 to 64 (p = 0.016). The median number of acid reflux episodes decreased from 73 to 43 (p = 0.016). Nonacid reflux episodes decreased from 23 to 21 (p = 0.306). The median bolus clearance time was 12 s before treatment and 11 s at 6 months (p = 0.798). The median acid exposure time was reduced from 6.8% to 3.4% (p = 0.008), and the DeMeester scores were reduced from 19 to 12 (p = 0.008). Endoscopic full-thickness plication significantly reduced total reflux episodes, acid reflux episodes, and total reflux exposure time. The DeMeester scores and total acid exposure time for the distal esophagus were significantly improved. No significant changes in nonacid reflux episodes and median bolus clearance time were encountered.
Ranjitkar, Sarbin; Smales, Roger J; Kaidonis, John A
Numerous case-control and other studies involving confirmation of gastroesophageal reflux disease (GERD) by esophageal pH-metry and the assessment of dental erosions have shown significant associations between the two conditions in both adults and children. By contrast, when asked to vote on whether GERD may cause dental erosions, only 42% of physicians strongly agreed that such an association existed in adults, and just 12.5% strongly agreed for children, respectively in two global consensus reports. Part of this divergence between the perceptions of physicians and the findings of research publications may reflect a general lack of oral health education during medical training, and cursory oral examinations being made under less-than-ideal conditions. Adequate salivary secretions are essential for the protection of the teeth and the oropharyngeal and esophageal mucosa. The quantity and quality of the saliva require monitoring as many drugs, including several of the proton pump inhibitors (PPIs), can cause hyposalivation. In addition, PPIs do not always result in adequate acid suppression. Therefore, collaboration between physicians and dentists is strongly advocated to prevent or ameliorate possible adverse oral effects from both endogenous and exogenous acids, and to promote adequate saliva production in patients with GERD. © 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.
Hathorn, Kelly E; Chan, Walter W; Lo, Wai-Kit
Lung transplantation is one of the highest risk solid organ transplant modalities. Recent studies have demonstrated a relationship between gastroesophageal reflux disease (GERD) and lung transplant outcomes, including acute and chronic rejection. The aim of this review is to discuss the pathophysiology, evaluation, and management of GERD in lung transplantation, as informed by the most recent publications in the field. The pathophysiology of reflux-induced lung injury includes the effects of aspiration and local immunomodulation in the development of pulmonary decline and histologic rejection, as reflective of allograft injury. Modalities of reflux and esophageal assessment, including ambulatory pH testing, impedance, and esophageal manometry, are discussed, as well as timing of these evaluations relative to transplantation. Finally, antireflux treatments are reviewed, including medical acid suppression and surgical fundoplication, as well as the safety, efficacy, and timing of such treatments relative to transplantation. Our review of the data supports an association between GERD and allograft injury, encouraging a strategy of early diagnosis and aggressive reflux management in lung transplant recipients to improve transplant outcomes. Further studies are needed to explore additional objective measures of reflux and aspiration, better compare medical and surgical antireflux treatment options, extend follow-up times to capture longer-term clinical outcomes, and investigate newer interventions including minimally invasive surgery and advanced endoscopic techniques. PMID:28507913
Horváth, Örs Péter; Bognár, Laura; Papp, András; Vereczkei, András
Gastroesophageal reflux disease affects more than 10% of the adult population. Most patients can be effectively treated with lifestyle changes and adequate acid-reducing therapy. However, about 10% of the patients remain symptomatic despite treatment and severe complications may develop. Interestingly, some of these complications seem to be a sort of defensive mechanism that may either alleviate the patient's symptoms or prevent developing further complications. In Barrett's esophagus, which can be unambigously considered as a complication of gastroesophageal reflux disease, reflux symptoms ruining the quality of life may significantly improve, since the metaplastic Barrett epithelium is much more resistent to gastric acid, than the normal epithelial lining of the esophagus. Furthermore, the motility disorders (hypertensive lower esophageal sphincter, achalasia, cricopharyngeal achalasia) and structural changes (Schatzki's ring, esophageal stricture, subglottic trachea stenosis), which develop as a complication of reflux may help to prevent aspiration that can cause new complaints and may lead to further complications. Orv Hetil. 2017; 158(20): 763-769.
Viliušytė, Edita; Macaitytė, Raminta; Vaitkus, Antanas; Rastenytė, Daiva
We hypothesize that peripheral vertigo is associated with gastroesophageal reflux disease (GERD). Two mechanisms could be considered – gastric acids may directly irritate the respiratory mucosa and cause inflammation, or Helicobacter pylori (H. pylori) could be present and cause local infection. Reflux material (Hydrochloric acid (HCl) and pepsin) could get into the middle ear via Eustachian tube and affect osseous structures directly. Disturbance of ossicles could cause tinnitus, which is more common for peripheral vertigo. H. pylori could also get in the esophagus and in the upper respiratory tract via gastroesophageal reflux, and could cause tympanosclerosis and fixation of ossicles. In our study group, 120 of 153 (78.4%) patients had gastroesophageal reflux disease (GERD). Diagnostic tests of H. pylori (rapid urease test or blood antibody test) were performed for 96 of 120 (80%) patients with GERD and were found positive for 32 of 96 (33.3%) patients. Peripheral vertigo was present in 93 of 120 (77.6%) patients with GERD compared to 33 of 126 (26%) patients without GERD (χ(2)=9.016, p=0.003). H. pylori and peripheral vertigo coexisted in 26 of 126 patients (20.6%) (OR 1.36; 95% CI 0.49-3.74, p=0.55). Our study demonstrated statistically significant association between peripheral vertigo and GERD but not between peripheral vertigo and H. pylori. Further more extensive investigations are needed in order to explore our hypothesis. Copyright © 2015 Elsevier Ltd. All rights reserved.
Sinn, Dong Hyun; Kim, Beom Jin; Son, Hee Jung; Kim, Jae J; Rhee, Jong Chul; Rhee, Poong-Lyul
Conventionally, pathological acid exposure (PAE), defined by acid reflux only, is used to identify gastro-esophageal reflux disease (GERD). However, weak acid reflux or non-acid reflux also induces reflux symptoms. Defining abnormal reflux based on all reflux episodes may better identify GERD and would be more useful among patients with atypical GERD symptoms, such as globus. Impedance-pHmetry results of 31 globus patients, off acid suppressants, were analysed. A median of 24 episodes of reflux were observed. Of the reflux episodes, 54% were non-acid reflux and 50% reached the proximal extent. PAE was observed in 6 patients (19%). For 5 patients (16%) without PAE, there was evidence of increased bolus exposure compared to normal controls (an intraesophageal bolus exposure for more than 1.4% of the recording time, defined as pathological bolus exposure, PBE). When GERD was defined by PAE or esophagitis, the prevalence of GERD was 29%. When GERD was defined by PBE, PAE or esophagitis, the prevalence was 42%. PBE identified 13% of the patients who otherwise would have been missed. A significant proportion of patients without PAE had evidence of PBE. PBE may be a more useful definition for identifying patients with abnormal increase in reflux in patients with globus. Further studies are warranted.
Mungan, Zeynel; Pınarbaşı Şimşek, Binnur
Gastroesophageal reflux disease (GERD), which is common in many communities, is associated with structural factors, eating habits, and the use of certain drugs. The use of such drugs can lead to the emergence of GERD and can also exacerbate existing reflux symptoms. These drugs can contribute to GERD by directly causing mucosal damage, by reducing lower esophageal sphincter pressure (LESP), or by affecting esophagogastric motility. In this article, we report our investigation of the relationships between GERD and medications within the scope of the "Turkish GERD Consensus Group." For the medication groups for which sufficient data were obtained (Figure 1), a systematic literature review in English was conducted using the keywords "gastroesophageal reflux" [MeSH Terms] and "anti-inflammatory agents, non-steroidal" [MeSH Terms], "gastroesophageal reflux" [MeSH Terms] and "acetylsalicylic acid" [MeSH Terms], "gastroesophageal reflux" [All Fields] and "estrogenic agents" [All Fields], "gastroesophageal reflux" [All Fields] and "progesterones" [All Fields], "gastroesophageal reflux" [All Fields] and "hormone replacement therapy" [All Fields], "gastroesophageal reflux" [MeSH Terms] and "diphosphonates" [MeSH Terms] OR "diphosphonates" [All Fields], "calcium channel blockers" [MeSH Terms] and "gastroesophageal reflux" [MeSH Terms], "gastroesophageal reflux" [MeSH Terms] and "nitrates" [MeSH Terms], "gastroesophageal reflux" [MeSH Terms] and "antidepressive agents" [MeSH Terms], "gastroesophageal reflux" [MeSH Terms] and "benzodiazepines" [MeSH Terms] and "hypnotic drugs" [MeSH Terms], "gastroesophageal reflux" [MeSH Terms] and "cholinergic antagonists" [MeSH Terms], "gastroesophageal reflux" [MeSH Terms] and "theophylline" [MeSH Terms], and "gastroesophageal reflux [MeSH Terms] AND "anti-asthmatic agents" [MeSH Terms]. The studies were analyzed and the results are presented here.
Keung, Charlotte; Hebbard, Geoffrey
If there are no features of serious disease, suspected gastro-oesophageal reflux disease can be initially managed with a trial of a proton pump inhibitor for 4-8 weeks. This should be taken 30-60 minutes before food for optimal effect. Once symptoms are controlled, attempt to withdraw acid suppression therapy. If symptoms recur, use the minimum dose that controls symptoms. Patients who have severe erosive oesophagitis, scleroderma oesophagus or Barrett's oesophagus require long-term treatment with a proton pump inhibitor. Lifestyle modification strategies can help gastro-oesophageal reflux disease. Weight loss has the strongest evidence for efficacy. Further investigation and a specialist referral are required if there is no response to proton pump inhibitor therapy. Atypical symptoms or signs of serious disease also need investigation.
Keung, Charlotte; Hebbard, Geoffrey
SUMMARY If there are no features of serious disease, suspected gastro-oesophageal reflux disease can be initially managed with a trial of a proton pump inhibitor for 4–8 weeks. This should be taken 30–60 minutes before food for optimal effect. Once symptoms are controlled, attempt to withdraw acid suppression therapy. If symptoms recur, use the minimum dose that controls symptoms. Patients who have severe erosive oesophagitis, scleroderma oesophagus or Barrett’s oesophagus require long-term treatment with a proton pump inhibitor. Lifestyle modification strategies can help gastro-oesophageal reflux disease. Weight loss has the strongest evidence for efficacy. Further investigation and a specialist referral are required if there is no response to proton pump inhibitor therapy. Atypical symptoms or signs of serious disease also need investigation. PMID:27041798
Baran, Masallah; Cagan Appak, Yeliz; Karakoyun, Miray; Yalcinkaya, Sevda; Eliacik, Kayi; Dundar, Bumin N
This study was designed to investigate the frequency of gastroesophageal reflux disease (GERD) in children with functional constipation (FC). It was structured to assess the improvement level in reflux symptoms by measuring the acid reflux in these patients after they had received FC treatment. Ninety-four children who suffered from constipation were evaluated prospectively. Data forms were completed to assess the GERD symptoms in all the cases. Twenty-four-hour pH meter monitoring was performed in 55 of the patients with GERD symptoms. The cases with abnormal acid reflux were treated by conventional therapy for FC. These cases were re-evaluated for GERD symptoms and weekly defecation frequency, and 24-h pH meter monitoring was performed at the end of a 3-month period. An abnormal level of acid reflux was determined in 23 of the 55 cases. After the constipation treatment, a significant improvement was achieved in the acid reflux index and GERD symptoms, whereas the weekly defecation frequency increased. GERD is a frequent problem in children with FC. Treatment of the constipation can improve the reflux symptoms and abnormal acid reflux in these cases. Physicians should bear in mind the co-occurrence of these two prevalent problems for better disease management.
Ye, Bi Xing; Jiang, Liu Qin; Lin, Lin; Wang, Ying; Wang, Meifeng
To determine the relationship between baseline impedance levels and gastroesophageal reflux, we retrospectively enrolled 110 patients (54 men and 56 female; mean age, 51 ± 14 years) with suspected gastroesophageal reflux disease (GERD) who underwent 24-h multichannel intraluminal impedance and pH monitoring. Patients were stratified according to symptom (typical or atypical) and reflux types (acid reflux, nonacid reflux [NAR], or no abnormal reflux). Mean nocturnal baseline impedance (MNBI) were measured 3 cm (distal esophagus) and 17 cm (proximal esophagus) above the lower esophageal sphincter. Median distal esophageal MNBI was lower in the acid reflux group (1244 Ω; 647-1969 Ω) than in the NAR (2586 Ω; 1368-3666 Ω) or no abnormal reflux groups (3082 Ω; 2495-4472 Ω; all P < .05). Distal MNBI were negatively correlated with DeMeester score and acid exposure time. Atypical symptoms were more frequently associated with NAR than typical symptoms (P < .01). Among patients with positive symptom-association probability (SAP) for NAR, median proximal MNBI tended to be lower in patients with typical symptoms (median, 3013 Ω; IQR, 2535-3410 Ω) than in those with atypical symptoms (median, 3386 Ω; IQR, 3044-3730 Ω, P = .05). Thus, atypical GERD symptoms were more likely to be associated with NAR. The mucosal integrity of the proximal esophagus might be relatively impaired in GERD patients with typical symptoms for NAR.
Ye, Bi Xing; Jiang, Liu Qin; Lin, Lin; Wang, Ying; Wang, Meifeng
Abstract To determine the relationship between baseline impedance levels and gastroesophageal reflux, we retrospectively enrolled 110 patients (54 men and 56 female; mean age, 51 ± 14 years) with suspected gastroesophageal reflux disease (GERD) who underwent 24-h multichannel intraluminal impedance and pH monitoring. Patients were stratified according to symptom (typical or atypical) and reflux types (acid reflux, nonacid reflux [NAR], or no abnormal reflux). Mean nocturnal baseline impedance (MNBI) were measured 3 cm (distal esophagus) and 17 cm (proximal esophagus) above the lower esophageal sphincter. Median distal esophageal MNBI was lower in the acid reflux group (1244 Ω; 647–1969 Ω) than in the NAR (2586 Ω; 1368–3666 Ω) or no abnormal reflux groups (3082 Ω; 2495–4472 Ω; all P < .05). Distal MNBI were negatively correlated with DeMeester score and acid exposure time. Atypical symptoms were more frequently associated with NAR than typical symptoms (P < .01). Among patients with positive symptom-association probability (SAP) for NAR, median proximal MNBI tended to be lower in patients with typical symptoms (median, 3013 Ω; IQR, 2535–3410 Ω) than in those with atypical symptoms (median, 3386 Ω; IQR, 3044–3730 Ω, P = .05). Thus, atypical GERD symptoms were more likely to be associated with NAR. The mucosal integrity of the proximal esophagus might be relatively impaired in GERD patients with typical symptoms for NAR. PMID:28906377
Soares, Ana Cristina Fontenele; de Freitas, Carla Lima; de Morais, Mauro Batista
To assess the knowledge and practice of pediatricians about infants with physiological reflux and gastroesophageal reflux disease. 140 pediatricians were interviewed during two scientific events in 2009 and 2010. The questions referred to two clinical cases of infants. One with symptoms of infant regurgitation (physiological reflux) and another with gastroesophageal reflux disease. Among 140 pediatricians, 11.4% (n=16) and 62.1% (n=87) would require investigation tests, respectively for infant regurgitation (physiological reflux) and gastroesophageal reflux disease. A series of upper gastrointestinal exams would be the first requested with a higher frequency. Medication would be prescribed by 18.6% (n=26) in the case of physiological reflux and 87.1% (n=122) in the case of gastroesophageal reflux disease. Prokinetic drugs would be prescribed more frequently than gastric acid secretion inhibitors. Sleeping position would be recommended by 94.2% (n=132) and 92.9% (n=130) of the respondents, respectively for the case of physiological reflux and gastroesophageal reflux disease; however, about half of the respondents would recommend the prone position. Only 10 (7.1%) of the pediatricians would exclude the cow's milk protein from the infants' diet. Approaches different from the international guidelines are often considered appropriate, especially when recommending a different position other than the supine and prescription of medication. In turn, the interviews enable us to infer the right capacity of the pediatricians to distinguish physiologic reflux and gastroesophageal reflux disease correctly. Copyright © 2014 Associação de Pediatria de São Paulo. Publicado por Elsevier Editora Ltda. All rights reserved.
Sidwa, Feroze; Moore, Alessandra L; Alligood, Elaine; Fisichella, P Marco
To review the current literature on the role of antireflux surgery (ARS) for the treatment of extraesophageal manifestations of GERD. The extraesophageal manifestations of gastroesophageal reflux disease (GERD) include chronic cough, laryngopharyngeal reflux, and asthma. They are responsible for significant morbidity in affected patients and a high economic burden on healthcare resources. We recently published a larger review on the symptoms, diagnosis, medical, and surgical treatment of the extraesophageal manifestations of GERD. Through our investigation, we found that the role of ARS for respiratory symptoms was unclear. Hence, we resorted through the data of our previous meta-analysis to compile a comprehensive and focused review on the role of ARS for respiratory symptoms. Using the archive of our previous meta-analysis, we selected studies extracted from the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases pertaining to the surgical treatment of extraesophageal manifestations of reflux (cough laryngopharyngeal reflux, and asthma). We applied a similar reporting methodology as was used in our previous manuscript and then hand searched the bibliographies of included studies yielding a total of 27 articles for review. We graded the level of evidence and classified recommendations by size of treatment effect per the American Heart Association Task Force on Practice Guidelines. Observational data indicated that syndromes of chronic cough, laryngopharyngeal reflux and asthma might improve after antireflux surgery only in highly selected patients-likely those with non-acid reflux-while those patients with objective markers of asthma severity do not. Because of the varied methods of diagnosis and surgical technique, non-comparative observational data may be unreliable. Additionally, our search found no randomized controlled trials (RCTs) comparing antireflux surgery to medical therapy in the treatment of cough or laryngopharyngeal reflux. One RCT
Melissas, John; Braghetto, Italo; Molina, Juan Carlos; Silecchia, Gianfranco; Iossa, Angelo; Iannelli, Antonio; Foletto, Mirto
Gastroesophageal reflux disease (GERD) and/or hiatus hernia (HH) are one of the most common disorders of the upper gastrointestinal tract. Despite the positive effect of sleeve gastrectomy (SG) regarding weight loss and improvement in obesity co-morbidities, there are concerns about the development of de novo gastroesophageal reflux disease or worsening the existing GERD after this bariatric operation. Furthermore, controversy exists on the consequences of SG in lower esophageal sphincter function and about the ideal procedure when a hiatus hernia is preoperatively diagnosed or discovered during the laparoscopic SG. This review systematically investigates the incidence, the pathophysiology of GERD and/or HH in morbidly obese individuals before and after SG, and the treatment options for concomitant HH repair during laparoscopic sleeve gastrectomy.
Iliaz, Sinem; Iliaz, Raim; Onur, Seda Tural; Arici, Serpil; Akyuz, Umit; Karaca, Cetin; Demir, Kadir; Besisik, Fatih; Kaymakoglu, Sabahattin; Akyuz, Filiz
The relationship between chronic obstructive pulmonary disease (COPD) exacerbations and gastroesophageal reflux (GER) has been investigated less than asthma-GER. We aimed to evaluate the presence of GER in patients with COPD and its impact on exacerbations. We included 24 patients with stable mild-moderate stage COPD and 19 volunteers as the control group. We conducted a gastroesophageal reflux disease (GERD) symptom questionnaire, gastroscopy, manometry, and an ambulatory 24-h pH-impedance study. According to the GERD questionnaire, only 5 (20.8%) patients with COPD had typical GER symptoms. According to the 24-h pH-impedance study, the mean DeMeester score (DMS) was 38.1 ± 34.6 in the COPD group and 13.3 ± 16.8 in the control group (p = 0.01). The acid reflux (DMS > 14.7) rate was higher in patients with COPD than in controls (73.9% vs 26.3%, p = 0.01). The symptom association probability positivity rate was 17.4% (n = 4) in the COPD group, which was similar to the controls (p = 0.11). The mean proximal extension rate of reflux (Z 17 cm) was 26.4 ± 12.9% in the COPD group. The proximal extent of reflux was positively correlated with the number of COPD exacerbations per year (p = 0.03, r = 0.448). In the motility results, only 2 (20%) patients in the control group had a minor motility disorder. Seventeen (70.8%) patients in the COPD group had a minor motility disorder, and 4 (16.7%) had major motility disorders (p < 0.001). In our study, gastroesophageal reflux was frequent in patients with COPD, but only a quarter had typical reflux symptoms. The proximal extent of reflux may trigger frequent exacerbations of COPD. Copyright © 2016 Elsevier Ltd. All rights reserved.
Chuang, Tang-Wei; Chen, Shou-Chien; Chen, Kow-Tong
The aim of this study was to explore the recent advances in diagnosis and treatment of gastroesophageal reflux disease (GERD). Previous studies were searched using the terms "gastroesophageal reflux disease" and "diagnosis" or "treatment" in Medline and Pubmed. Articles that were not published in the English language, manuscripts without an abstract, reviews, meta-analysis, and opinion articles were excluded from the review. After a preliminary screening, all of the articles were reviewed and synthesized to provide an overview of the contemporary approaches to GERD. GERD has a variety of symptomatic manifestations, which can be grouped into typical, atypical and extra-esophageal symptoms. Those with the highest specificity for GERD are acid regurgitation and heartburn. In the absence of other alarming symptoms, these symptoms allow one to make a presumptive diagnosis of GERD and initiate empiric therapy. GERD-associated complications include erosive esophagitis, peptic stricture, Barrett's esophagus, esophageal adenocarcinoma and pulmonary disease. Management of GERD may involve lifestyle modifications, medical and surgical therapy. Medical therapy involves acid suppression, which can be achieved with antacids, histamine-receptor antagonists or proton-pump inhibitors. Whereas most patients can be effectively managed with medical therapy, others may go on to require anti-reflux surgery after undergoing a proper pre-operative evaluation. The management of this disease requires a complex approach. Maintenance therapy of GERD after using anti-secretory drugs should be continuously monitored. © Acta Gastro-Enterologica Belgica.
COMBINED 24-HOURS ESOPHAGEAL PH MONITORING AND MULTICHANNEL INTRALUMINAL IMPEDANCE FOR COMPARISON OF GASTROESOPHAGEAL REFLUX IN CHILDREN WITH TYPICAL VERSUS ATYPICAL SYMPTOMS OF GASTROESOPHAGEAL REFLUX DISEASE.
Dehghani, Seyed Mohsen; Taghavi, Seyed Alireza; Javaherizadeh, Hazhir; Nasri, Maryam
- Gastroesophageal reflux disease is the most common esophageal disorder in pediatrics. - The aim of this study was to compare reflux parameters of typical and atypical symptoms of gastroesophageal reflux disease using 24-hour esophageal pH monitoring and multichannel intraluminal impedance in pediatric population. - In this prospective study, 43 patients aged less than 18 year with suspected gastroesophageal reflux disease were enrolled. The patients were divided into two groups based on the main presenting symptoms (typical versus atypical). Twenty four-hour pH monitoring and multichannel intraluminal impedance were performed in all the patients for comparing these two group regarding association of symptoms and reflux. Number of refluxes, pH related reflux, total reflux time, reflux more than 5 minutes, longest time of the reflux, lowest pH at reflux, reflux index were recorded and compared. Data comparison was done using SPSS. - The mean age of the patients was 5.7±3.4 years and 65.1% were male. Out of 43 patients 24 cases had typical symptoms and 19 had atypical symptoms. The mean reflux events detected by multichannel intraluminal impedance was more than mean reflux events detected by pH monitoring (308.4±115.8 vs 69.7±66.6) with P value of 0.037, which is statistically significant. The mean symptom index and symptom association probability were 35.01% ± 20.78% and 86.42% ± 25.79%, respectively in multichannel intraluminal impedance versus 12.73% ± 12.48% and 45.16% ± 42.29% in pH monitoring (P value <0.001). Number of acid reflux was 46.26±47.16 and 30.9±22.09 for atypical and typical symptoms respectively. The mean symptom index was 18.12% ± 13.101% and 8.30% ± 10.301% in atypical and typical symptoms respectively (P=0.034). Bolus clearance was longer in atypical symptoms compared typical symptoms(P<0.05). - Symptom index was significantly higher in atypical symptoms compared to typical symptoms. Higher number of acid reflux was found in children
Prachuapthunyachart, Sittichoke; Jarasvaraparn, Chaowapong; Gremse, David A
Esophageal multichannel intraluminal impedance-pH monitoring has become one of the preferred tests to correlate observed reflux-like behaviors with esophageal reflux events. The Gastroesophageal reflux disease Assessment Symptom Questionnaire is a validated tool used to distinguish infants with gastroesophageal reflux disease from healthy children. The aim of this study was to determine whether the Gastroesophageal reflux disease Assessment Symptom Questionnaire composite symptom scores and individual symptom scores correlate with outcomes in esophageal multichannel intraluminal impedance-pH monitoring. A total of 26 patients with gastroesophageal reflux disease-associated symptoms, aged 0-2 years, for whom both esophageal multichannel intraluminal impedance-pH monitoring and Gastroesophageal reflux disease Assessment Symptom Questionnaire survey results were available were included in the study. Gastroesophageal reflux disease Assessment Symptom Questionnaire score data were collected from a 7-day recall of parent's responses about the frequency and severity of gastroesophageal reflux disease symptoms, which determined the individual symptom scores. The composite symptom scores is the sum of all individual symptom scores. Multichannel intraluminal impedance-pH study results were compared to Gastroesophageal reflux disease Assessment Symptom Questionnaire data using Pearson correlation. Among 26 patients, a total number of 2817 (1700 acid and 1117 non-acid) reflux episodes and 845 clinical reflux behaviors were recorded. There were significant correlations between the reflux index and the individual symptom scores for coughing/gagging/choking (r 2 = 0.2842, p = 0.005), the impedance score and individual symptom scores for coughing/gagging/choking (r 2 = 0.2482, p = 0.009), the reflux symptom index for acid reflux-related coughing/gagging/choking and the individual symptom scores for coughing/gagging/choking (r 2 = 0.1900, p = 0.026), the impedance score and
Saleh, C M G; Smout, A J P M; Bredenoord, A J
For over 50 years, barium studies have been used to diagnose gastro-esophageal reflux disease (GERD), but the value of this test is controversial. Our study aimed to determine if barium esophagograms can be used to diagnose GERD. Barium esophagograms and pH-impedance measurement were performed in 20 subjects with reflux symptoms. pH-impedance measurements were used as gold standard for the diagnosis of GERD. Gastro-esophageal reflux measured with the barium study was defined as a positive outcome. 50% of patients presented gastro-esophageal reflux on the barium esophagogram. No significant differences were observed in acid exposure time between subjects with (median: 7.4%; interquartile range, IQR: 8.4%) or without reflux at barium esophagography (median: 5.95%; IQR: 13.05%; p > 0.05). Nor did we find differences in median proximal extent of reflux measured with impedance monitoring between patients with a positive (median: 6.7%; IQR: 1.95%) and negative barium study (median: 7.1%; IQR: 0.68%; p > 0.05). Patients with reflux on barium esophagogram did not have a positive symptom association probability more often than those who did not have reflux at barium esophagography. Lastly, there were no differences in numbers of acid, weakly acidic or total reflux episodes between those with positive or negative barium esophagogram (p > 0.05). No correlations were found between the maximum proximal extent of gastro-esophageal reflux during esophagography and pH-impedance parameters. Presence or absence of gastro-esophageal reflux during barium esophagography does not correlate with incidence or extent of reflux observed during 24-h pH-impedance monitoring and is not of value for the diagnosis of GERD. © 2014 John Wiley & Sons Ltd.
Prachuapthunyachart, Sittichoke; Jarasvaraparn, Chaowapong; Gremse, David A
Background: Esophageal multichannel intraluminal impedance-pH monitoring has become one of the preferred tests to correlate observed reflux-like behaviors with esophageal reflux events. The Gastroesophageal reflux disease Assessment Symptom Questionnaire is a validated tool used to distinguish infants with gastroesophageal reflux disease from healthy children. The aim of this study was to determine whether the Gastroesophageal reflux disease Assessment Symptom Questionnaire composite symptom scores and individual symptom scores correlate with outcomes in esophageal multichannel intraluminal impedance-pH monitoring. Methods: A total of 26 patients with gastroesophageal reflux disease–associated symptoms, aged 0–2 years, for whom both esophageal multichannel intraluminal impedance-pH monitoring and Gastroesophageal reflux disease Assessment Symptom Questionnaire survey results were available were included in the study. Gastroesophageal reflux disease Assessment Symptom Questionnaire score data were collected from a 7-day recall of parent’s responses about the frequency and severity of gastroesophageal reflux disease symptoms, which determined the individual symptom scores. The composite symptom scores is the sum of all individual symptom scores. Multichannel intraluminal impedance-pH study results were compared to Gastroesophageal reflux disease Assessment Symptom Questionnaire data using Pearson correlation. Results: Among 26 patients, a total number of 2817 (1700 acid and 1117 non-acid) reflux episodes and 845 clinical reflux behaviors were recorded. There were significant correlations between the reflux index and the individual symptom scores for coughing/gagging/choking (r2 = 0.2842, p = 0.005), the impedance score and individual symptom scores for coughing/gagging/choking (r2 = 0.2482, p = 0.009), the reflux symptom index for acid reflux-related coughing/gagging/choking and the individual symptom scores for coughing/gagging/choking (r2 = 0.1900, p = 0
Dirou, S; Germaud, P; Bruley des Varannes, S; Magnan, A; Blanc, F-X
Gastroesophageal reflux disease (GERD) frequently occurs in association with chronic respiratory diseases although the casual link is not always clear. Several pathophysiological and experimental factors are considered to support a role for GERD in respiratory disease. Conversely, respiratory diseases and bronchodilator treatment can themselves exacerbate GERD. When cough or severe asthma is being investigated, GERD does not need to be systematically looked for and a therapeutic test with proton pump inhibitors is not always recommended. pH impedance monitoring is now the reference diagnostic tool to detect non acid reflux, a form of reflux for which proton pump inhibitor treatment is ineffective. Recent data have shown a potential role of GERD in idiopathic pulmonary fibrosis and bronchiolitis obliterans following lung transplantation, leading to discussions about the place of surgery in this context. However, studies using pH impedance monitoring are still needed to better understand and manage the association between GERD and chronic respiratory diseases. Copyright © 2015 SPLF. Published by Elsevier Masson SAS. All rights reserved.
Hershcovici, T; Fass, R
Up to a third of the patients who receive proton pump inhibitor (PPI) once daily will demonstrate lack or partial response to treatment. There are various mechanisms that contribute to PPI failure and they include residual acid reflux, weakly acidic and weakly alkaline reflux, esophageal hypersensitivity, and psychological comorbidity, among others. Some of these underlying mechanisms may coincide in the same patient. Evaluation for proper compliance and adequate dosing time of PPIs should be the first management step before ordering invasive diagnostic tests. Doubling the PPI dose or switching to another PPI is the second step of management. Upper endoscopy and pH testing appear to have limited diagnostic value in patients who failed PPI treatment. In contrast, esophageal impedance with pH testing (multichannel intraluminal impedance MII-pH) on therapy appears to provide the most insightful information about the subsequent management of these patients (step 3). In step 4, treatment should be tailored to the specific underlying mechanism of patient's PPI failure. For those who demonstrate weakly acidic or weakly alkaline reflux as the underlying cause of their residual symptoms, transient lower esophageal sphincter relaxation reducers, endoscopic treatment, antireflux surgery and pain modulators should be considered. In those with functional heartburn, pain modulators are the cornerstone of therapy. © 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.
Turk, Akif; Selimoglu, Ahmet; Demir, Kadir; Celik, Osman; Saglam, Erkin; Tarhan, Fatih
Aim of this study is to examine the effectiveness of dextranomer/hyaluronic acid copolymer and polyacrylate polyalcohol copolymer in endoscopic treatment of vesicoureteral reflux disease in adult patients with and without chronic renal failure. Thirty two patients (12 female, 20 male) with a total of 50 renal units were treated for vesicoureteral reflux. There were 26 (81%) chronic renal failure patients. The success of treatment was evaluated by voiding cystouretrography at 3rd and 12th months after subureteric injection. The persistence of reflux was considered as failure. Patients were divided into two groups according to injected material. Age, sex, grade of reflux and treatment results were recorded and evaluated. Reflux was scored as grade 1 in seven (14%), grade 2 in 16 (32%), grade 3 in 21 (42%) and grade 4 in six (12%) renal units. There was not patient with grade 5 reflux. Fourteen renal units (28%) were treated with dextranomer/hyaluronic acid copolymer (group 1) and 36 renal units (72%) were treated with polyacrylate polyalcohol copolymer (group 2). The overall treatment success was achieved at 40 renal units (80%). The treatment was successful at 11 renal units (79%) in group 1 and 29 renal units (81%) in group 2 (p = 0.71). There was not statistically significant difference between two groups with patients with chronic renal failure in terms of treatment success (p = 1.00). The effectiveness of two bulking agents was similar in treatment of vesicoureteral reflux disease in adult patients and patients with chronic renal failure.
Lam, C; Liu, W F; Bel, R D; Chan, K; Miller, L; Brown, M C; Chen, Z; Cheng, D; Patel, D; Xu, W; Darling, G E; Liu, G
Gastroesophageal reflux disease (GERD) may lead to Barrett's esophagus (BE). Previously, a large genome-wide association study found two germline markers to be associated with BE, FOXF1 rs9936833 (C allele) and MHC rs9257809 (A allele). This study evaluated whether these two polymorphisms are associated with gastroesphageal acid reflux as measured by 24-hour pH testing. Patients with acid reflux symptoms referred for esophageal manometry and 24-hour pH monitoring at University Health Network (Toronto, ON) were enrolled. DNA extracted from blood was genotyped using a Taqman Polymerase Chain Reaction (PCR) assay. DeMeester scores of ≥14.7 or prior evidence of reflux esophagitis on endoscopy defined individuals with esophageal acid reflux. Logistic regression analysis, adjusted for clinical risk factors, was used to calculate odds ratios with 95% confidence intervals for each polymorphism in relation to the presence of acid reflux. Of 182 patients, the median age was 50 years and 62% were female; 95 (52%) met the definition of GERD. In the multivariable analysis, both FOXF1 rs9936833 (OR = 1.82; 95%CI: 1.12-2.96; P = 0.02) and MHC rs9257809 (OR = 9.36; 95%CI: 2.92-29.99; P < 0.001) remained significantly associated with presence of acid reflux. When both polymorphisms were placed in the same model, the adjusted ORs were 2.10 (95%CI: 1.24-3.53; P = 0.005) and 10.95 (95%CI: 3.32-36.09; P < 0.001), respectively. The association for risk allele C in FOXF1 rs9936833 and risk allele A in MHC rs9257809 with the presence of acid reflux suggests a potential pathophysiologic mechanism for the role of genetic influences in BE development. © 2016 International Society for Diseases of the Esophagus.
Pehl, C; Pfeiffer, A; Wendl, B; Kaess, H
Patients with reflux disease often complain of heartburn after ingestion of coffee. Induction of gastro-oesophageal reflux has been demonstrated by pH-metry following the intake of coffee in healthy volunteers. The reflux was reduced when the coffee had undergone a decaffeination process. The aim of this study was to investigate the effect of decaffeination of coffee on reflux in patients with reflux disease. Seventeen reflux patients underwent two osesophageal 3-h pH measurements. The patients received, in a double-blind study design in a randomized order, 300 mL of either regular or decaffeinated coffee together with a standardized breakfast. The fraction time oesophageal pH < 4 was calculated during the three postprandial hours. For regular coffee the fraction time was calculated to a median of 17.9% with a range of 0.7-56.6%. The fraction time was significantly reduced to 3.1% (0-49.9%) after ingestion of decaffeinated coffee. The amount of gastro-oesophageal reflux induced by the intake of regular coffee in patients with reflux disease can be reduce by the decaffeination of coffee.
Randomised clinical trial: relief of upper gastrointestinal symptoms by an acid pocket-targeting alginate-antacid (Gaviscon Double Action) - a double-blind, placebo-controlled, pilot study in gastro-oesophageal reflux disease.
Thomas, E; Wade, A; Crawford, G; Jenner, B; Levinson, N; Wilkinson, J
The alginate-antacid, Gaviscon Double Action (Gaviscon DA; Reckitt Benckiser, Slough, UK) suppresses reflux after meals by creating a gel-like barrier that caps and displaces the acid pocket distal to the oesophago-gastric junction. The effect of Gaviscon DA on reflux and dyspepsia symptoms has not yet been demonstrated with a modern trial design. A pilot study to assess the efficacy and safety of Gaviscon DA compared with matched placebo for decreasing upper gastrointestinal symptoms in symptomatic gastro-oesophageal reflux disease (GERD) patients. A randomised, double-blind, parallel group study was performed in 110 patients with symptoms of GERD. Patients received Gaviscon DA or placebo tablets for 7 consecutive days. The primary endpoint compared the change in overall Reflux Disease Questionnaire (RDQ) symptom score (combined heartburn/regurgitation/dyspepsia). Secondary endpoints assessed individual dimensions, GERD dimension (heartburn and regurgitation) and overall treatment evaluation (OTE). There was a greater decrease in overall RDQ symptom score in the Gaviscon DA group compared with the placebo group (Least Squares Mean difference -0.55; P = 0.0033), and for each of the dimensions independently. Patients in the Gaviscon DA group evaluated their overall treatment response higher than patients in the placebo group [mean (standard deviation) OTE 4.1 (2.44) vs. 1.9 (3.34); P = 0.0005]. No differences in the incidence of adverse events were observed between treatment groups. Gaviscon DA decreases reflux and dyspeptic symptoms in GERD patients compared with matched placebo and has a favourable benefit-risk balance. Larger scale clinical investigations of medications targeting the acid pocket are warranted. (EudraCT, 2012-002188-84). © 2014 John Wiley & Sons Ltd.
Medical therapy remains the most popular treatment for gastroesophageal reflux disease (GERD). Whilst interest in drug development for GERD has declined over the last few years primarily due to the conversion of most proton pump inhibitor (PPI)'s to generic and over the counter compounds, there are still numerous areas of unmet needs in GERD. Drug development has been focused on potent histamine type 2 receptor antagonist's, extended release PPI's, PPI combination, potassium-competitive acid blockers, transient lower esophageal sphincter relaxation reducers, prokinetics, mucosal protectants and esophageal pain modulators. It is likely that the aforementioned compounds will be niched for specific areas of unmet need in GERD, rather than compete with the presently available anti-reflux therapies. PMID:24466441
Cengiz, Seda; Cengiz, M Inanç; Saraç, Y Sinasi
Chronic regurgitation of gastric acids in patients with gastroesophageal reflux disease may cause dental erosion, which can lead in combination with attrition or bruxism to extensive loss of coronal tooth tissue. This clinical report describes treatment of severe tooth wear of a gastroesophageal reflux disease patient who is 54-year-old Turkish male patient. After his medical treatment, severe tooth wear, bruxism and decreased vertical dimensions were determined. The vertical dimension was re-established and maxillary and mandibular anterior and posterior teeth were prepared for metal-ceramic restorations. Metal-ceramic fixed partial dentures were fabricated as full mouth restorations for both maxillary and mandibular arches because of splinting all teeth. And then maxillary stabilization splint was fabricated for his bruxism history. Significant loss of coronal tooth structure must taken into consideration. Gastroesophageal reflux disease by itself or in combination with attrition, abrasion or bruxism may be responsible for the loss. An extensive diagnostic evaluation is essential for the medical and dental effects of the problem.
Cengiz, M İnanç; Saraç, Y Şinasi
Introduction Chronic regurgitation of gastric acids in patients with gastroesophageal reflux disease may cause dental erosion, which can lead in combination with attrition or bruxism to extensive loss of coronal tooth tissue. Case presentation This clinical report describes treatment of severe tooth wear of a gastroesophageal reflux disease patient who is 54-year-old Turkish male patient. After his medical treatment, severe tooth wear, bruxism and decreased vertical dimensions were determined. The vertical dimension was re-established and maxillary and mandibular anterior and posterior teeth were prepared for metal-ceramic restorations. Metal-ceramic fixed partial dentures were fabricated as full mouth restorations for both maxillary and mandibular arches because of splinting all teeth. And then maxillary stabilization splint was fabricated for his bruxism history. Conclusion Significant loss of coronal tooth structure must taken into consideration. Gastroesophageal reflux disease by itself or in combination with attrition, abrasion or bruxism may be responsible for the loss. An extensive diagnostic evaluation is essential for the medical and dental effects of the problem. PMID:19830044
Nakahara, Kenichi; Fujiwara, Yasuhiro; Tsukahara, Takuya; Yamagami, Hirokazu; Tanigawa, Tetsuya; Shiba, Masatsugu; Tominaga, Kazunari; Watanabe, Toshio; Urade, Yoshihiro; Arakawa, Tetsuo
Gastroesophageal reflux disease (GERD) is strongly associated with sleep disturbances. Proton pump inhibitor (PPI) therapy improves subjective but not objective sleep parameters in patients with GERD. This study aimed to investigate the association between GERD and sleep, and the effect of PPI on sleep by using a rat model of chronic acid reflux esophagitis. Acid reflux esophagitis was induced by ligating the transitional region between the forestomach and the glandular portion and then wrapping the duodenum near the pylorus. Rats underwent surgery for implantation of electrodes for electroencephalogram and electromyogram recordings, and they were transferred to a soundproof recording chamber. Polygraphic recordings were scored by using 10-s epochs for wake, rapid eye movement sleep, and non-rapid eye movement (NREM) sleep. To examine the role of acid reflux, rats were subcutaneously administered a PPI, omeprazole, at a dose of 20 mg/kg once daily. Rats with reflux esophagitis presented with several erosions, ulcers, and mucosal thickening with basal hyperplasia and marked inflammatory infiltration. The reflux esophagitis group showed a 34.0% increase in wake (232.2±11.4 min and 173.3±7.4 min in the reflux esophagitis and control groups, respectively; p<0.01) accompanied by a reduction in NREM sleep during light period, an increase in sleep fragmentation, and more frequent stage transitions. The use of omeprazole significantly improved sleep disturbances caused by reflux esophagitis, and this effect was not observed when the PPI was withdrawn. Acid reflux directly causes sleep disturbances in rats with chronic esophagitis.
Nakahara, Kenichi; Fujiwara, Yasuhiro; Tsukahara, Takuya; Yamagami, Hirokazu; Tanigawa, Tetsuya; Shiba, Masatsugu; Tominaga, Kazunari; Watanabe, Toshio; Urade, Yoshihiro; Arakawa, Tetsuo
Background & Aims Gastroesophageal reflux disease (GERD) is strongly associated with sleep disturbances. Proton pump inhibitor (PPI) therapy improves subjective but not objective sleep parameters in patients with GERD. This study aimed to investigate the association between GERD and sleep, and the effect of PPI on sleep by using a rat model of chronic acid reflux esophagitis. Methods Acid reflux esophagitis was induced by ligating the transitional region between the forestomach and the glandular portion and then wrapping the duodenum near the pylorus. Rats underwent surgery for implantation of electrodes for electroencephalogram and electromyogram recordings, and they were transferred to a soundproof recording chamber. Polygraphic recordings were scored by using 10-s epochs for wake, rapid eye movement sleep, and non-rapid eye movement (NREM) sleep. To examine the role of acid reflux, rats were subcutaneously administered a PPI, omeprazole, at a dose of 20 mg/kg once daily. Results Rats with reflux esophagitis presented with several erosions, ulcers, and mucosal thickening with basal hyperplasia and marked inflammatory infiltration. The reflux esophagitis group showed a 34.0% increase in wake (232.2±11.4 min and 173.3±7.4 min in the reflux esophagitis and control groups, respectively; p<0.01) accompanied by a reduction in NREM sleep during light period, an increase in sleep fragmentation, and more frequent stage transitions. The use of omeprazole significantly improved sleep disturbances caused by reflux esophagitis, and this effect was not observed when the PPI was withdrawn. Conclusions Acid reflux directly causes sleep disturbances in rats with chronic esophagitis. PMID:25215524
Gao, Feng; Gao, Yan; Chen, Xue; Qian, Jie; Zhang, Jie
By means of 24 h multi-channel intraluminal impedance and pH recording (MII/pH), patients with heartburn and normal upper gastrointestinal endoscopy findings can be classified into those with non-erosive reflux disease (NERD) and those with reflux hypersensitivity (RH). Therefore, in this study, we investigated the difference in oesophageal function tests in Chinese patients with NERD and RH. NERD patients were selected from the digestive department, Beijing Anzhen Hospital and Beijing Chao-Yang Hospital, Capital Medical University, after upper gastrointestinal endoscope, high-resolution manometry and impedance (HRiM), and MII/pH examinations between 2014 and 2016. In total, 111 NERD patients with abnormal acid exposure, and 92 RH patients were enrolled. Values for NERD and RH were as follows: lower oesophageal sphincter pressure, 15.3 ± 8.9 and 19.3 ± 23.3 mmHg (P = 0.122); integrated relaxation pressure, 7.5 ± 4.8 and 7.9 ± 5.2 mmHg (P = 0.485); distal contractile integral, 751.9 ± 856.2 and 661.9 ± 961.7 mmHg∙s∙cm (P = 0.482); ineffective oesophageal motility rate, 49.5% and 41.3% (P = 0.241); fragmented peristalsis rate, 5.4% and 9.8% (P = 0.235); hiatal hernia rate, 9.0% and 8.6% (P = 0.938); total bolus transit time, 6.3 ± 1.3 and 6.5 ± 1.3 s (P = 0.119); complete bolus transit rate, 76.1 ± 33.0% and 73.1 ± 32.0% (P = 0.224); total acid exposure time, 6.1 ± 3.7% and 0.8 ± 0.8% (P < 0.001); total bolus exposure time, 2.5 ± 2.1% and 1.5 ± 1.1% (P < 0.001); proximal acid reflux events, 13.2 ± 10.5 and 9.7 ± 8.9 (P = 0.011); distal acid reflux events, 25.3 ± 15.8 and 13.4 ± 11.2 (P < 0.001); post-reflux swallow-induced peristaltic wave index, 25.1 ± 9.5% and 32.6 ± 15.2% (P < 0.001); and mean nocturnal baseline impedance, 1,450.2 ± 750.8 and 2,503.6 ± 964.1 ohms (P < 0.001), respectively
Dyspepsia is a syndrome characterized by symptoms and signs of upper gastrointestinal tract and the adjacent organs. It is estimated that 25% of the community have symptoms of dyspepsia syndrome. One-third of patients who visit general physician practices are patients with dyspepsia syndrome; and half of patients who visit gastroenterologists are also patients with dyspepsia syndrome. Dyspepsia syndrome and gastroesophageal reflux disease (GERD) are very prevalent in the community throughout the world.Gastroesophageal reflux disease (GERD) is more and more commonly found in daily medical practice. Until now,the natural history of disease on GERD and dyspepsia is hardly understood, even though many scientists studied both conditions and there are frequently overlapping. In an individual, GERD and dyspepsia may occur simultaneously and therefore they are hardly to be discriminated.The management of GERD is performed in keeping with Indonesia and Asia Pacific consensus, life-style modification and administering the acid suppression agents (Proton pump inhibitor (drug of choice), H2-receptor antagonist, etc),prokinetic agents (Cisapride, domperidone, etc). Life-style modification shall be performed as follows, i.e. sleep with 30-45 degree elevated head or upper chest, do not avoid sour beverages, chocolate, coffee or alcohol, avoid fat and various fried foods, sour food, less stress, stop smoking, small but frequent feeding, etc. There is a correlation between dyspepsia syndrome and gastroesophageal reflux disease(GERD), particularly between the functional dyspepsia and non-erosive gastroesophageal reflux (NERD). More appropriate definition is necessary to differentiate the dyspepsia syndrome and GERD. Further studies are needed to establish distinct definition and criteria between dyspepsia syndrome and GERD.
Wu, Justin C Y
The prevalence of gastroesophageal reflux disease (GERD) ranges from 2.5% to 7.1% in most population-based studies in Asia. There is evidence that GERD and its complications are rising, coinciding with a decline in Helicobacter pylori (H. pylori) infection. Asian GERD patients share similar risk factors and pathophysiological mechanisms with their Western counterparts. Possible causes for the lower prevalence of GERD include less obesity and hiatus hernia, a lesser degree of esophageal dysmotility, a high prevalence of virulent strains of H. pylori, and low awareness. Owing to the lack of precise translation for 'heartburn' in most Asian languages, reflux symptoms are often overlooked or misinterpreted as dyspepsia or chest pain. Furthermore, a symptom-based diagnosis with a therapeutic trial of the proton pump inhibitor (PPI) may be hampered by the high prevalence of H. pylori-related disease. The risk stratification for prompt endoscopy, use of a locally-validated, diagnostic symptom questionnaire, and response to H. pylori'test and treat' help improve the accuracy of the PPI test for diagnoses. PPI remain the gold standard treatment, and 'on-demand' PPI have been shown to be a cost-effective, long-term treatment. The clinical course of GERD is benign in most patients in Asia. The risk of progression from non-erosive reflux disease to erosive esophagitis is low, and treatment response to a conventional dose of PPI is generally higher. Although H. pylori eradication may lead to more resilient GERD in a subset of patients, the benefits of H. pylori eradication outweigh the risks, especially in Asian populations with a high incidence of gastric cancer.
Jaimchariyatam, Nattapong; Tantipornsinchai, Warangkana; Desudchit, Tayard; Gonlachanvit, Sutep
Literature has addressed the increased prevalence of gastroesophageal reflux disease (GERD) in obstructive sleep apnea (OSA). Significant improvement of GERD has been found after OSA treatment. However, precise mechanisms underlying this correlation remain unclear. We examined the association between nocturnal gastroesophageal reflux (GER) and sleep events in patients with coexisting OSA and GERD. A case-crossover study among 12 patients with coexisting moderate-severe OSA and GERD was conducted. Participants underwent simultaneous polysomnography and esophageal impedance and pH monitoring. GER subtypes (ie, acid reflux, non-acid reflux) were defined as outcomes. Respective control time points were selected in all eligible control periods. Each sleep event was assessed individually. Estimated odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed. A p-value of < 0.05 was considered significant. Patients were determined as moderate to severe OSA (respiratory disturbance index of 42.66 [±22.09]). There were a total of 50 GER episodes, 22 acid reflux and 28 non-acid reflux. Arousals and awakenings were significantly associated with subsequent GER events. The OR for GER following an arousal was 2.31 (95% CI 1.39-3.68; p < 0.001) and following an awakening was 3.71 (95% CI 1.81-7.63; p < 0.001). GER events were significantly less likely to occur after other respiratory events (OR 0.38 [95% CI 0.18-0.82]; p = 0.01). No sleep events followed GER events (p > 0.05). Both awakening and arousal appear to precipitate any subtype of GER events in patients with coexisting GERD and moderate to severe OSA. However, GER events were significantly less likely to occur after other respiratory events and did not appear to cause sleep-related events. Copyright © 2016 Elsevier B.V. All rights reserved.
Tsoukali, Emmanouela; Sifrim, Daniel
The most common extraesophageal manifestations of gastroesophageal reflux disease (GERD) include chronic cough, asthma and laryngitis. There are two mechanisms proposed to explain extraesophageal syndromes caused by GERD. The first one is a direct way via irritation and/or microaspiration and the second one is an indirect, vagally mediated way. The investigation of extraesophageal manifestations of GERD is difficult and the empirical therapy with proton pump inhibitors usually double dose for at least three months is still the most common approach. PMID:24714277
Mello, Michael; Gyawali, C Prakash
High-resolution manometry (HRM) allows nuanced evaluation of esophageal motor function, and more accurate evaluation of lower esophageal sphincter (LES) function, in comparison with conventional manometry. Pathophysiologic correlates of gastroesophageal reflux disease (GERD) and esophageal peristaltic performance are well addressed by this technique. HRM may alter the surgical decision by assessment of esophageal peristaltic function and exclusion of esophageal outflow obstruction before antireflux surgery. Provocative testing during HRM may assess esophageal smooth muscle peristaltic reserve and help predict the likelihood of transit symptoms following antireflux surgery. HRM represents a continuously evolving new technology that compliments the evaluation and management of GERD. Copyright © 2014 Elsevier Inc. All rights reserved.
Preetha, A; Sujatha, D; Patil, Bharathi A; Hegde, Sushmini
Many systemic diseases exert their influence on oral health. Among these, gastroesophageal reflux disease (GERD) is the most common. In this study, 100 patients who were previously diagnosed with GERD were examined following a 12-hour fast and evaluated in terms of the severity (grade) of the disease as well as any oral, dental, and/or salivary pH changes. Results found 11 patients with tooth erosion. These patients were older, and their average mean duration of GERD was longer in comparison to those without erosion. There was an inverse relationship between salivary pH and the GERD duration and grade of severity. As the GERD grade increased, the severity of tooth erosion increased. Patients with erosion also exhibited oral mucosal changes. Thus severe, long-term GERD was found to be potentially detrimental to oral soft tissues, dental structures, and salivary pH, whereas milder forms of the disease did not necessarily cause dental side effects.
Ferreira, Cristina Targa; Carvalho, Elisa de; Sdepanian, Vera Lucia; Morais, Mauro Batista de; Vieira, Mário César; Silva, Luciana Rodrigues
there are many questions and little evidence regarding the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children. The association between GERD and cow's milk protein allergy (CMPA), overuse of abdominal ultrasonography for the diagnosis of GERD, and excessive pharmacological treatment, especially proton-pump inhibitors (PPIs) are some aspects that need clarification. This review aimed to establish the current scientific evidence for the diagnosis and treatment of GERD in children. a search was conducted in the MEDLINE, PubMed, LILACS, SciELO, and Cochrane Library electronic databases, using the following keywords: gastroesophageal reflux; gastroesophageal reflux disease; proton-pump inhibitors; and prokinetics; in different age groups of the pediatric age range; up to May of 2013. abdominal ultrasonography should not be recommended to investigate gastroesophageal reflux (GER). Simultaneous treatment of GERD and CMPA often results in unnecessary use of medication or elimination diet. There is insufficient evidence for the prescription of prokinetics to all patients with GER/GERD. There is little evidence to support acid suppression in the first year of life, to treat nonspecific symptoms suggestive of GERD. Conservative treatment has many benefits and with low cost and no side-effects. there have been few randomized controlled trials that assessed the management of GERD in children and no examination can be considered the gold standard for GERD diagnosis. For these reasons, there are exaggerations in the diagnosis and treatment of this disease, which need to be corrected. Copyright © 2013 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.
Savarino, Edoardo; Zentilin, Patrizia; Marabotto, Elisa; Bodini, Giorgia; Della Coletta, Marco; Frazzoni, Marzio; de Bortoli, Nicola; Martinucci, Irene; Tolone, Salvatore; Pellegatta, Gaia; Savarino, Vincenzo
Medical therapy of gastroesophageal reflux disease (GERD) is based on the use of proton pump inhibitors (PPIs) as first choice treatment. Despite their effectiveness, about 20-30% of patients report an inadequate response and alternative drugs are required. Areas covered: This review provides an overview of current pharmacotherapy for treating GERD by showing the results of PPIs, reflux inhibitors, antidepressants and mucosa protective medications. Expert opinion: Medical therapy of GERD does not definitely cure the disease, because even PPIs are not able to change the key factors responsible for it. However, they remain the mainstay of medical treatment, allowing us to alleviate symptoms, heal esophagitis and prevent complications in the majority of cases. Nevertheless, many patients do not respond, because acid does not play any pathogenetic role. Prokinetics and reflux inhibitors have the potential to control motor abnormalities, but the results of clinical trials are inconsistent. Antidepressant drugs are effective in specific subgroups of NERD patients with visceral hypersensitivity, but larger, controlled clinical studies are necessary. Protective drugs or medical devices have been recently adopted to reinforce mucosal resistance and preliminary trials have confirmed their efficacy either combined with or as add-on medication to PPIs in refractory patients.
Parasa, S; Sharma, P
Gastro-oesophageal reflux disease (GORD) is on the rise with more than 20% of the western population reporting symptoms and is the most common gastrointestinal disorder in the United States. This increase in GORD is not exactly clear but has been attributed to the increasing prevalence of obesity, changing diet, and perhaps the decreasing prevalence of H. pylori infection. Complications of GORD could be either benign or malignant. Benign complications include erosive oesophagitis, bleeding and peptic strictures. Premalignant and malignant lesions include Barrett's metaplasia, and oesophageal cancer. Management of both the benign and malignant complications can be challenging. With the use of proton-pump inhibitors, peptic strictures (i.e., strictures related to reflux) have significantly declined. Several aspects of Barrett's management remain controversial including the stage in the disease process which needs to be intervened, type of the intervention and surveillance of these lesions to prevent development of high grade dysplasia and oesophageal adenocarcinoma. Copyright © 2013 Elsevier Ltd. All rights reserved.
Babaei, Arash; Venu, Mukund; Naini, Sohrab Rahimi; Gonzaga, Jason; Lang, Ivan; Massey, Benson; Jadcherla, Sudarshan; Shaker, Reza
Background & Aims Normal responses of the upper esophageal sphincter (UES) and esophageal body to liquid reflux events prevent esophagopharyngeal reflux and its complications, but abnormal responses have not been characterized. We investigated whether patients with supra-esophageal reflux disease (SERD) have impaired UES and esophageal body responses to simulated reflux events. Methods We performed a prospective study of 25 patients with SERD (19–82 y old, 13 female) and complaints of regurgitation and supra-esophageal manifestations of reflux. We also included 10 patients with gastroesophageal reflux disease (GERD; 32–60 y old, 7 female) without troublesome regurgitation and supra-esophageal symptoms and 24 healthy asymptomatic individuals (controls; 19–49 y old, 13 female). UES and esophageal body pressure responses, along with luminal distribution of infusate during esophageal rapid and slow infusion of air or liquid, were monitored by concurrent high-resolution manometry and intraluminal impedance. Results A significantly smaller proportion of patients with SERD had UES contractile reflexes in response to slow esophageal infusion of acid than controls or patients with GERD. Only patients with SERD had abnormal UES relaxation responses to rapid distension with saline. Diminished esophageal peristaltic contractions resulted in esophageal stasis in patients with GERD or SERD. Conclusions Patients with SERD and complaints of regurgitation have impaired UES and esophageal responses to simulated liquid reflux events. These patterns could predispose them to esophagopharyngeal reflux. PMID:26188682
Zenzeri, Letizia; Quitadamo, Paolo; Tambucci, Renato; Ummarino, Dario; Poziello, Antonio; Miele, Erasmo; Staiano, Annamaria
Respiratory symptoms are a possible atypical clinical picture of gastro-esophageal reflux disease (GERD). However, a significant number of patients with GERD-related respiratory symptoms do not report improvement despite aggressive acid-suppressive therapy. Some of these refractory cases may be due to the recently appreciated entity of non-acid or weakly acidic reflux. The aim of our study is to assess the pH-impedance features of GER inducing airway symptoms, compared with GER inducing typical gastro-intestinal (GI) symptoms. We prospectively enrolled infants and children with GERD-related respiratory symptoms from January 2015 to December 2015. Age- and sex-matched patients with GERD-related GI symptoms were enrolled as comparison group. The overall number, the acidity pattern, and the height of reflux episodes were compared between the two groups. Forty patients (M/F: 20/20; mean age: 58.3 months) were enrolled in the study group and 40 in the comparison group. The mean acid exposure index was 7.9% within the study group and 15.9% within the comparison group (p:0.026). Children with respiratory symptoms versus children with GI symptoms had a mean of 40.8 acid reflux episodes versus 62.4 (p:0.001), a mean of 2.2 weakly acid reflux episodes versus 20.1 (p:0.002), and a mean of 22.1 weakly alkaline reflux episodes versus 10.2 (P < 0.001). Separate analysis of both infants and children was performed. The main finding of this prospective, controlled study is that children >1 year with GERD-related respiratory symptoms showed a significantly higher number of weakly alkaline refluxes than children with GERD-related GI symptoms. This supports the hypothesis that respiratory symptoms are less related to acidity than GI symptoms. Pediatr Pulmonol. 2017;52:669-674. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.
Kawahara, Hisayoshi; Tazuke, Yuko; Soh, Hideki; Yoneda, Akihiro; Fukuzawa, Masahiro
To clarify the effects of rikkunshito on acid reflux, non-acid reflux, and esophageal clearance in patients with gastroesophageal reflux disease (GERD). We enrolled seven patients with vomiting and/or stridor (median 6 years; 1 month-17 years), with a percent total time of esophageal pH <4.0 (reflux index) over 4.0%. Rikkunshito (TJ-43; Tsumura Co, Tokyo, Japan) was given in three divided doses before meals. We retrospectively investigated its efficacy using pH-multichannel intraluminal impedance before and 7 (6-10) days after starting treatment. Statistical analyses were conducted using Wilcoxon signed-rank test. In the pH analyses alone, the median number of acid reflux episodes >5 min (14 versus 10, p = 0.046) and median acid-clearance time (184 versus 134 s, p = 0.03) decreased significantly, although median decrease in reflux index did not reach significance (16.0 versus 17.9%, p = 0.06). In the combined impedance and pH analyses, the median number (36 versus 36, p = 0.03) and median duration (1.9 versus 1.1%, p = 0.046) of acid reflux decreased significantly; non-acid reflux and bolus clearance time did not change. Rikkunshito effectively reduced acid reflux, but not esophageal clearance, in patients with GERD.
Mattioli, G; Caffarena, P E; Battistini, E; Fregonese, B; Barabino, A; Jasonni, V
The patients treated for oesophageal atresia present a correlation between the clinical sintomatology after recanalization characterized by disfagia, dispnea, recurrent cough, chronic pneumopaties and oesophageal anomalies. Where morphological alterations accounting for the presence of gastro-oesophageal reflux (GOR) were not evident, possible functional alterations of the motility were considered. The incidence of GOR was considerably high and, expression of a congenital alteration of the lower oesophageal sphincter and of oesophageal peristalsis, becomes even more severe due to further stretching of the gastro-esophageal junction. The authors underline that the early demonstration of histological changes, even before recanalization, and the motility disorders of the oesophagus have to be well studied, while the LES is normalized, in order to prevent and treat the possible appearance of the well-known complications of GOR.
Shimazu, Rintaro; Yamamoto, Mihoko; Minesaki, Akimichi; Kuratomi, Yuichiro
In this study, we evaluated pathological changes in the tooth and pharynx of GERD rats to elucidate the association between gastric acid reflux and oral and pharyngeal diseases. An experimental rat model of chronic acid reflux esophagitis was surgically created. The oral cavities were observed histologically every 2 weeks until 20 weeks after surgery. At 10 weeks after surgery, molar crown heights in GERD rats were shorter than that in control rats, and inflammatory cell infiltration by gastric acid reflux was found in the periodontal mucosa of GERD rats. Furthermore, dental erosion progressed in GERD rats at 20 weeks after surgery, and enamel erosion and dentin exposure were observed. During the same period, inflammatory cell infiltration was observed in the mucosa of the posterior part of the tongue. These findings suggest that gastric acid reflux may be one of the exacerbating factors of dental erosion, periodontitis and glossitis. We investigated oral changes in an experimental rat model of GERD and observed development of dental erosion, periodontitis and glossitis. Our findings suggested chronic gastric acid reflux may be involved in the pathogenesis of oral disease. Copyright © 2017 Elsevier B.V. All rights reserved.
López-Alonso, Manuel; Moya, Maria Jose; Cabo, Jose Antonio; Ribas, Juan; del Carmen Macías, Maria; Silny, Jiry; Sifrim, Daniel
Gastroesophageal reflux is a physiologic process and is considered pathologic (gastroesophageal reflux disease) when it causes symptoms or results in complications. It is common in preterm infants and occurs in healthy neonates. Twenty-four-hour pH monitoring commonly is used in children for diagnosis of gastroesophageal reflux disease, and abnormal reflux is considered with detection of increased esophageal acid exposure. However, in neonates, relatively few gastroesophageal reflux episodes cause esophageal acidification to pH < 4. Premature infants receive frequent feeds, which can induce a weaker acid secretory response than that observed in older infants and adults. As a consequence, gastric pH may be > 4 for prolonged periods, and reflux of gastric contents might be less acidic or even alkaline. Esophageal impedance monitoring can detect weakly acidic and even alkaline gastroesophageal reflux. The role of weakly acidic reflux in the pathophysiology of gastroesophageal reflux disease in preterm infants is not clear. To date, studies that have used impedance-pH in neonates assessed the association between nonacid reflux and cardiorespiratory symptoms, but no impedance data from healthy preterm neonates have been available to determine whether those symptomatic neonates had an increased number of weakly acidic reflux episodes or increased reactivity to a physiologic number of reflux events. Our aim with this study was to provide impedance-pH values for acid, weakly acidic, and weakly alkaline reflux from healthy preterm neonates. Esophageal impedance was recorded for 24 hours in 21 asymptomatic preterm neonates by replacing the conventional feeding tube with a specially designed feeding tube that included 9 impedance electrodes (8 French). All neonates were asymptomatic, with spontaneous breathing. Reflux monitoring was performed after comprehensive explanation and on receipt of written parental consent. Esophageal and gastric pH were monitored using a separate
Tenca, Andrea; de Bortoli, Nicola; Mauro, Aurelio; Frazzoni, Marzio; Savarino, Edoardo; Massironi, Sara; Russo, Salvatore; Bertani, Lorenzo; Marchi, Santino; Penagini, Roberto
The factors influencing new markers of gastro-esophageal reflux disease detected by impedance-pH monitoring - mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave (PSPW) index - need to be evaluated. To compare endoscopy-negative heartburn with chronic autoimmune atrophic gastritis (CAAG). 24 patients with CAAG, 25 with non-erosive reflux disease (NERD) and 25 with functional heartburn (FH) were included. In all patients the main impedance-pH monitoring parameters were calculated. CAAG and NERD patients had a number of reflux events (non-acid ones being more common among the former group) which was higher than that found in FH (p<0.001). MNBI decreased progressively in FH (>3000Ohm), CAAG (>2000Ohm) and NERD (<1000Ohm) patients (p=0.0046). The PSPW index was similar between CAAG and NERD patients but significantly lower in comparison to FH (p<0.0001). Patients with CAAG have evidence of non-acid reflux based on the high number of reflux events and confirmed by low values of MNBI and PSPW index. MNBI is a strong marker of acid/non-acid reflux-induced mucosal damage, whereas the PSPW index can reliably discriminate patients with reflux from those with FH, independently of the acidity of refluxate. Copyright © 2017 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Kgomo, Mpho; Mokoena, Taole R; Ker, James A
Squamous cell carcinoma of the oesophagus is a common cancer among South Africans. Due to the absence of effective screening and surveillance programme for early detection and late presentation, squamous cell carcinoma of the oesophagus is usually diagnosed at an advanced stage or when metastasis has already occurred. The 5-year survival is often quoted at 5%-10%, which is poor. To determine the association between oesophageal squamous cell carcinoma (OSCC) and non-acid gastro-oesophageal reflux disease. Study design: A cross-sectional case-control analytical study of patients referred to the Gastroenterology Division of Steve Biko Academic Hospital in Pretoria, South Africa. All patients had combined multichannel impedance and pH studies done and interpreted after upper gastroscopy using the American College of Gastroenterology guidelines by two clinicians. Thirty-two patients with OSCC were recruited: non-acid reflux was found in 23 patients (73%), acid reflux in 2 patients (6%) and 7 patients (22%) had normal multichannel impedance and pH studies.Forty-nine patients matched by age, gender and race were recruited as a control group. Non-acid reflux was found in 11 patients (22%), acid reflux in 31 patients (63%) and 7 patients (14%) had normal multichannel impedance and pH monitoring study. The significance of the association between non-acid reflux and OSCC was tested using χ 2 , and simple logistic regression was used to adjust for the effects of potential confounders.The OR of developing OSCC in patients with non-acid gastro-oesophageal reflux was 8.8 (95% CI 3.2 to 24.5, P<0.0001) in this South African group.Alcohol and smoking had no effect on these results.
Kgomo, Mpho; Mokoena, Taole R; Ker, James A
Introduction Squamous cell carcinoma of the oesophagus is a common cancer among South Africans. Due to the absence of effective screening and surveillance programme for early detection and late presentation, squamous cell carcinoma of the oesophagus is usually diagnosed at an advanced stage or when metastasis has already occurred. The 5-year survival is often quoted at 5%–10%, which is poor. Objectives To determine the association between oesophageal squamous cell carcinoma (OSCC) and non-acid gastro-oesophageal reflux disease. Methods Study design A cross-sectional case–control analytical study of patients referred to the Gastroenterology Division of Steve Biko Academic Hospital in Pretoria, South Africa. All patients had combined multichannel impedance and pH studies done and interpreted after upper gastroscopy using the American College of Gastroenterology guidelines by two clinicians. Results Thirty-two patients with OSCC were recruited: non-acid reflux was found in 23 patients (73%), acid reflux in 2 patients (6%) and 7 patients (22%) had normal multichannel impedance and pH studies. Forty-nine patients matched by age, gender and race were recruited as a control group. Non-acid reflux was found in 11 patients (22%), acid reflux in 31 patients (63%) and 7 patients (14%) had normal multichannel impedance and pH monitoring study. Conclusion The significance of the association between non-acid reflux and OSCC was tested using χ2, and simple logistic regression was used to adjust for the effects of potential confounders. The OR of developing OSCC in patients with non-acid gastro-oesophageal reflux was 8.8 (95% CI 3.2 to 24.5, P<0.0001) in this South African group. Alcohol and smoking had no effect on these results. PMID:29177066
Duke, Meredith C; Farrell, Timothy M
The prevalence of gastroesophageal reflux disease (GERD) has mirrored the increase in obesity, and GERD is now recognized as an obesity-related comorbidity. There is growing evidence that obesity, specifically central obesity, is associated with the complications of chronic reflux, including erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. While fundoplication is effective in creating a competent gastroesophageal junction and controlling reflux in most patients, it is less effective in morbidly obese patients. In these patients a bariatric operation has the ability to correct both the obesity and the abnormal reflux. The Roux-en-Y gastric bypass is the preferred procedure.
Roman, S; Gyawali, C P; Savarino, E; Yadlapati, R; Zerbib, F; Wu, J; Vela, M; Tutuian, R; Tatum, R; Sifrim, D; Keller, J; Fox, M; Pandolfino, J E; Bredenoord, A J
An international group of experts evaluated and revised recommendations for ambulatory reflux monitoring for the diagnosis of gastro-esophageal reflux disease (GERD). Literature search was focused on indications and technical recommendations for GERD testing and phenotypes definitions. Statements were proposed and discussed during several structured meetings. Reflux testing should be performed after cessation of acid suppressive medication in patients with a low likelihood of GERD. In this setting, testing can be either catheter-based or wireless pH-monitoring or pH-impedance monitoring. In patients with a high probability of GERD (esophagitis grade C and D, histology proven Barrett's mucosa >1 cm, peptic stricture, previous positive pH monitoring) and persistent symptoms, pH-impedance monitoring should be performed on treatment. Recommendations are provided for data acquisition and analysis. Esophageal acid exposure is considered as pathological if acid exposure time (AET) is greater than 6% on pH testing. Number of reflux episodes and baseline impedance are exploratory metrics that may complement AET. Positive symptom reflux association is defined as symptom index (SI) >50% or symptom association probability (SAP) >95%. A positive symptom-reflux association in the absence of pathological AET defines hypersensitivity to reflux. The consensus group determined that grade C or D esophagitis, peptic stricture, histology proven Barrett's mucosa >1 cm, and esophageal acid exposure greater >6% are sufficient to define pathological GERD. Further testing should be considered when none of these criteria are fulfilled. © 2017 John Wiley & Sons Ltd.
Gastroesophageal reflux disease (GERD) is highly prevalent in the Western world. Patients with GERD have a 10 fold increased risk to develop a Barrett's esophagus. Patients with Barrett's esophagus have a higher risk for an esophageal adenocarcinoma. Men have more severe reflux with a higher grade of inflammation and acid reflux. This seems to be the reason why men develop a Barrett's esophagus more frequently--the risk is approximately 2 to 3 fold and the risk for an esophageal adenocarcinoma is even 3 to 6 times higher. © Georg Thieme Verlag KG Stuttgart · New York.
Gastroesophageal reflux disease (GERD) is highly prevalent in the Western world. Patients with GERD have a 10-fold increased risk to develop a Barrett's esophagus. Patients with Barrett's esophagus have a higher risk for an esophageal adenocarcinoma. Men have more severe reflux with a higher grade of inflammation and acid reflux. This seems to be the reason why men develop a Barrett's esophagus more frequently - the risk is approximately 2-3-fold and the risk for an esophageal adenocarcinoma is even 3-6 times higher. © Georg Thieme Verlag KG Stuttgart · New York.
Desart, Kenneth; Rossidis, Georgios; Michel, Michael; Lux, Tamara; Ben-David, Kfir
Laparoscopic sleeve gastrectomy (LSG) has gained significant popularity in the USA, and consequently resulted in patients experiencing new-onset gastroesophageal reflux disease (GERD) following this bariatric procedure. Patients with GERD refractory to medical therapy present a more challenging situation limiting the surgical options to further treat the de novo GERD symptoms since the gastric fundus to perform a fundoplication is no longer an option. The aim of this study is to determine if the LINX® magnetic sphincter augmentation system is a safe and effective option for patients with new gastroesophageal reflux disease following laparoscopic sleeve gastrectomy. This study was conducted at the University Medical Center. This is a retrospective review of seven consecutive patients who had a laparoscopic LINX® magnetic sphincter device placement for patients with refractory gastroesophageal reflux disease after laparoscopic sleeve gastrectomy between July 2014 and April 2015. All patients were noted to have self-reported greatly improved gastroesophageal reflux symptoms 2-4 weeks after their procedure. They were all noted to have statistically significant improved severity and frequency of their reflux, regurgitation, epigastric pain, sensation of fullness, dysphagia, and cough symptoms in their postoperative GERD symptoms compared with their preoperative evaluation. This is the first reported pilot case series, illustrating that the LINX® device is a safe and effective option in patients with de novo refractory gastroesophageal reflux disease after a laparoscopic sleeve gastrectomy despite appropriate weight loss.
Dixon, Anne E.; Clerisme-Beaty, Emmanuelle M.; Sugar, Elizabeth A.; Cohen, Rubin I.; Lang, Jason E.; Brown, Ellen D.; Richter, Joel E.; Irvin, Charles G.; Mastronarde, John G.
Background Obesity is a risk factor for asthma. Obese asthmatics often have poor asthma control and respond poorly to therapy. It has been suggested that co-morbidities associated with obesity, such as reflux and obstructive sleep apnea, could be important factors contributing to poor asthma control in obese patients. Objectives The purpose of this study was to determine if (i) reflux and/or (ii) symptoms of sleep apnea contribute to poor asthma control in obesity. Methods We studied asthmatic subjects participating in a trial of reflux treatment. Participants underwent baseline evaluation of asthma symptoms and lung function. 304 participants underwent esophageal pH probe testing. 246 participants were evaluated for obstructive sleep apnea symptoms. Results Of 402 participants in this trial, 51% were obese. Role of reflux in asthma control Those with higher body mass index reported a higher prevalence of reflux symptoms, but the prevalence of pH probe acid reflux was similar in all groups. Reflux was not associated with measures of asthma control in obese patients. Role of obstructive sleep apnea in asthma control Symptoms and self-report of obstructive sleep apnea were more common with increasing body mass index and associated with worse asthma control as measured by the Juniper Asthma Control Questionnaire and Asthma Symptom Utility Index. Conclusions Our data suggest that obstructive sleep apnea, but not gastroesophageal reflux disease may contribute significantly to poor asthma control in obese patients. PMID:21819338
Zhang, Q; Lehmann, A; Rigda, R; Dent, J; Holloway, R H
Background and aims: Transient lower oesophageal sphincter relaxations (TLOSRs) are the major cause of gastro-oesophageal reflux in normal subjects and in most patients with reflux disease. The gamma aminobutyric acid (GABA) receptor type B agonist, baclofen, is a potent inhibitor of TLOSRs in normal subjects. The aim of this study was to investigate the effect of baclofen on TLOSRs and postprandial gastro-oesophageal reflux in patients with reflux disease. Methods: In 20 patients with reflux disease, oesophageal motility and pH were measured, with patients in the sitting position, for three hours after a 3000 kJ mixed nutrient meal. On separate days at least one week apart, 40 mg oral baclofen or placebo was given 90 minutes before the meal. Results: Baclofen reduced the rate of TLOSRs by 40% from 15 (13.8–18.3) to 9 (5.8–13.3) per three hours (p<0.0002) and increased basal lower oesophageal sphincter pressure. Baclofen also significantly reduced the rate of reflux episodes by 43% from 7.0 (4.0–12.0) to 4.0 (1.5–9) per three hours (median (interquartile range); p<0.02). However, baclofen had no effect on oesophageal acid exposure (baclofen 4.9% (1.7–12.4) v placebo 5.0% (2.7–15.5)). Conclusions: In patients with reflux disease, the GABAB agonist baclofen significantly inhibits gastro-oesophageal reflux episodes by inhibition of TLOSRs. These findings suggest that GABAB agonists may be useful as therapeutic agents for the management of reflux disease. PMID:11772961
Passaretti, Sandro; Mazzoleni, Giorgia; Vailati, Cristian; Testoni, Pier Alberto
To investigate the relationship between pathological oropharyngeal (OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes. In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease (GERD). We enrolled only patients with a reflux symptom index (RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal high-resolution manometry (HRM). Patients were divided into two groups on the basis of a normal or pathological pH-metric finding (Ryan Score) and all manometric characteristics of the two groups were compared. We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure (median 71 mmHg vs 126 mmHg, P = 0.004) and the median proximal contractile integral (median 215.5 cm•mmHg•s vs 313.5 cm•mmHg•s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mmHg isobaric contour (38.7% vs 15.38%, P < 0.0001). In patients with suspected GERD-related extra-esophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.
Jiang, Liuqin; Ye, Bixing; Lin, Lin; Wang, Ying; Wang, Meifeng
Abstract Numerous studies have investigated utility of esophageal intraluminal baseline impedance levels (BILs) in gastroesophageal reflux disease (GERD). However, effect of BILs in refractory GERD (RGERD) has not been well investigated. The aim of this study is to evaluate role of BILs in RGERD patients. Total 62 subjects with refractory gastroesophageal reflux symptoms underwent 24-hour impedance-pH monitoring and gastroendoscopy. Distal BILs in acid reflux type were significantly lower than those in nonacid reflux type and functional heartburn (FH) group. Distal BILs of reflux esophagitis (RE) patients were lower than those of nonerosive reflux disease (NERD) patients, while there were no statistical significance between 2 groups. Patients with severe esophagitis had lower distal BILs than those with mild esophagitis and NERD patients, and patients with severe esophagitis in acid reflux type had the lowest distal BILs. Distal BILs were significantly negatively correlated with DeMeester score, episodes of acid reflux, and acid exposure time, but no correlated with episodes of nonacid reflux. Characteristics of BILs in RGERD patients were similar with those in GERD patients, but might be more complicated. Evaluating BILs in RGERD patients could achieve a better understanding of pathophysiology in RGERD. PMID:27537561
Shimazu, Rintaro; Aoki, Shigehisa; Kuratomi, Yuichiro
To elucidate the association between gastric acid reflux and respiratory diseases by studying the histological changes of the lower airway in rats with chronic acid reflux esophagitis. An experimental rat model of chronic acid reflux esophagitis was surgically created. The lower airways of these rats were histologically observed for more than 50 weeks. Although there were no histological changes which induced gastric acid reflux at 10 weeks after surgery, thickening of the basal laminae and the proliferation of the collagenous fibers were observed in the alveolar epithelium at 20 weeks after surgery. At 50 weeks after surgery, the collagenous fibers obliterated the pulmonary alveoli and bronchial lumen. These findings observed in the GERD rats are similar to the pathological findings of human pulmonary fibrosis. In this study, we reported pathological changes in the lower airways of GERD rat models observed for more than 50 weeks. These results suggest that gastric acid reflux may be one of the pathogenic or exacerbating factors of pulmonary fibrosis. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Harnik, Ian G
This issue provides a clinical overview of gastroesophageal reflux disease, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.
Herdman, Christine; Marzio, Dina Halegoua-De; Shah, Paurush; Denuna-Rivera, Susie; Doghramji, Karl; Cohen, Sidney; Dimarino, Anthony J
Nocturnal acid reflux is associated with symptomatic and asymptomatic sleep arousals, leading to fragmented sleep. The frequency and influence of acid reflux in patients with various forms of insomnia has not been reported. The aim of this study was to quantify nocturnal acid and nonacid reflux in patients with primary sleep disorders as previously diagnosed by polysomnography. THIRTY ONE SUBJECTS WERE STUDIED: (A) 9 subjects with a polysomnographically diagnosed sleep disorder (1 with restless legs syndrome, 4 with narcolepsy, 4 with periodic limb movement disorder); (B) 12 subjects with primary insomnia (PI) and unrevealing polysomnography; and (C) 10 controls without disturbed sleep. All subjects underwent a physical examination and 24 h transnasal pH and impedance monitoring to detect acid and non-acid reflux. The 21 subjects with fragmented sleep due to a primary sleep disorder had significantly more recumbent acid exposure (>1.2% of time) as compared with control subjects (33% versus 0%). When fragmented sleep subjects were divided into two groups, 17% of PI subjects and 55% of subjects with a diagnosed sleep disorder had significant recumbent acid exposure (P=0.009). Likewise, the median recumbent nonacid events were increased in the sleep disordered group (P=0.011). This study indicates that patients with primary sleep disorders have prominent nocturnal acid reflux without symptoms of daytime acid reflux. Acid reflux is most prominent in patients with polysomnographic findings of disturbed sleep as compared to patients with PI; while non acid reflux is increased minimally in these patients.
Xu, Xianghuai; Yang, Zhongmin; Chen, Qiang; Yu, Li; Liang, Siwei; Lü, Hanjing; Qiu, Zhongmin
Little is known about non-acid gastroesophageal reflux-induced chronic cough (GERC). The purpose of the study is to explore the clinical characteristics of non-acid GERC. Clinical symptoms, cough symptom score, capsaicin cough sensitivity, gastroesophageal reflux diagnostic questionnaire (GerdQ) score, findings of multichannel intraluminal impedance-pH monitoring (MII-pH) and response to pharmacological anti-reflux therapy were retrospectively reviewed in 38 patients with non-acid GERC and compared with those of 49 patients with acid GERC. Non-acid GERC had the similar cough character, cough symptom score, and capsaicin cough sensitivity to acid GERC. However, non-acid GERC had less frequent regurgitation (15.8% vs 57.1%, χ(2) = 13.346, P = 0.000) and heartburn (7.9% vs 32.7%, χ(2) = 7.686, P = 0.006), and lower GerdQ score (7.4 ± 1.4 vs 10.6 ± 2.1, t = -6.700, P = 0.003) than acid GERC. Moreover, MII-pH revealed more weakly acidic reflux episodes, gas reflux episodes and a higher symptom association probability (SAP) for non-acid reflux but lower DeMeester score, acidic reflux episodes and SAP for acid reflux in non-acid GERC than in acid GERC. Non-acid GERC usually responded to the standard anti-reflux therapy but with delayed cough resolution or attenuation when compared with acid GERC. Fewer patients with non-acid GERC needed an augmented acid suppressive therapy or treatment with baclofen. There are some differences in the clinical manifestations between non-acid and acid GERC, but MII-pH is essential to diagnose non-acid GERC. © 2014 John Wiley & Sons Ltd.
Dzhulay, G S; Sekareva, E V
To estimate esophageal and gastric pH values on an empty stomach and after stimulation of gastric secretion and gastric and duodenal motor-evacuatory activity in patients with gastroesophageal reflux disease (GERD) associated with pathological refluxes, such as gastroesophageal reflux (GER) and duodenogastroesophageal reflux (DGER). The observational cross-sectional study was conducted to investigate and compare the parameters of intraesophageal and intragastric pH metry and peripheral electrogastroenterography in 103 GERD patients with endoscopically positive distal reflux esophagitis in GER and DGER. The patients with GERD developed pathological esophageal refluxes (both GER and DGER) in various degrees of impaired gastric production, from anacidity to hyperacidity. The patients with predominant DGER were found to have gastric hyperacidity and normal acidity slightly less frequently than those with predominant GER. The patients with GERD developing in the presence of predominant GER had moderate gastric stasis with discoordinated antroduodenal propulsion resulting from hypomotor dyskinesia of the stomach and duodenum. When DGER was predominant in the patients with GERD, the signs of gastric stasis and duodenal hyperkinesia were concurrent with discoordinated antroduodenal and duodenojejunal propulsion. The specific features of the esophagogastroduodenal secretory and motor evacuatory disorders found create conditions for the pathological refluxes into the esophagus, which differ in the composition of refluxate.
Narayanan, Sarath Kumar; Cohen, Ralph Clinton; Karpelowsky, Jonathan Saul
This study is to determine the association of ambulatory pH monitoring (24hr pH) with symptoms of gastroesophageal reflux and its other investigations. The clinical and epidemiological profiles of subjects referred for reflux disorders are also studied. Symptoms or group of symptoms, profiles and prior investigations of 1259 consecutive pediatric subjects (with 1332 24hr pH studies performed) referred for evaluation of reflux disorders between 1988 and 2012 were retrospectively studied. Chi-square or fisher exact test was used for hypothesis testing, student t-test for the comparison of means and the Wilcoxon rank-sum test for comparing medians of continuous variables. Gastroesophageal reflux disease (GERD), defined as reflux causing major symptoms and complications, was diagnosed in 57.5% subjects of the total sample. Forty-three percent were girls and 56.7% were boys. The most common age group was between 4 months and 2 years (51.2%). Vomiting (64.4%) and irritability (74%) were the most common symptoms with the neurological conditions (23.2%) being the most frequent underlying condition. The parameters used in 24hr pH were significantly higher in those diagnosed with GERD (P < 0.0001). The prevalence of GERD was found to be significantly higher when both gastrointestinal and respiratory symptoms were present (P = 0.008) at 66.4% than when compared with gastrointestinal (56.5%) and respiratory (52.2%) symptoms in isolation. Symptoms alone were not reliable in diagnosing GERD. Only 57.5% had GERD among patients referred for reflux disorders. 24hr pH is reliable and should be considered routine in reflux disorders, as it identifies patients with pathologic reflux and avoids a needless surgery. © 2016 International Society for Diseases of the Esophagus.
Boeckxstaens, Guy; El-Serag, Hashem B; Smout, André J P M; Kahrilas, Peter J
The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future. PMID:25583739
Naik, Rishi D; Vaezi, Michael F
Gastroesophageal reflux disease (GERD) is a condition that develops when there is reflux of stomach contents, which typically manifests as heartburn and regurgitation. These esophageal symptoms are well recognized; however, there are extra-esophageal manifestations of GERD, which include asthma, chronic cough, laryngitis and sinusitis. With the rising incidence of asthma, there is increasing interest in identifying how GERD impacts asthma development and therapy. Due to the poor sensitivity of endoscopy and pH monitoring, empiric therapy with proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. If unresponsive, diagnostic testing with pH monitoring off therapy and/or impedance/pH monitoring on therapy, may be reasonable in order to assess for baseline presence of reflux with the former and exclude continued acid or weakly acid reflux with the latter tests. PPI-unresponsive asthmatics, without overt regurgitation, usually have either no reflux or causes other than GERD. In this group, PPI therapy should be discontinued. In those with GERD as a contributing factor acid suppressive therapy should be continued as well as optimally treating other etiologies requiring concomitant treatment. Surgical fundoplication is rarely needed but in those with a large hiatal hernia, moderate-to-severe reflux by pH monitoring surgery might be helpful in eliminating the need for high-dose acid suppressive therapy.
Bor, Serhat; Bayrakci, Berna; Yildirim, Esra; Vardar, Rukiye
Background There is a general belief that gastro-oesophageal reflux increases after meals and especially following a rapid intake. Objective To evaluate the impact of rapid vs. slow food intake on gastro-oesophageal reflux disease (GORD) patients. Materials and methods Forty-six GORD patients with heartburn and / or acid regurgitation once a week or more often common were included in this study. Participants were asked to eat the same standard meal within either 5 or 30 minutes under observation in a random order on 2 consecutive days. A total of 28 hours of recording were obtained by intraoesophageal impedance pH and number of liquid and mixed reflux episodes within 3 hours of the slow- and fast-eating postprandial periods were calculated. Results While all patients defined GORD symptoms, 10 (21.7%) had pathological 24-h intraoesophageal impedance measurement, 15 (32.6%) had pathological DeMeester and 21.7% had erosive oesophagitis. No difference has been shown according to the eating speed when all reflux episodes were taken together (754 vs. 733). Speed of food intake also did not have an impact on patients with normal vs. pathological 24-h intraoesophageal impedance or erosive vs. non-erosive. During the first postprandial hour, approximately half of the reflux events were non-acid, compared to 34.2% during the second hour and 26.8% during the third hour (p < 0.001). The number of acid reflux episodes was significantly higher than non-acid reflux especially during the second and third hours and in total for 3 hours. Conclusions This first study addressing the effect of eating speed on reflux episodes in GORD patients did not support the general belief that reflux increases following fast eating. Acid and non-acid reflux were similar at the first postprandial hour, then acid reflux episodes were predominantly higher, which implicate the importance of acid pockets. PMID:24917982
Bor, Serhat; Bayrakci, Berna; Erdogan, Askin; Yildirim, Esra; Vardar, Rukiye
There is a general belief that gastro-oesophageal reflux increases after meals and especially following a rapid intake. To evaluate the impact of rapid vs. slow food intake on gastro-oesophageal reflux disease (GORD) patients. Forty-six GORD patients with heartburn and / or acid regurgitation once a week or more often common were included in this study. Participants were asked to eat the same standard meal within either 5 or 30 minutes under observation in a random order on 2 consecutive days. A total of 28 hours of recording were obtained by intraoesophageal impedance pH and number of liquid and mixed reflux episodes within 3 hours of the slow- and fast-eating postprandial periods were calculated. While all patients defined GORD symptoms, 10 (21.7%) had pathological 24-h intraoesophageal impedance measurement, 15 (32.6%) had pathological DeMeester and 21.7% had erosive oesophagitis. No difference has been shown according to the eating speed when all reflux episodes were taken together (754 vs. 733). Speed of food intake also did not have an impact on patients with normal vs. pathological 24-h intraoesophageal impedance or erosive vs. non-erosive. During the first postprandial hour, approximately half of the reflux events were non-acid, compared to 34.2% during the second hour and 26.8% during the third hour (p < 0.001). The number of acid reflux episodes was significantly higher than non-acid reflux especially during the second and third hours and in total for 3 hours. This first study addressing the effect of eating speed on reflux episodes in GORD patients did not support the general belief that reflux increases following fast eating. Acid and non-acid reflux were similar at the first postprandial hour, then acid reflux episodes were predominantly higher, which implicate the importance of acid pockets.
Ganesh, Meenakshi; Hertzberg, Anne; Nurko, Samuel; Needleman, Howard; Rosen, Rachel
Objectives The relationship between tooth erosion (TE) and gastroesophageal reflux (GER) in children has not been clearly established and there are no studies to determine the relationship with refluxate height, non-acid reflux and erosions. The aim of this study was to determine the relationship between TE and acid and non-acid GER measured using combined pH and multichannel intraluminal impedance (pH-MII). Methods We conducted a prospective cohort study of children presenting for pH-MII testing. Once consented, patients completed questionnaires about their reflux symptoms and diet, and then underwent pH-MII catheter placement and a dental examination. The Keels-Coffield erosion index was used to score extent and severity of TE. Reflux parameters of patients with and without TE were compared using Student's t test. Results Twenty-seven patients participated in the study, all of whom were on acid suppression at the time of pH-MII testing. Ten out of 27 patients (37%) had TE. There were significant positive correlations between acid reflux episodes (r=0.44, p=0.02), the % time that acid reflux was present in the distal esophagus (r=0.44, p=0.02), and reflux index (r=0.54, p=0.004) with number of TE in a given patient. The % time that acid reflux was present in the proximal esophagus was positively correlated with the number of teeth erosions per patient with borderline significance (r=0.38, p=0.05). Conclusions There was a positive correlation between acid reflux parameters and TE. Acid, rather than non-acid reflux, seems to have a significant role in the pathogenesis of TE. PMID:26230904
Doumit, Michael; Krishnan, Usha; Jaffé, Adam; Belessis, Yvonne
Gastro-esophageal reflux (GOR) may contribute to lung disease in children with cystic fibrosis (CF). There is conflicting evidence regarding the effect of chest physiotherapy (CPT) in the head-down position on GOR. Furthermore, there is currently no evidence on the impact of physiotherapy on GOR as assessed by pH-multichannel intraluminal impedance (pH-MII). (1) To characterize GOR in young children with CF. (2) To determine whether the head-down position during physiotherapy exacerbates GOR. Children were studied using pH-MII monitoring over 24-hr, during which they received two 20-min sessions of CPT. One session was performed in "modified" drainage positions with no head-down tilt and the alternate session in "gravity-assisted" drainage positions, which included 20° head-down tilt. Twenty children with CF (8 males), median age 12 months (range 8-34) were recruited. A total of 1,374 reflux episodes were detected in all children, of which 869 (63%) were acid and 505 (37%) were non-acid. Seventy-two percent of the episodes migrated proximally. During CPT, there was no significant difference between total number of reflux episodes in the modified or gravity-assisted positions, median [inter-quartile range (IQR)] 1 (0-2.5) compared to 1 (0.75-3) episode, respectively, P = 0.63. There was also no significant difference between the number of reflux episodes which migrated proximally, median (IQR) 1 (0-2) compared to 0 (0-2) episodes, respectively, P = 0.75. In young children with CF, GOR is primarily acidic and proximal migration is common. Physiotherapy in the head-down position does not appear to exacerbate GOR. The impact of GOR on lung disease remains to be elucidated. Copyright © 2011 Wiley Periodicals, Inc.
Sethi, Sajiv; Richter, Joel E
Gastroesophageal reflux disease (GERD) is a common disease that presents with a variety of symptoms including heartburn and acid regurgitation. Although dietary modification is currently regarded as first-line therapy for the disease, the role of diet in the pathogenesis and management of GERD is still poorly understood. The present article aims to review recent literature that examines the relationship of diet and GERD. Increased awareness of medications side effects and widespread overuse has brought nonpharmacological therapies to the forefront for the management of GERD. Recent findings have established the important role of nutrition for the managements of symptoms of GERD. Increasing scientific evidence has produced objective data on the role of certain trigger foods, whereas population studies endorse decreased reflux symptoms by following certain diets. Obesity has been linked with increased symptoms of GERD as well. Furthermore, the importance of lifestyle techniques such as head of bed elevation and increased meal to sleep time may provide nonpharmacologic methods for effective symptom control in GERD. We provide a comprehensive review on the association between diet and its role in the development and management of GERD.
Liakakos, Theodore; Karamanolis, George; Patapis, Paul; Misiakos, Evangelos P.
Background. Gastroesophageal reflux disease is a common condition with increasing prevalence worldwide. The disease encompasses a broad spectrum of clinical symptoms and disorders from simple heartburn without esophagitis to erosive esophagitis with severe complications, such as esophageal strictures and intestinal metaplasia. Diagnosis is based mainly on ambulatory esophageal pH testing and endoscopy. There has been a long-standing debate about the best treatment approach for this troublesome disease. Methods and Results. Medical treatment with PPIs has an excellent efficacy in reversing the symptoms of GERD, but they should be taken for life, and long-term side effects do exist. However, patients who desire a permanent cure and have severe complications or cannot tolerate long-term treatment with PPIs are candidates for surgical treatment. Laparoscopic antireflux surgery achieves a significant symptom control, increased patient satisfaction, and complete withdrawal of antireflux medications, in the majority of patients. Conclusion. Surgical treatment should be reserved mainly for young patients seeking permanent results. However, the choice of the treatment schedule should be individualized for every patient. It is up to the patient, the physician and the surgeon to decide the best treatment option for individual cases. PMID:20069112
Li, Chung-Hsien; Hsieh, Tsung-Cheng; Hsiao, Tsung-Hsien; Wang, Pin-Chao; Tseng, Tai-Chung; Lin, Hans Hsienhong; Wang, Chia-Chi
Gastroesophageal reflux disease (GERD) is diagnosed based on typical symptoms in clinical practice. It can be divided into two groups using endoscopy: erosive and nonerosive reflux disease (NERD). This study aims to determine the risk factors of reflux symptoms and mucosal injury. This was a two-step case-control study derived from a cohort of 998 individuals having the data of reflux disease questionnaire (RDQ) and endoscopic findings. Those with minor reflux symptoms were excluded. The first step compared symptomatic GERD patients with healthy controls. The 2(nd) step compared patients with erosive esophagitis with healthy controls. In this study, the prevalence of symptomatic GERD and erosive esophagitis were 163 (16.3%) and 166 (16.6%), respectively. A total of 507 asymptomatic individuals without mucosal injury of the esophagus on endoscopy were selected as healthy controls. Compared with healthy controls, multivariate analyses showed that symptomatic GERD patients had a higher prevalence of hypertriglyceridemia [odds ratio (OR), 1.83; 95% confidence interval (CI) 1.13-2.96] and obesity (OR, 1.85; 95% CI 1.08-3.02). By contrast, male sex (OR, 2.24; 95% CI 1.42-3.52), positive Campylo-like organism (CLO) test (OR, 0.56; 95% CI 0.37-0.84), and hiatus hernia (OR, 14.36; 95% CI 3.05-67.6) were associated with erosive esophagitis. In conclusion, obesity and hypertriglyceridemia were associated with reflux symptoms. By contrast, male sex, negative infection of Helicobacter pylori, and hiatus hernia were associated with mucosal injury. Our results suggested that risk factors of reflux symptoms or mucosal injury might be different in GERD patients. The underlying mechanism awaits further studies to clarify. Copyright © 2015. Published by Elsevier Taiwan.
Vaezi, Michael F
Gastroesophageal reflux disease (GERD) is a common condition that presents with symptoms of heartburn and regurgitation. Asthma is an equally common medical condition that often coexists with GERD. The clinical scenario of difficult-to-treat asthma in the setting of concomitant GERD leads to the possibility of GERD-induced asthma. However, asthma may also induce GERD, so confusion has developed about the role of GERD in patients with moderate to severe asthma. Acid-suppressive therapy may be initiated in patients with asthma, but controlled studies have recently questioned the role of such therapy and, thus, have caused further confusion in this field. Recent advancements in the field of esophageal physiologic testing in GERD have introduced the concept of impedance–pH monitoring, which suggests a possible role of nonacid reflux in those who continue to be symptomatic despite acid-suppressive therapy. However, recent data caution about the role of surgical fundoplication based solely on the results of impedance monitoring. This article reviews current knowledge in the fields of GERD and asthma and suggests a possible treatment option for this group of patients. PMID:28435409
Linz, Dominik; Hohl, Mathias; Vollmar, Johanna; Ukena, Christian; Mahfoud, Felix; Böhm, Michael
Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and mortality. Multiple conditions like hypertension, heart failure, diabetes, sleep apnoea, and obesity play a role for the initiation and perpetuation of AF. Recently, a potential association between gastroesophageal reflux disease (GERD) and AF development has been proposed due to the close anatomic vicinity of the oesophagus and the left atrium. As an understanding of the association between acid reflux disease and AF may be important in the global multimodal treatment strategy to further improve outcomes in a subset of patients with AF, we discuss potential atrial arrhythmogenic mechanisms in patients with GERD, such as gastric and subsequent systemic inflammation, impaired autonomic stimulation, mechanical irritation due to anatomical proximity of the left atrium and the oesophagus, as well as common comorbidities like obesity and sleep-disordered breathing. Data on GERD and oesophageal lesions after AF-ablation procedures will be reviewed. Treatment of GERD to avoid AF or to reduce AF burden might represent a future treatment perspective but needs to be scrutinized in prospective trials. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: email@example.com.
Savarino, E; Pohl, D; Zentilin, P; Dulbecco, P; Sammito, G; Sconfienza, L; Vigneri, S; Camerini, G; Tutuian, R; Savarino, V
Introduction: Functional dyspepsia and non-erosive reflux disease (NERD) are prevalent gastrointestinal conditions with accumulating evidence regarding an overlap between the two. Still, patients with NERD represent a very heterogeneous group and limited data on dyspeptic symptoms in various subgroups of NERD are available. Aim: To evaluate the prevalence of dyspeptic symptoms in patients with NERD subclassified by using 24 h impedance-pH monitoring (MII-pH). Methods: Patients with typical reflux symptoms and normal endoscopy underwent impedance-pH monitoring off proton pump inhibitor treatment. Oesophageal acid exposure time (AET), type of acid and non-acid reflux episodes, and symptom association probability (SAP) were calculated. A validated dyspepsia questionnaire was used to quantify dyspeptic symptoms prior to reflux monitoring. Results: Of 200 patients with NERD (105 female; median age, 48 years), 81 (41%) had an abnormal oesophageal AET (NERD pH-POS), 65 (32%) had normal oesophageal AET and positive SAP for acid and/or non-acid reflux (hypersensitive oesophagus), and 54 (27%) had normal oesophageal AET and negative SAP (functional heartburn). Patients with functional heartburn had more frequent (p<0.01) postprandial fullness, bloating, early satiety and nausea compared to patients with NERD pH-POS and hypersensitive oesophagus. Conclusion: The increased prevalence of dyspeptic symptoms in patients with functional heartburn reinforces the concept that functional gastrointestinal disorders extend beyond the boundaries suggested by the anatomical location of symptoms. This should be regarded as a further argument to test patients with symptoms of gastro-oesophageal reflux disease in order to separate patients with functional heartburn from patients with NERD in whom symptoms are associated with gastro-oesophageal reflux. PMID:19460766
Blondeau, Kathleen; Mertens, Veerle; Vanaudenaerde, Bart A; Verleden, Geert M; Van Raemdonck, Dirk E; Sifrim, Daniel; Dupont, Lieven J
Gastroesophageal reflux (GER) and aspiration of bile acids have been implicated as non-alloimmune risk factors for the development of bronchiolitis obliterans syndrome (BOS) after lung transplantation. The aim of our study was to investigate the association between GER and gastric aspiration of bile acids and to establish which reflux characteristics may promote aspiration of bile acids into the lungs and may feature as a potential diagnostic tool in identifying lung transplantation (LTx) patients at risk for aspiration. Twenty-four stable LTx recipients were studied 1 year after transplantation. All patients underwent 24-hour ambulatory impedance-pH recording for the detection of acid (pH <4) and weakly acidic (pH 4 to 7) reflux. On the same day, bronchoalveolar lavage fluid (BALF) was collected and then analyzed for the presence of bile acids (Bioquant enzymatic assay). Increased GER was detected in 13 patients, of whom 9 had increased acid reflux and 4 had exclusively increased weakly acidic reflux. Sixteen patients had detectable bile acids in the BALF (0.6 [0.4 to 1.5] micromol/liter). The 24-hour esophageal volume exposure was significantly increased in patients with bile acids compared to patients without bile acids in the BALF. Acid exposure and the number of reflux events (total, acid and weakly acidic) were unrelated to the presence of bile acids in the BALF. However, both nocturnal volume exposure and the number of nocturnal weakly acidic reflux events were significantly higher in patients with bile acids in the BALF. Weakly acidic reflux events, especially during the night, are associated with the aspiration of bile acids in LTx recipients and may therefore feature as a potential risk factor for the development of BOS.
Jeong, In Du; Park, Moo In
The prevalence of gastroesophageal reflux disease (GERD) and the incidence of some of its complications have risen strikingly over the last few decades. With the increase in our understanding of the pathophysiology of GERD along with the development of proton pump inhibitors, the diagnostic and therapeutic approaches to GERD have changed dramatically over the past decade. However, GERD still poses a problem to many clinicians since the spectrum of the disease has evolved to encompass more challenging presentations such as refractory GERD and extra-esophageal manifestations. The aim of this article is to provide a review of available current translational research on GERD. This review includes acid pocket, ambulatory pH monitoring, impedance pH monitoring, mucosa impedance, and high resolution manometry. This article discusses current translational research on GERD.
Guerrero Garcia Hall, Mats; Wenner, Jörgen; Öberg, Stefan
The macroscopic appearance of the normal squamocolumnar junction (SCJ) is often described as serrated with short projections of columnar mucosa that extend into the esophagus. As studies of the normal SCJ are sparse, the aim of this study was to test the hypothesis that the normal SCJ is even and that irregularities are manifestations of acid reflux. Fifty asymptomatic subjects and 149 patients with symptoms suggestive of gastroesophageal reflux disease underwent endoscopy and 48-h pH monitoring with a pH electrode positioned immediately above the SCJ. The shape of the SCJ was assessed according to the Z-line appearance classification and correlated with clinical characteristics and the degree of esophageal acid exposure in the most distal esophagus. Even SCJs without irregularities were significantly more common in asymptomatic subjects compared with patients (50% versus 10%, p < .001) and were never found in patients with erosive esophagitis. The median degree of distal esophageal acid exposure in individuals with an even SCJ was within normal limits. With increasing degree of irregularity of the SCJ, the frequency and duration of reflux episodes, the degree of distal esophageal acid exposure, and the prevalence of abnormal acid exposure increased progressively and significantly. The shape of the normal SCJ is even and also minimal irregularities are a consequence of acid reflux, likely due to the formation of small areas of metaplastic columnar mucosa.
Ciorba, Andrea; Bianchini, Chiara; Zuolo, Michele; Feo, Carlo Vittorio
A wide variety of symptoms and diseases of the upper aerodigestive tract are associated to gastro-oesophageal reflux disease (GORD). These disorders comprise a large variety of conditions such as asthma, chronic otitis media and sinusitis, chronic cough, and laryngeal disorders including paroxysmal laryngospasm. Laryngo-pharyngeal reflux disease is an extraoesophageal variant of GORD that can affect the larynx and pharynx. Despite numerous research efforts, the diagnosis of laryngopharyngeal reflux often remains elusive, unproven and controversial, and its treatment is then still empiric. Aim of this paper is to review the current literature on upper aerodigestive tract disorders in relation to pathologic gastro-oesophageal reflux, focusing in particular on the pathophysiology base and results of the surgical treatment of GORD.
Ciorba, Andrea; Bianchini, Chiara; Zuolo, Michele; Feo, Carlo Vittorio
A wide variety of symptoms and diseases of the upper aerodigestive tract are associated to gastro-oesophageal reflux disease (GORD). These disorders comprise a large variety of conditions such as asthma, chronic otitis media and sinusitis, chronic cough, and laryngeal disorders including paroxysmal laryngospasm. Laryngo-pharyngeal reflux disease is an extraoesophageal variant of GORD that can affect the larynx and pharynx. Despite numerous research efforts, the diagnosis of laryngopharyngeal reflux often remains elusive, unproven and controversial, and its treatment is then still empiric. Aim of this paper is to review the current literature on upper aerodigestive tract disorders in relation to pathologic gastro-oesophageal reflux, focusing in particular on the pathophysiology base and results of the surgical treatment of GORD. PMID:25685756
Rohof, Wout O; Bennink, Roelof J; de Jonge, Hugo; Boeckxstaens, Guy E
Approximately 30% of patients with gastroesophageal reflux disease have symptoms resistant to treatment with proton pump inhibitors (PPIs). Several mechanisms such as esophageal hypersensitivity, increased mucosal permeability, and possibly the position of the gastric acid pocket might underlie a partial response to PPIs. To what extent these mechanisms interact and contribute to PPI-resistant symptoms, however, has not been investigated previously. In 18 gastroesophageal reflux disease patients (9 PPI responders and 9 PPI partial responders), esophageal sensitivity, mucosal permeability, and postprandial reflux parameters were determined during PPI use. Esophageal sensitivity for distension was measured by gradual balloon inflation at 5 and 15 cm above the lower esophageal sphincter. The mucosal permeability of 4 esophageal biopsy specimens per patient was determined in Ussing chambers by measuring the transepithelial electrical resistance and transmucosal flux of fluorescein. Postprandial reflux parameters were determined using concurrent high-resolution manometry/pH impedance after a standardized meal. In addition, the acid pocket was visualized using scintigraphy. No difference in the rate of postprandial acid reflux, in the pH of the acid pocket (PPI responders 3.7 ± 0.7 vs PPI partial responders 4.2 ± 0.4; P = .54), or in the position of the acid pocket was observed in PPI partial responders compared with PPI responders. In addition, the permeability of the esophageal mucosa was similar in both groups, as shown by a similar transepithelial electrical resistance and flux of fluorescein. PPI partial responders had more reflux episodes with a higher mean proximal extent, compared with PPI responders, and were more sensitive to balloon distension, both in the upper and lower esophagus. PPI-resistant symptoms most likely are explained by increased proximal reflux in a hypersensitive esophagus and less likely by increased mucosal permeability or the position of
Keohane, John; Quigley, Eamonn M M
Functional dyspepsia or nonulcer dyspepsia, and nonerosive reflux disease (NERD) or endoscopy-negative reflux disease, are common reasons for referral to a gastroenterologist. Although there is much confusion with regard to definition, recent research would suggest that these 2 conditions are linked and may represent components in the spectrum of the same disease entity, in terms of both symptoms and pathophysiology. Several theories have been proposed regarding the etiology of these disorders, including acid exposure, visceral hypersensitivity, impaired fundal accommodation, delayed gastric emptying, and Helicobacter pylori infection.
... medications. But there is little evidence pinpointing the effects of bile reflux in people. Unlike acid reflux, bile reflux usually can't be completely controlled by changes in diet or lifestyle. Treatment involves medications or, in severe cases, surgery. ...
Molina, Ezequiel J; Short, Scott; Monteiro, Glen; Gaughan, John P; Macha, Mahender
Gastroesophageal reflux disease (GERD) is associated with allograft dysfunction after lung transplantation (LTX). We attempted to identify outcomes in LTX recipients with clinical evidence of GERD. Retrospective review of 162 LTX recipients at our institution between January 1994 and June 2006 was performed. GERD was confirmed in symptomatic patients by esophagogastroduodenoscopy (EGD) and/or esophagography. Occurrence of biopsy-proven obliterative bronchiolitis (OB) and bronchiolitis obliterans syndrome (BOS) were analyzed. Kaplan-Meier analysis of survival and Cox proportional hazard analysis of risk factors were performed. GERD was diagnosed in 21 (13%) of patients, usually following LTX (71%). There was no difference in mean survival (1603 +/- 300 vs. 1422 +/- 131 days; log rank P > 0.05), or development of OB (5% vs. 6%, respectively; P > 0.05) in patients with GERD compared with patients without GERD. However, there was correlation between GERD and BOS (P = 0.01). Symptomatic GERD is increased following LTX. Patients with symptomatic GERD demonstrated an increased incidence of BOS, but survival was not affected in this study. More sensitive and specific diagnostic tools should be implemented in all LTX recipients to investigate the impact of symptomatic and silent GERD and thus improve outcomes after LTX.
Seccombe, J; Mirza, F; Hachem, R; Gyawali, C P
Advanced pulmonary disorders are linked to esophageal hypomotility and reflux disease. However, characterization of esophageal function using high resolution manometry (HRM) and ambulatory pH monitoring, segregation by pulmonary pathology, and comparison to traditional reflux disease are all limited in the literature. Over a 4 year period, 73 patients (55.2 ± 1.3 years, 44F) were identified who underwent esophageal function testing as part of lung transplant evaluation for advanced pulmonary disease (interstitial lung disease, ILD = 47, obstructive lung disease, OLD = 24, other = 2). Proportions of patients with motor dysfunction (≥ 80% failed sequences = severe hypomotility) and/or abnormal reflux parameters (acid exposure time, AET ≥ 4%) were determined, and compared to a cohort of 1081 patients (48.4 ± 0.4 years, 613F) referred for esophageal function testing prior to antireflux surgery (ARS). The proportion of esophageal body hypomotility was significantly higher within advanced pulmonary disease categories (35.6%), particularly ILD (44.7%), compared to ARS patients (12.1%, P < 0.0001). Abnormal AET was noted in 56.5%, and was similar between ILD and OLD, but less frequent than in the ARS group (P = 0.04). Post-transplant chronic rejection trended towards association with pretransplant elevated AET in OLD (P = 0.08) but not ILD. Mortality was not predicted by esophageal motor pattern or reflux evidence. Interstitial lung disease has a highly significant association with esophageal body hypomotility. Consequently, prevalence of abnormal esophageal acid exposure is high, but implications for post lung transplant chronic rejection remain unclear. © 2013 John Wiley & Sons Ltd.
Jung, Da Hyun; Park, Hyojin
Achalasia and gastroesophageal reflux disease (GERD) are on opposite ends of the spectrum of lower esophageal sphincter dysfunction. Heartburn is the main symptom of GERD. However, heartburn and regurgitation are frequently observed in patients who have achalasia. The diagnosis of achalasia might be delayed because these symptoms are misinterpreted as gastroesophageal reflux. Here, we reviewed the clinical characteristics of patients with the erroneous diagnosis of GERD who actually had untreated achalasia. PMID:27771944
Ristic, Nina; Milovanovic, Ivan; Radusinovic, Milica; Stevic, Marija; Ristic, Milos; Ristic, Maja; Kisic Tepavcevic, Darija; Alempijevic, Tamara
Objectives The aim of this study was to compare the different diagnostic approaches in detection of gastroesophageal reflux disease in children presented with symptoms suggesting gastroesophageal reflux disease. Methods The study design was cross sectional. The study retrospectively included all children who underwent combined multiple intraluminal impedance and pH (pH-MII) monitoring due to gastrointestinal and/or extraesophageal symptoms suggesting gastroesophageal reflux disease at University Children's Hospital in Belgrade, from July 2012 to July 2016. Results A total of 218 (117 boys/101 girls), mean age 6.7 years (range 0.06–18.0 years), met the inclusion criteria. Gastroesophageal reflux disease was found in 128 of 218 children (57.4%) by pH-MII and in 76 (34.1%) children by pH metry alone. Using pH-MII monitoring as gold standard, sensitivity of pH-metry was lowest in infants (22.9%), with tendency to increase in older age groups (reaching 76.4% in children ≥ 9 years). The sensitivity of pH-metry alone in children with extraesophageal symptoms was 38.1%, while the sensitivity of pH-metry in children with gastrointestinal symptoms was 63.8%. Reflux esophagitis was identified in 31 (26.1%) of 119 children who underwent endoscopy. Logistic regression analysis showed that best predictors of endoscopic reflux esophagitis are the longest acid episode (OR = 1.52, p<0.05) and DeMeester reflux composite score (OR = 3.31, p<0.05). The significant cutoff values included DeMeester reflux composite score ≥ 29 (AUC 0.786, CI 0.695–0.877, p<0.01) and duration of longest acid reflux ≥ 18 minutes (AUC 0.784, CI 0.692–0.875, p<0.01). Conclusions The results of our study suggested that compared with pH-metry alone, pH-MII had significantly higher detection rate of gastroesophageal reflux disease, especially in infants. Our findings also showed that pH-MII parameters correlated significantly with the endoscopically confirmed erosive esophagitis. PMID:29095882
Ristic, Nina; Milovanovic, Ivan; Radusinovic, Milica; Stevic, Marija; Ristic, Milos; Ristic, Maja; Kisic Tepavcevic, Darija; Alempijevic, Tamara
The aim of this study was to compare the different diagnostic approaches in detection of gastroesophageal reflux disease in children presented with symptoms suggesting gastroesophageal reflux disease. The study design was cross sectional. The study retrospectively included all children who underwent combined multiple intraluminal impedance and pH (pH-MII) monitoring due to gastrointestinal and/or extraesophageal symptoms suggesting gastroesophageal reflux disease at University Children's Hospital in Belgrade, from July 2012 to July 2016. A total of 218 (117 boys/101 girls), mean age 6.7 years (range 0.06-18.0 years), met the inclusion criteria. Gastroesophageal reflux disease was found in 128 of 218 children (57.4%) by pH-MII and in 76 (34.1%) children by pH metry alone. Using pH-MII monitoring as gold standard, sensitivity of pH-metry was lowest in infants (22.9%), with tendency to increase in older age groups (reaching 76.4% in children ≥ 9 years). The sensitivity of pH-metry alone in children with extraesophageal symptoms was 38.1%, while the sensitivity of pH-metry in children with gastrointestinal symptoms was 63.8%. Reflux esophagitis was identified in 31 (26.1%) of 119 children who underwent endoscopy. Logistic regression analysis showed that best predictors of endoscopic reflux esophagitis are the longest acid episode (OR = 1.52, p<0.05) and DeMeester reflux composite score (OR = 3.31, p<0.05). The significant cutoff values included DeMeester reflux composite score ≥ 29 (AUC 0.786, CI 0.695-0.877, p<0.01) and duration of longest acid reflux ≥ 18 minutes (AUC 0.784, CI 0.692-0.875, p<0.01). The results of our study suggested that compared with pH-metry alone, pH-MII had significantly higher detection rate of gastroesophageal reflux disease, especially in infants. Our findings also showed that pH-MII parameters correlated significantly with the endoscopically confirmed erosive esophagitis.
Koda, Yu Kar Ling; Ozaki, Marcos J; Murasca, Kelly; Vidolin, Eliana
In infants, it is not always easy to distinguish between pathological and physiological gastroesophageal reflux based only on clinical criteria. In Brazil, studies about gastroesophageal reflux disease in infants are few and are even rare those that used prolonged esophageal pH monitoring for its evaluation. To describe the clinical features of gastroesophageal reflux disease and to determine its prevalence in infants with gastroesophageal reflux attending a tertiary Pediatric Gastroenterology Service and submitted to esophageal pH monitoring for investigation. Descriptive study in 307 infants in whom esophageal pH monitoring (Mark III Digitrapper, Synectics Medical AB, Sweden) was performed during the period December, 1998-December, 2008. The clinical features studied were age group (1-12 months and 13-24 months), and clinical manifestations that motivated the indication of pH monitoring. One hundred twenty-four (40.4%) were female and 183 (59.6%) male with mean age 12.2 +/- 6.2 months (1-23 months). The prevalence of gastroesophageal reflux disease was 18.2% (56/307). One hundred forty-eight (48.2%) were 1-12 months old and 159 (51.8%), 13-24 months. No significant difference was found between the prevalence of these two age groups (P = 0.3006). Gastroesophageal reflux disease was more frequent in those with digestive manifestations (24.2%), crisis of cyanosis/apnea (23.8%) and mixed manifestations (21.5%). Respiratory manifestations were the most frequent indication (39.1%) of pH monitoring. However, the prevalence of gastroesophageal reflux disease was lower (12.5%) in this group compared with in those with digestive manifestations (P = 0.0574), crisis of cyanosis/apnea (P = 0.0882) and mixed manifestations (P = 0.1377). All infants that presented clinical manifestations as crisis of cyanosis/apnea and abnormal pH-metry were < 3 months of age. In our Service, the prevalence of gastroesophageal reflux disease associated with acid reflux in infants revealed
Lo, W-K; Goldberg, H J; Burakoff, R; Feldman, N; Chan, W W
Gastroesophageal reflux disease has been associated with poor outcomes following lung transplantation. However, the association between pretransplant reflux and post-transplant readmission, an indicator of early clinical outcome, has not been previously assessed. This was a retrospective cohort study of lung transplant recipients undergoing pretransplant multichannel intraluminal impedance and pH (MII-pH) study off acid suppression at a tertiary care center since 2007. Subjects with pretransplant fundoplication were excluded. Time to readmission was defined as duration from post-transplant discharge to next hospital admission for any reason. Subgroup analysis was performed to exclude elective readmissions. Time-to-event analysis was performed using Cox proportional hazards model, with appropriate censoring. Forty-three subjects (60% men, mean age: 57, median follow-up: 1.7 years) met inclusion criteria for the study. Patient demographics and pretransplant cardiopulmonary function were similar between readmission cohorts. Time to all-cause readmission was associated with increased distal acid episodes (HR: 3.15, p = 0.04) and proximal acid episodes (HR: 3.61, p = 0.008) on impedance, increased acid exposure on pH (HR: 2.22, p = 0.04), and elevated Demeester score (HR: 2.26, p = 0.03). When elective readmissions were excluded, early readmission remained significantly associated with increased proximal acid reflux episodes (HR: 2.49, p = 0.04). All findings were confirmed on Kaplan-Meier analysis. Elevated proximal acid reflux on pretransplant MII-pH testing was associated with early readmission following lung transplantation, even after excluding elective readmissions. Exposure to severe acid reflux has measurable effects on early postoperative outcomes such as readmission, and aggressive early antireflux therapy should be considered. © 2015 John Wiley & Sons Ltd.
Molyneux, Ian D.; Morice, Alyn H.
It is increasingly accepted that the effects of gastro-oesophageal reflux are not limited to the gastrointestinal tract. The adjacent respiratory structures are also at risk from material ejected from the proximal oesophagus as a result of the failure of anatomical and physiological barriers. There is evidence of the influence of reflux on several respiratory and otorhinological conditions and although in many cases the precise mechanism has yet to be elucidated, the association alone opens potential novel avenues of therapy to clinicians struggling to treat patients with apparently intractable respiratory complaints. This review provides a description of the airway reflux syndrome, its effects on the lung and current and future therapeutic options. PMID:23251752
The report from the HUNT Study provides the most convincing evidence yet that weight loss has beneficial effects on occurrence and severity of heartburn and regurgitation and their response to acid suppressant therapy. These data should re-invigorate clinicians to encourage weight loss in their reflux disease patients.
Gastro-oesophageal reflux disease results from impaired function of the LOS and acid clearance of the distal oesophagus. Most patients do not require investigation and respond either to lifestyle changes, antacid/alginates, H2A, PPI or a combination of these treatments. Surgery is only rarely indicated.
Youssef, Tarek Fouad; Ahmed, Mohamed Rifaat
To determine the incidence of Helicobacter pylori (HP) stool antigen (HPSA) in patients with laryngopharyngeal reflux disease (LPRD), and to make a comparison of 2 treatment regimens that have been used based on the presence or absence of HPSA positivity in patients with LPRD. Randomized controlled study. Suez Canal University Hospital, Ismalia, Egypt. A total of 212 patients with symptoms of LPRD. Patients were evaluated by laryngoscopy, ambulatory pH monitoring for 24 hours, and HPSA testing. Esomeprazole magnesium as a monotherapy was evaluated vs triple therapy in patients with HP infection. To determine the incidence of HPSA in patients with LPRD, and to make a comparison of 2 treatment regimens that have been used based on the presence or absence of HPSA positivity in patients with LPRD. Persistent dry cough and a feeling of a lump in the throat (globus sensation) were the most frequent symptoms of LPRD, while posterior laryngeal inflammation was the main laryngoscopic finding. Results from the HPSA test were positive in 57% of the studied group. Patients with negative HPSA were treated with esomeprazole as single modality with a reported improvement score of 96.6%. Patients with positive HPSA test results were divided into 2 groups: 1 received only esomeprazole, with reported improvement in 40%, whereas the second group was treated with esomeprazole, plus amoxicillin sodium and clarithromycin (triple therapy) and reported a 90% incidence of symptom improvement. The incidence of HP infection in patients with LPRD in our study was 57%. Triple therapy showed a higher cure rate in patients with HPSA-positive test results.
Fernandes, Michel R; De Oliveira, Marina; Callegari-Jacques, Sidia M; Gonçalves, Gissele V R; Fornari, Fernando
Evaluation of esophageal clearance by orange juice swallowing could be useful to identify different categories of gastroesophageal reflux disease. We determined whether a juice test at the beginning of esophageal pH monitoring can identify nonerosive reflux disease (NERD) among heartburn patients. Multiple swallows of orange juice (pH 3) were performed at the beginning of esophageal pH monitoring in 71 heartburn patients off acid-suppressive therapy. The area between pH drop below 5 and recovery to 5 was calculated from pH tracings and named Delta5 (mmol∙L⁻¹∙sec). Fifteen healthy subjects served to determine Delta5 cutoff (95th percentile). Patients were classified as NERD, non-NERD (a mix of reflux hypersensitivity, functional heartburn, and undetermined), and erosive disease depending on acid exposure, reflux symptom analysis, and upper endoscopy. Delta5 cutoff in healthy subjects was 251 mmol·L⁻¹∙sec. Among 71 patients, 23 had NERD, 26 had non-NERD, and 22 had erosive disease. Compared to non-NERD, Delta5 was higher in both NERD (median [interquartile range]: 316 [213-472] vs 165 [105-225]; P ＜ 0.01) and erosive disease (310 [169-625] vs 165 [105-225]; P ＜ 0.01). An elevated Delta5 (＞ 251 mmol∙L⁻¹∙sec) showed sensitivity of 74% and specificity of 81% for identification of NERD. Positive and negative likelihood ratios were 3.84 and 0.32 respectively, whereas test accuracy was 78%. A juice test with calculation of Delta5 helps in the identification of true NERD among heartburn patients with endoscopy-negative reflux disease. In these patients, an elevated Delta5 could make prolonged reflux testing unnecessary.
Dy, Fei; Amirault, Janine; Mitchell, Paul D; Rosen, Rachel
To determine the sensitivity of salivary pepsin compared with multichannel intraluminal impedance with pH testing (pH-MII), endoscopy, and gastroesophageal reflux disease (GERD) questionnaires. We prospectively recruited 50 children from Boston Children's Hospital who were undergoing pH-MII to evaluate for GERD. The patients completed 24-hour pH-MII testing, completed symptom and quality of life questionnaires, and provided a saliva specimen that was analyzed using the PepTest lateral flow test. A subset of patients also underwent bronchoscopy and esophagogastroduodenoscopy. Receiver operating characteristic curve analyses were performed to determine the sensitivity of salivary pepsin compared with each reference standard. Twenty-one of the 50 patients (42%) were salivary pepsin-positive, with a median salivary pepsin concentration of 10 ng/mL (IQR, 10-55 ng/mL). There was no significant difference in the distributions of acid, nonacid, total reflux episodes, full column reflux, or any other reflux variable in patients who were pepsin-positive compared with those who were pepsin-negative (P > .50). There was no significant correlation between the number of reflux episodes and pepsin concentration (P > .10). There was no positive relationship between salivary pepsin positivity, any extraesophageal symptoms or quality of life scores, or inflammation on bronchoscopy or esophagogastroduodenoscopy (P > .30). Salivary pepsin measurement has a low sensitivity for predicting pathological gastroesophageal reflux in children. Copyright © 2016 Elsevier Inc. All rights reserved.
Asanuma, Kiyotaka; Iijima, Katsunori; Shimosegawa, Tooru
The incidence of esophageal adenocarcinoma (EAC) has risen sharply in western countries over the past 4 decades. This type of cancer is considered to follow a transitional process that goes from gastro-esophageal reflux disease (GERD) to Barrett's esophagus (BE, a metaplastic condition of the distal esophagus), a precursor lesion and ultimately adenocarcinoma. This spectrum of GERD is strongly predominant in males due to an unidentified mechanism. Several epidemiologic studies have described that the prevalence of GERD, BE and EAC in women is closely related to reproductive status, which suggests a possible association with the estrogen level. Recently, we revealed in an in vivo study that the inactivation of mast cells by the anti-inflammatory function of estrogen may account for the gender difference in the GERD spectrum. Other studies have described the contribution of female steroid hormones to the gender difference in these diseases. Estrogen is reported to modulate the metabolism of fat, and obesity is a main risk factor of GERDs. Moreover, estrogen could confer esophageal epithelial resistance to causative refluxate. These functions of estrogen might explain the approximately 20-year delay in the incidence of BE and the subsequent development of EAC in women compared to men, and this effect may be responsible for the male predominance. However, some observational studies demonstrated that hormone replacement therapy exerts controversial effects in GERD patients. Nevertheless, the estrogen-related endocrine milieu may prevent disease progression toward carcinogenesis in GERD patients. The development of innovative alternatives to conventional acid suppressors may become possible by clarifying the mechanisms of estrogen.
Asanuma, Kiyotaka; Iijima, Katsunori; Shimosegawa, Tooru
The incidence of esophageal adenocarcinoma (EAC) has risen sharply in western countries over the past 4 decades. This type of cancer is considered to follow a transitional process that goes from gastro-esophageal reflux disease (GERD) to Barrett’s esophagus (BE, a metaplastic condition of the distal esophagus), a precursor lesion and ultimately adenocarcinoma. This spectrum of GERD is strongly predominant in males due to an unidentified mechanism. Several epidemiologic studies have described that the prevalence of GERD, BE and EAC in women is closely related to reproductive status, which suggests a possible association with the estrogen level. Recently, we revealed in an in vivo study that the inactivation of mast cells by the anti-inflammatory function of estrogen may account for the gender difference in the GERD spectrum. Other studies have described the contribution of female steroid hormones to the gender difference in these diseases. Estrogen is reported to modulate the metabolism of fat, and obesity is a main risk factor of GERDs. Moreover, estrogen could confer esophageal epithelial resistance to causative refluxate. These functions of estrogen might explain the approximately 20-year delay in the incidence of BE and the subsequent development of EAC in women compared to men, and this effect may be responsible for the male predominance. However, some observational studies demonstrated that hormone replacement therapy exerts controversial effects in GERD patients. Nevertheless, the estrogen-related endocrine milieu may prevent disease progression toward carcinogenesis in GERD patients. The development of innovative alternatives to conventional acid suppressors may become possible by clarifying the mechanisms of estrogen. PMID:26855539
Wang, K; Duan, L P; Ge, Y; Xia, Z W; Xu, Z J
To study the role of esophagogastric junction contractile index (EGJ-CI) in evaluating the function of anti-reflux barrier, and in differentiating patients with gastroesophageal reflux disease (GERD) from those with functional heartburn (FH). A total of 115 patients presenting heartburn were enrolled in the study from January 2012 to June 2015.All subjects had completed Gerd-Q questionnaire and undergone gastroscopy, 24-hour pH-impedance monitoring and esophageal high-resolution manometry. GERD patients were divided into as reflux esophagitis, acid-nonerosive reflux disease (NERD) and weakly acid-NERD groups. Patients with normal esophageal mucosa, normal acid exposure and negative proton pump inhibitor test were enrolled in FH group. EGJ-CI (mmHg·cm) as well as EGJ rest pressure and 4s integrated relaxation pressure (IRP 4s) were measured. Among the 115 patients, 18 were reflux esophagitis [(49.0±18.9) years, M∶F=10∶8], 25 were acid-NERD [(48.7±14.4) years, M∶F=13∶12], 37 were weakly acid-NERD [(52.0±14.8) years, M∶F=15∶22] and 35 were FH [(53.6±14.8), M∶F=8∶27]. No differences of Gerd-Q scores were noticed between the four groups. (1)Negative correlations were demonstrated between EGJ-CI and esophageal acid exposure time (r=-0.283, P=0.002), EGJ-CI and acid reflux events (r=-0.233, P=0.012), EGJ-CI and weakly acid reflux events (r=-0.213, P=0.022), EGJ-CI and non-acid reflux events (r=-0.200, P=0.032). (2)The value of EGJ-CI was significantly higher in FH patients than in the three subgroups of GERD(all P<0.01). EGJ rest pressure of FH group was higher than that of acid-NERD (P<0.01). IRP 4s in acid-NERD group was lower than that of FH and weakly acid-NERD (P<0.05). (3)The area under curve (AUC) of EGJ-CI was higher than that of EGJ-CIT, EGJ rest pressure or IRP 4s(0.686 vs 0.678, 0.641 and 0.578). The cut-off value of EGJ-CI to differentiate GERD from FH was 9.74 mmHg·cm with sensitivity 82.86% and specificity 51.52%. The EGJ-CI values are
Mermelstein, Joseph; Chait Mermelstein, Alanna; Chait, Maxwell M
A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist. PMID:29606884
Sawaya, R A; Macgill, A; Parkman, H P; Friedenberg, F K
According to the Montreal Consensus Group's classification, gastroesophageal reflux disease develops when the reflux of stomach contents causes troublesome symptoms and/or complications such as esophagitis. The characteristic gastroesophageal reflux disease symptoms included in this statement are retrosternal burning and regurgitation. Troublesome is meant to imply that these symptoms impact on the well-being of affected individuals; in essence, quality of life (QOL). Whether heartburn and regurgitation symptoms would be characterized as more troublesome in those with confirmed pathologic acid reflux was determined. A second purpose was to assess how well troublesome scores correlated with the results of a validated, disease-specific QOL instrument. Subjects who underwent esophagogastroduodenoscopy (EGD) with 48-hour wireless esophageal pH testing off proton pump inhibitor therapy were interviewed. Esophagitis on EGD or pH < 4.0 for ≥4.5% of time over the 2-day period was considered positive for acid reflux. Assessment of how troublesome their symptoms of heartburn and regurgitation were made using separate 0-100 visual analog scales (VAS). Subjects were then asked to complete the Quality of Life in Reflux and Dyspepsia (QOLRAD) 25-item questionnaire. Sixty-seven patients (21 males, 46 females) with mean age 47.8 ± 15.6 years were identified. Forty (59.7%) had an EGD or pH study positive for acid reflux. Overall 35/40 (87.5%) complained of either heartburn or regurgitation. There was no difference (P= 0.80) in heartburn VAS troublesome ratings for those with (54.0 ± 43.9) and without (56.7 ± 37.6) confirmed acid reflux. The same was true for regurgitation VAS troublesome ratings (P= 0.62). Likewise, mean QOLRAD scores did not differ between those with and without confirmed acid reflux by pH or EGD (4.5 ± 1.7 vs. 4.3 ± 1.7; P= 0.61). There was a moderately strong inverse correlation between patient self-rated VAS troublesome scores for both heartburn and
Kawamura, O; Shimoyama, Y; Hosaka, H; Kuribayashi, S; Maeda, M; Nagoshi, A; Zai, H; Kusano, M
Gastro-esophageal reflux disease (GERD)-related chronic cough (CC) may have multifactorial causes. To clarify the characteristics of esophagopharyngeal reflux (EPR) events in CC patients whose cough was apparently influenced by gastro-esophageal reflux (GER), we studied patients with CC clearly responding to full-dose proton pump inhibitor (PPI) therapy (CC patients). Ten CC patients, 10 GERD patients, and 10 healthy controls underwent 24-h ambulatory pharyngo-esophageal impedance and pH monitoring. Weakly acidic reflux was defined as a decrease of pH by >1 unit with a nadir pH >4. In six CC patients, monitoring was repeated after 8 weeks of PPI therapy. The number of each EPR event and the symptom association probability (SAP) were calculated. Symptoms were evaluated by a validated GERD symptom questionnaire. Weakly acidic gas EPR and swallowing-induced acidic/weakly acidic EPR only occurred in CC patients, and the numbers of such events was significantly higher in the CC group than in the other two groups (P < 0.05, respectively). Symptom association probability analysis revealed a positive association between GER and cough in three CC patients. Proton pump inhibitor therapy abolished swallowing-induced acidic/weakly acidic EPR, reduced weakly acidic gas EPR, and improved symptoms (all P < 0.05). Most patients with CC responding to PPI therapy had weakly acidic gas EPR and swallowing-induced acidic/weakly acidic EPR. A direct effect of acidic mist or liquid refluxing into the pharynx may contribute to chronic cough, while cough may also arise indirectly from reflux via a vago-vagal reflex in some patients. © 2011 Blackwell Publishing Ltd.
Kim, Young Sun; Kim, Nayoung; Kim, Gwang Ha
It is important to understand sex and gender-related differences in gastroesophageal reflux disease (GERD) because gender-related biologic factors might lead to better prevention and therapy. Non-erosive reflux disease (NERD) affects more women than men. GERD symptoms are more frequent in patients with NERD than in those with reflux esophagitis. However, men suffer pathologic diseases such as reflux esophagitis, Barrett’s esophagus (BE), and esophageal adenocarcinoma (EAC) more frequently than women. The prevalence of reflux esophagitis is significantly increased with age in women, especially after their 50s. The mean age of EAC incidence in women is higher than in men, suggesting a role of estrogen in delaying the onset of BE and EAC. In a chronic rat reflux esophagitis model, nitric oxide was found to be an aggravating factor of esophageal injury in a male-predominant way. In addition, the expression of esophageal occludin, a tight junction protein that plays an important role in the esophageal defense mechanism, was up-regulated in women. This explains the male predominance of reflux esophagitis and delayed incidence of BE or EAC in women. Moreover, the symptoms such as heartburn, regurgitation, and extra-esophageal symptoms have been more frequently reported by women than by men, suggesting that sex and gender play a role in symptom perception. Differential sensitivity with augmented symptoms in women might have diagnostic and therapeutic influence. Furthermore, recent studies have suggested that hormone replacement therapy has a protective effect against esophageal cancer. However, an anti-inflammatory role of estrogen remains compelling, which means further study is necessary in this area. PMID:27703114
Pauwels, A; Altan, E; Tack, J
Gastro-esophageal reflux (GER), the retrograde flow of gastric contents into the esophagus is a physiologic phenomenon, which can evoke symptoms and/or lesions in the esophagus (=gastro-esophageal reflux disease or GERD). Proton pump inhibitors (PPIs) reduce gastric acidity; however, as they are unable to control transient lower esophageal sphincter relaxations (TLESRs), the main mechanism for reflux in GERD, they do not abolish reflux. TLESRs occur predominantly in the postprandial period, and they are believed to be triggered by gastric distention. Gastric accommodation (GA) is the physiologic response to gastric distention and serves to prevent a rise in gastric wall tension during food intake. We aimed to study the relationship between GA and TLESRs, as they both are triggered by gastric distention. We studied 12 GERD patients (average age 37 years [range 18-62], 7m/5f) and nine healthy volunteers (average age 27 years [range 22-36], 2m/7f) using high resolution manometry-impedance measurement before and after a mixed meal challenge. We determined the number of TLESRs (with or without reflux) and measured pre- and postprandial IGP. The change in IGP between the pre- and postprandial period (ΔIGP) is used as surrogate for GA. We also measured LES pressure before and after the meal and calculated the change (ΔLESp). There were no statistical differences between pre- and postprandial IGP in GERD and healthy volunteers and similarly, there was no significant difference between pre- and postprandial LES pressures in GERD patients and healthy volunteers. The number of TLESRs (with or without reflux) was similar in GERD and healthy volunteers. More importantly, we did observe a negative correlation between ΔIGP and the number of TLESRs, irrespective of whether they were associated with reflux or not, in the GERD patients (without reflux r = -0.67, p = 0.017; with reflux r = -0.81, p = 0.0014). The same observations were found in healthy volunteers, where ΔIGP and
Iannella, Giannicola; Di Nardo, Giovanni; Plateroti, Rocco; Rossi, Paolo; Plateroti, Andrea Maria; Mariani, Paola; Magliulo, Giuseppe
Numerous investigations postulated that laryngopharyngeal reflux (LPR) is implicated in the pathogenesis of various upper airway inflammatory diseases as sinusitis or dacryostenosis. The presence of pepsin in tears might be confirmed the presuntive hypothesis of the arrival in the nasolacrimal ducts and precorneal tears film through the laryngopharyngeal reflux of either gastric acid or stomach secretions (pepsin) with inflammatory potentialities. The aim of this preliminary study was to identify the presence or absence of pepsin in the tears collected from children with a high suspicion of LPR who underwent 24-h pH (MII-pH) monitoring to confirm the disease. This study enrolled 20 patients suffering from symptoms of laryngopharyngeal reflux that underwent 24-h multichannel intraluminal impedance (MII)-pH monitoring to confirm the disease. The findings of the study group were compared with those of a control group of patients with negative pH monitoring. The quantitative analysis of human pepsin concentration in the tear samples was performed by ELISA method in both groups. Four children (20%) of the study group showed pepsin in the tears. All of the subjects belonging to the control group were negative for its presence. No difference differences in the total number of reflux episodes and the number of weakly basic reflux in the pepsin positive patients vs. pepsin negative children were present. 20% of the children with diagnosed LPR showed pepsin in the tears. Our specific investigation might provide information regarding sinusitis or dacryostenosis. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Refractory gastro-esophageal reflux disease (GERD), defined as persistent symptoms despite proton pump inhibitor (PPI) therapy, is an increasingly prevalent condition and is becoming a major challenge for the clinician. Since non-acidic reflux may be associated with symptoms persisting during PPI treatment, the lower esophageal sphincter (LES), the most important barrier protecting against reflux, has become an important target for the treatment of (refractory) GERD. Preclinical research has identified several receptors that are involved in the control of transient lower esophageal sphincter relaxations (TLESRs), the predominant mechanism of both acid and non-acidic reflux events, and several drugs have now been tested in humans. The GABA(B) agonist baclofen has demonstrated to effectively reduce the rate of TLESRs and the amount of reflux in both GERD patients and healthy volunteers. Nevertheless, the occurrence of central side effects limits its clinical use for the treatment of GERD. Several analogues are being developed to overcome this limitation and have shown promising results. Additionally, metabotropic glutamate receptor 5 (mGluR5) receptor antagonists have shown to reduce both acid and non-acidic reflux in GERD patients and several molecules are currently being evaluated. Although CB(1) antagonists have been shown to reduce TLESRs, they are also associated with central side effects, limiting their clinical applicability. Despite the identification of several potentially interesting drugs, the main challenge for the future remains the reduction of central side effects. Moreover, future studies will need to demonstrate the efficacy of these treatments in patients with refractory GERD.
Gastro-esophageal reflux disease (GERD) is very prevalent and has a high burden on health security system costs. Nevertheless, pathophysiology is complex and not well-understood. Several mechanisms have been proposed: decreased salivation, impaired esophageal clearance, decreased lower esophageal sphincter pressure resting tone, presence of hiatal hernia, increased number of transient lower esophageal sphincter relaxations (TLESRs), increased acid, and pepsin secretion, pyloric incompetence provoking duodeno-gastro-esophageal reflux of bile acids and trypsin. Independent of the relevance of each mechanism, the ultimate phenomenon is that mucosal epithelium is exposed for a longer time to agents as acid and pepsin or is in contact to luminal agents not commonly present in gastric refluxate as trypsin or bile acids. This leads to a visible damage of the epithelium (erosive esophagitis -EE) or impairing mucosal integrity without any sign of macroscopic alteration as occurs in non-erosive reflux disease (NERD). Luminal factors are not the only responsible for such impairment; more recent data indicate that endogenous factors may also play a role. This review will update the most recent findings on the putative pathophysiological mechanisms and specially will focus on the role of esophageal mucosal integrity in GERD. Methodologies used for the evaluation of mucosal integrity, its relevance in EE and NERD, its involvement in symptoms perception and the effect of luminal and endogenous factors will be discussed. © 2013 John Wiley & Sons Ltd.
Over the past decade, incidence of gastroesophageal reflux disease (GERD) showed an increasing trend resulting from factors, including lifestyle and dietary habits; however, both etiology and pathological mechanisms remain controversial. GERD occurs as a result of a variety of mechanisms and there is no single factor. Symptoms of GERD are often non-typical, with a likelihood of being overlooked by non-gastroenterology professionals. Therefore, improving GERD awareness in non-gastroenterology practitioners, along with early diagnosis and treatment, provide potential benefit to clinicians and patients alike. Increasing evidence suggests GERD has specific connections with a variety of non-digestive tract conditions, may contribute an aggravating compounding effect on other diseases, prolong hospitalization, and increase subsequent medical costs. This review considers and emphasizes the association between GERD and non-digestive tract conditions, including atrial fibrillation, chronic obstructive pulmonary disease, primary pulmonary fibrosis and energy metabolism related to diet.
Miner, Philip B; Silberg, Debra G; Ruth, Magnus; Miller, Frank; Pandolfino, John
The γ-aminobutyric acid type B-receptor agonist lesogaberan (AZD3355) has been developed for use in patients with gastroesophageal reflux disease (GERD) symptoms despite proton pump inhibitor (PPI) therapy (partial responders). This study aimed to explore the dose-response effect of lesogaberan on reflux episodes in partial responders. In this randomized, single-centre, double-blind, crossover, placebo-controlled study, partial responders taking optimised PPI therapy were given 30, 90, 120 and 240 mg doses of lesogaberan. Each dose was given twice (12 h apart) during a 24-h period, during which impedance-pH measurements were taken. Twenty-five patients were included in the efficacy analysis and 27 in the safety analysis. The effect of lesogaberan on the mean number of reflux episodes was dose-dependent, and all doses significantly reduced the mean number of reflux episodes relative to placebo. Lesogaberan also dose-dependently reduced the mean number of acid reflux episodes (except the 30 mg dose) and weakly acid reflux episodes (all doses) significantly, relative to placebo. Regardless of dose, lesogaberan had a similar effect on the percentage of time with esophageal pH < 4 [mean reduction: 68.5% (30 mg), 54.2% (90 mg), 65.9% (120 mg), 72.1% (240 mg); p < 0.05 except 90 mg dose]. No adverse events led to discontinuation and no serious adverse events occurred during active treatment. Lesogaberan inhibited reflux in a dose-dependent manner in partial responders taking optimised PPI therapy, and these effects were significant versus placebo. All lesogaberan doses were well tolerated and were not associated with clinically relevant adverse events. ClinicalTrials.gov identifier: NCT01043185.
Dickman, Ram; Maradey-Romero, Carla; Gingold-Belfer, Rachel; Fass, Ronnie
Gastroesophageal reflux disease (GERD) is a highly prevalent gastrointestinal disorder. Proton pump inhibitors have profoundly revolutionized the treatment of GERD. However, several areas of unmet need persist despite marked improvements in the therapeutic management of GERD. These include the advanced grades of erosive esophagitis, nonerosive reflux disease, maintenance treatment of erosive esophagitis, refractory GERD, postprandial heartburn, atypical and extraesophageal manifestations of GERD, Barrett’s esophagus, chronic protein pump inhibitor treatment, and post-bariatric surgery GERD. Consequently, any future development of novel therapeutic modalities for GERD (medical, endoscopic, or surgical), would likely focus on the aforementioned areas of unmet need. PMID:26130628
Higo, T; Mukaisho, K; Ling, Z-Q; Oue, K; Chen, K-H; Araki, Y; Sugihara, H; Yamamoto, G; Hattori, T
To explore the association between dental erosion and gastro-oesophageal reflux disease (GORD), we used an animal model of GORD. We performed an operation to force gastro-duodenal contents reflux in male Wistar rats, and examined the teeth in the reflux rats at 15 or 30 weeks postoperatively. Dental erosion was evaluated based on a slightly modified index from a previous report. Estimation of pH was employed in the oesophageal and gastric contents. Macroscopically, dental erosion was only detected in the reflux rats. Histopathologically, dentin exposure was detected in three of the seven cases after 30 weeks. Alveolar bone destruction and osteomyelitis were also noted in severe cases. The pH of the oesophageal and stomach contents was 6.93 +/- 0.15 and 3.7 +/- 0.39, respectively. We confirmed the relationship between dental erosion and GORD. First step of dental erosion caused by GORD is the loss of surface enamel induced by regurgitation of an acidic liquid and acidic gas. Subsequently, further destruction of dental hard tissues and tooth supporting structure is accelerated by mixed juice with gastric and duodenal contents. The reflux animal model is a useful tool to examine the mechanism of dental erosion in GORD.
Oh, Hyun Jin; Choi, Myung-Gyu; Park, Jae Myung; Song, Kyo Young; Yoo, Han Mo
Esophageal reflux symptom has been reported as common in patients with subtotal gastrectomy. Management of postoperative esophageal reflux symptom is not satisfactory. The aim of this study is to investigate prevalence of esophageal reflux symptom after subtotal gastrectomy and assess factors affecting esophageal reflux symptom in subtotal gastrectomy patients. We prospectively enrolled 100 consecutive patients with subtotal gastrectomy who were regularly followed up by endoscopic examination. Acid secretory capacity was assessed by measuring messenger RNA (mRNA) expression of H + /K + -adenosine triphosphatase (ATPase) via real-time polymerase chain reaction (PCR) in biopsy specimens. In total, 47 % of patients had typical esophageal reflux symptom, where heartburn or regurgitation was experienced at least weekly. Age, sex, body mass index, and type of reconstruction did not differ between esophageal reflux and non-esophageal-reflux groups. The esophageal reflux group had longer duration from time of operation until study (median 5.0 versus 3.6 years; P = 0.017). Hill grade for gastroesophageal (GE) flap valve was higher in the esophageal reflux group than in the non-esophageal-reflux group (P = 0.027). H + /K + -ATPase mRNA expression was higher in the esophageal reflux group than in the non-esophageal-reflux group [3967.6 (± 7583.7) versus 896.2 (± 1456.0); P = 0.006]. Multivariate analysis revealed that postoperative duration, H + /K + -ATPase mRNA expression level, and GE flap valve disruption were significantly associated with esophageal reflux symptom development. Esophageal reflux symptom is common in patients after subtotal gastrectomy, possibly because of anti-reflux-barrier impairment and preservation of acid secretory capacity following surgery. Optimal acid suppression may be helpful in managing postoperative esophageal reflux symptom.
Mattos, Ângelo Zambam de; Marchese, Gabriela Meirelles; Fonseca, Bárbara Brum; Kupski, Carlos; Machado, Marta Brenner
Proton pump inhibitors and histamine H2 receptor antagonists are two of the most commonly prescribed drug classes for pediatric gastroesophageal reflux disease, but their efficacy is controversial. Many patients are treated with these drugs for atypical manifestations attributed to gastroesophageal reflux, even that causal relation is not proven. To evaluate the use of proton pump inhibitors and histamine H2 receptor antagonists in pediatric gastroesophageal reflux disease through a systematic review. A systematic review was performed, using MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases. The search was limited to studies published in English, Portuguese or Spanish. There was no limitation regarding date of publication. Studies were considered eligible if they were randomized-controlled trials, evaluating proton pump inhibitors and/or histamine H2 receptor antagonists for the treatment of pediatric gastroesophageal reflux disease. Studies published only as abstracts, studies evaluating only non-clinical outcomes and studies exclusively comparing different doses of the same drug were excluded. Data extraction was performed by independent investigators. The study protocol was registered at PROSPERO platform (CRD42016040156). After analyzing 735 retrieved references, 23 studies (1598 randomized patients) were included in the systematic review. Eight studies demonstrated that both proton pump inhibitors and histamine H2 receptor antagonists were effective against typical manifestations of gastroesophageal reflux disease, and that there was no evidence of benefit in combining the latter to the former or in routinely prescribing long-term maintenance treatments. Three studies evaluated the effect of treatments on children with asthma, and neither proton pump inhibitors nor histamine H2 receptor antagonists proved to be significantly better than placebo. One study compared different combinations of omeprazole, bethanechol and placebo for the
Altorjay, Aron; Juhasz, Arpad; Kellner, Viola; Sohar, Gellert; Fekete, Matyas; Sohar, Istvan
With the availability of a minimally invasive approach, anti-reflux surgery has recently experienced a renaissance as a cost-effective alternative to life-long medical treatment in patients with gastroesophageal reflux disease (GERD). We are not aware of the fact whether reflux episodes causing complaints for a long time i.e., at least for one year are associated with metabolic changes in the lower esophageal sphincter, and if so, whether these may influence functional results achieved after anti-reflux surgery. Between 1 January 2001 and 31 December 2002 we performed anti-reflux surgery on 79 patients. Muscle samples were taken from the lower esophageal sphincter (LES) in 33 patients during anti-reflux surgery. Inclusion criteria were: LES resting pressure below 10 mmHg and a marked, pH proven acid exposure to the esophagus of at least one year's duration, causing subjective complaints and requiring continuous proton pump inhibitor treatment. Control samples were obtained from muscle tissue in the gastroesophageal junction that had been removed from 17 patients undergoing gastric or esophageal resection. Metabolic and lysosomal enzyme activities and special protein concentrations 16 parameters in total were evaluated in tissue taken from control specimens and tissue taken from patients with GERD. The biochemical parameters of these intra-operative biopsies were used to correlate the results of anti-reflux operations (Visick I and II-III). In the reflux-type muscle, we found a significant increase of the energy-enzyme activities e.g., creatine kinase, lactate dehydrogenase, beta-hydroxybutyrate dehydrogenase, and aspartate aminotransaminase-. The concentration of the structural protein S-100 and the myofibrillar protein troponin I were also significantly increased. Among lysosomal enzymes, we found that the activities of cathepsin B, tripeptidyl-peptidase I, dipeptidyl-peptidase II, beta-hexosaminidase B, beta-mannosidase and beta-galactosidase were significantly
Altorjay, Aron; Juhasz, Arpad; Kellner, Viola; Sohar, Gellert; Fekete, Matyas; Sohar, Istvan
AIM: With the availability of a minimally invasive approach, anti-reflux surgery has recently experienced a renaissance as a cost-effective alternative to life-long medical treatment in patients with gastroesophageal reflux disease (GERD). We are not aware of the fact whether reflux episodes causing complaints for a long time i.e., at least for one year are associated with metabolic changes in the lower esophageal sphincter, and if so, whether these may influence functional results achieved after anti-reflux surgery. METHODS: Between 1 January 2001 and 31 December 2002 we performed anti-reflux surgery on 79 patients. Muscle samples were taken from the lower esophageal sphincter (LES) in 33 patients during anti-reflux surgery. Inclusion criteria were: LES resting pressure below 10 mmHg and a marked, pH proven acid exposure to the esophagus of at least one year’ duration, causing subjective complaints and requiring continuous proton pump inhibitor treatment. Control samples were obtained from muscle tissue in the gastroesophageal junction that had been removed from 17 patients undergoing gastric or esophageal resection. Metabolic and lysosomal enzyme activities and special protein concentrations 16 parameters in total were evaluated in tissue taken from control specimens and tissue taken from patients with GERD. The biochemical parameters of these intra-operative biopsies were used to correlate the results of anti-reflux operations (Visick I and II-III). RESULTS: In the reflux-type muscle, we found a significant increase of the energy-enzyme activities e.g., creatine kinase, lactate dehydrogenase, β-hydroxybutyrate dehydrogenase, and aspartate aminotransaminase-. The concentration of the structural protein S-100 and the myofibrillar protein troponin I were also significantly increased. Among lysosomal enzymes, we found that the activities of cathepsin B, tripeptidyl-peptidase I, dipeptidyl-peptidase II, β-hexosaminidase B, β-mannosidase and β-galactosidase were
Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Kashiwagi, Hideyuki; Yanaga, Katsuhiko
Kusano et al. developed a questionnaire for the evaluation of gastroesophageal reflux disease (GERD), the frequency scale for the symptoms of GERD (FSSG). The FSSG is now widely used in Japan. We investigated the relationship between FSSG results and cardiac sphincter endoscopic findings. The subjects were 470 patients who responded to the FSSG before undergoing endoscopy. From the FSSG results, we calculated the total, acid reflux, and dysmotility scores. Endoscopic findings were assessed in terms of the anatomic-functional-pathological (AFP) classification as the A factor, or degree and type of hiatal hernia, and the valve factor, or laxity of the cardiac sphincter. The degree of esophagitis was assessed using the modified Los Angeles classification. We investigated correlations between each score and the anatomy of the cardia. With either definition of esophagitis (grade M or greater, or grade A or greater), the total and acid reflux scores were both significantly higher in the group with reflux esophagitis than in the group without reflux esophagitis. Examination of the relationship between FSSG scores and the A factor revealed no significant differences in the total, acid reflux, or dysmotility scores whether a hiatal hernia was present or absent. Similarly, examination of the valve factor showed no significant difference in any scores between V0 and V1 versus V1 and V2, indicating no correlation between cardiac sphincter laxity and FSSG scores. The FSSG was useful in determining whether reflux esophagitis is present, but it did not predict the anatomy of the cardia.
Kahrilas, Peter J.; Smith, Jaclyn A.; Dicpinigaitis, Peter V.
Along with upper airway cough syndrome (formerly, postnasal drip syndrome) and eosinophilic airway inflammation (asthma, non-asthmatic eosinophilic bronchitis), gastroesophageal reflux disease (GERD) is generally considered among the most common etiologies of chronic cough. Indeed, cough management guidelines published by numerous respiratory societies worldwide recommend evaluation and treatment of GERD as an integral component of the diagnostic/therapeutic algorithm for the management of chronic cough. However, a significant number of patients with chronic cough presumed due to GERD do not report improvement despite aggressive acid-suppressive therapy. Some of these refractory cases may be due to the recently appreciated entity of non-acid or weakly acidic reflux. Further contributing to the controversy are recent studies demonstrating that patients with chronic cough do not have excessive reflux events relative to healthy volunteers. Although a temporal relationship between cough and reflux events has been suggested by studies utilizing impedance-pH monitoring of reflux events and objective cough recording, consensus is lacking in terms of whether this temporal relationship proves a causal link between reflux and cough. The 4th American Cough Conference, held in New York in June, 2013, provided an ideal forum for the debate of this issue between two internationally recognized experts in the field of reflux and chronic cough. PMID:24221340
Jung, Kyoungwon; Park, Moo In; Park, Seun Ja; Moon, Won; Kim, Sung Eun; Kim, Jae Hyun
Since the development of ambulatory esophageal pH monitoring test to diagnose gastroesophageal reflux disease (GERD), several parameters have been introduced. The aim of this study was to assess whether using the symptom index (SI), symptom sensitivity index (SSI), and symptom association probability (SAP), in addition to the DeMeester score (DS), would be useful for interpreting the Bravo pH monitoring test. A retrospective study, which included 68 patients with reflux symptoms refractory to proton pump inhibitor (PPI) therapy who underwent a Bravo capsule pH test between October 2006 and May 2015, was carried out. Acid reflux parameters and symptom reflux association parameters were analyzed. The median percent time of total pH<4 and DS were 2.90% (interquartile range [IQR] 1.13-6.03%) and 11.10 (IQR 4.90-22.80), respectively. According to the analysis of the day-to-day variation in percent time of total pH<4 (r=0.724) and DS (r=0.537), there was a significant correlation between Day 1 and Day 2. The positive rate of Bravo test according to DS was 27 (39.7%). Although thirty patients experienced symptoms during the test, there were no significant differences of reflux parameters compared with other patients. In the symptom group, 7 patients (23.3%) were identified as having negative DS and an abnormal symptom-related index. There were no significant test-related complications. In addition to the analysis of traditional acid parameters of the Bravo capsule pH test, diagnosis of GERD, including reflux hypersensitivity, can be improved by performing an analysis of the symptom-reflux association and of the day-to-day variation.
Loh, Yiwen; McGlone, Emma Rose; Reddy, Marcus; Khan, Omar A
A best evidence topic in surgery was written according to a structured protocol. The question addressed whether LINX™ Reflux management system is an efficacious treatment for patients with symptoms of gastro-oesophageal reflux disease (GORD) not controlled by proton pump inhibitors (PPI). Forty-eight LINX-related papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. All three studies were prospective case studies. They demonstrated that LINX is an efficacious treatment for GORD patients with good short and medium term outcomes and an acceptable safety profile. Further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Scott, David R; Simon, Ronald A
Supraesophageal reflux of gastric contents can contribute to perennial nasopharyngitis, cough, and asthma. However, effective treatment strategies for supraesophageal reflux disease (SERD) remain inadequately defined. The purpose of this study is to assess the prevalence and timing of SERD and to investigate the efficacy of head-of-bed elevation in its treatment. A retrospective chart review of patients seen at Scripps Clinic Division of Allergy, Asthma and Immunology was performed who had undergone overnight nasopharyngeal pH monitoring with a commercially available nasopharyngeal pH-monitoring device, Dx-pH Measurement System from Restech, San Diego, Calif. Subjects with reflux were classified based on the position of reflux as either supine only, upright only, or both supine and upright. In a subset of subjects with supine-only reflux, pH monitoring was compared before and after elevating the head of bed 6 inches. Adequate nasopharyngeal pH-monitoring data were obtained for 235 patients. Reflux was detected in 113 (48%) patients. The pattern of reflux observed was 62 (55%) supine only, 4 (4%) upright only, and 47 (42%) upright and supine. Sequential overnight nasopharyngeal pH monitoring before and after head-of-bed elevation was obtained in 13 individuals with supine-only reflux. Ten subjects demonstrated significant improvement, 8 of whom demonstrated complete resolution of supine reflux with 6 inches of head-of-bed elevation. This study provides new evidence that SERD frequently occurs in the supine position and that 6 inches of head-of-bed elevation is effective in reducing supine SERD. Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Matsuzaki, Hiroumi; Makiyama, Kiyoshi; Hoshino, Masahiro; Oshima, Takeshi
To evaluate the relationship between laryngopharyngeal reflux disease and presence of lumbar kyphosis. A cross-sectional study. We included 20 patients with lumbar kyphosis and 31 control subjects. A diagnosis of laryngopharyngeal reflux disease and gastroesophageal reflux disease was made if the Reflux Symptom Index score was ≥13 and if the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease was ≥8, respectively. We compared the prevalence of the two reflux diseases, frequent reflux symptoms, and demographic factors between the two groups. There was no significant difference in demographic factors between the two groups. Five (25%) of 20 patients with lumbar kyphosis had a Reflux Symptom Index ≥13 compared with one (3.2%) of 31 controls. Seven (35.0%) of 20 patients had a Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease ≥8 compared with three (9.7%) of 31 controls. A comparison of the prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease showed a significant difference between patients with kyphosis and controls (P value = 0.029 and 0.036, respectively). In Reflux Symptom Index, heartburn, hoarseness, and a swallowing problem were significantly frequent symptoms in the kyphosis group compared with the control group. The prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease was significantly higher in patients with lumbar kyphosis than in controls. Therefore, otolaryngologists and orthopedic surgeons should be aware that patients with lumbar kyphosis are likely to have gastroesophageal reflux disease and also laryngopharyngeal reflux disease. Copyright Â© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Zsolt, Simonka; Paszt, Attila; Géczi, Tibor; Abrahám, Szabolcs; Tóth, Illés; Horváth, Zoltán; Pieler, József; Tajti, János; Varga, Akos; Tiszlavicz, László; Németh, István; Izbéki, Ferenc; Rosztóczy, András; Wittmann, Tibor; Lázár, György
Barrett's esophagus (BE) is the only known precursor of adenocarcinoma occuring in the lower third of the esophagus. According to statistics, severity and elapsed time of gastroesophageal reflux disease (GERD) are major pathogenetic factors in the development of Barrett's esophagus. In a retrospective study between 2001 and 2008, we compared the preoperative results (signs and sympthoms, 24 hour pH manometry, esophageal manometry, Bilitec) and treatment efficacy of 176 GERD patients and 78 BE patients, who have undergone laparoscopic Nissen procedure for reflux disease. The two groups of patients had similar demographic features, and elapsed time of reflux sympthoms were also equal. Both groups were admitted for surgery after a median time of 1.5 years (19.87 vs. 19.20 months) of ineffective medical (proton pump inhibitors) treatment. Preoperative functional tests showed a more severe presence of acid reflux in the BE group (DeMeester score 18.9 versus 41.9, p < 0.001). On the other hand, mano-metry - despite confirming lower esophageal sphincter (LES) damage - did not show difference between the two groups (12.10 vs. 12.57 mmHg, p = 0.892). We did not experience any mortality cases with laparoscopic antireflux procedures, although in two cases we had to convert during the operation (1 due to extensive adhesions, and 1 due to injury to the spleen). 3 months after the procedure - according to Visick score - both groups experienced a significant decrease, or lapse in reflux complaints (group I: 73%, group II: 81% of patients), LES functions improved (17.58 vs.18.70 mmHg), and the frequency and exposition of acid reflux decreased (DeMeester score 7.73 vs. 12.72). The severity of abnormal acid reflux occuring parallel with the incompetent function of the damaged LES triggers not only inflammation in the gastroesophageal junction (GEJ), but also metaplastic process, and the development of Barrett's esophagus. Laparoscopic Nissen procedure for reflux disease can further
Blondeau, Kathleen; Mertens, Veerle; Tack, Jan; Sifrim, Daniel
Background/Aims Impedance-pH monitoring allows detailed characterization of gastroesophageal reflux and esophageal activity associated with reflux. We assessed the characteristics of nocturnal reflux and esophageal activity preceding and following reflux. Methods Impedance-pH tracings from 11 healthy subjects and 76 patients with gastroesophageal reflux disease off acid-suppressive therapy were analyzed. Characteristics of nocturnal supine reflux, time distribution and esophageal activity seen on impedance at 2 minute intervals preceding and following reflux were described. Results Patients had more nocturnal reflux events than healthy subjects (8 [4-12] vs 2 [1-5], P = 0.002), with lower proportion of weakly acidic reflux (57% [35-78] vs 80% [60-100], P = 0.044). Nocturnal reflux was mainly liquid (80%) and reached the proximal esophagus more often in patients (6% vs 0%, P = 0.047). Acid reflux predominated in the first 2 hours (66%) and weakly acidic reflux in the last 3 hours (70%) of the night. Most nocturnal reflux was preceded by aboral flows and cleared by short lasting volume clearance. In patients, prolonged chemical clearance was associated with less esophageal activity. Conclusions Nocturnal weakly acidic reflux is as common as acid reflux in patients with gastroesophageal reflux disease, and predominates later in the night. Impedance-pH can predict prolonged chemical clearance after nocturnal acid reflux. PMID:21602991
Oh, Jung Hwan
Gastroesophageal reflux disease (GERD) is prevalent in Asia as well as in Western countries. Sleep disturbance and breathing disorders during sleep are becoming increasingly prevalent, and they are commonly associated with GERD. The relationship between GERD and obstructive sleep apnea (OSA) is still questionable, and it has expanded to include Barrett's esophagus. Nocturnal gastroesophageal reflux (nGER) symptoms might be clinically important in the explanation of this association. The therapy for reflux symptoms has resulted in improved subjective sleep parameters and enhanced sleep quality, thus supporting a direct relationship between GERD and sleep disturbance. This review discusses the epidemiology of sleep disturbances in GERD patients; the causative relationship between GERD and OSA, even though it remains an area of controversy; and the possible role of nGER in sleep problems. It also provides an update on the current state of knowledge linking GERD and sleep. © 2016 New York Academy of Sciences.
Vaezi, Michael F; Sifrim, Daniel
A detailed critique of objective measurements of gastroesophageal reflux disease (GERD) would improve management of patients suspecting of having reflux, leading to rational selection of treatment and better outcomes. Many diagnostic tests for GERD have been developed over the past decades. We analyze their development, positive- and negative-predictive values, and ability to predict response to treatment. These features are important for development of medical, surgical, and endoscopic therapies for GERD. We discuss the value of available diagnostic tests and review their role in management of patients with persistent reflux symptoms despite adequate medical or surgical treatment. This is becoming a significant health economic problem, due to the widespread use of proton pump inhibitors. GERD is believed to cause nonesophageal symptoms, such as those provoked by ear, nose, throat, or respiratory disorders. We analyze the value of GERD diagnostic tests in evaluation of these troublesome, nonesophageal symptoms. Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.
Tak, Abdul Momin; Scott, Richard D; Khan, Nadeem A
Sebaceous glands in the esophagus are very rare and have been reported mostly in autopsy studies. They have been considered to be of no clinical significance. We report a 50-year-old man with gastroesophageal reflux disease who had sebaceous glands in the esophagus on endoscopic biopsy.
Cusimano, Alessia; Macaione, I; Fiorentino, E
Swallowing, voice disorders, throat discomfort and subjective neck discomfort are usually reported by patients with a known thyroid nodule and are correlated to nodular thyroid disease itself. Moreover, in endemic goitrous areas, total thyroidectomy (TT) is the most frequently performed surgical procedure. We are used to relate swallowing, voice and throat discomfort to the mechanical effects of nodular goiter or to thyroidectomy itself, but in both these cases the relationship between symptoms and the thyroid mass or its removal is not always clear or easily demonstrated. How can we explain the persistence of local neck symptoms after TT? And how can TT worsen the dysphagic or dysphonic disorders attributed to the goiter's effect over the surrounding structures? During these years, many articles have analyzed the relationship between the thyroid disease and the laryngopharyngeal reflux, finding more and more evidences of their consensuality, leading to important new management considerations and notable medico-legal implications; if the reason of local neck symptoms is not the thyroid disease, we have to study and specially cure the reflux disease, with specific test and drugs. Therefore, the aim of our study, relying on the published literature, was to investigate how, in demonstrated presence of reflux laryngopharyngitis in patients with nodular goiter and local neck symptoms before and after uncomplicated TT, the surgery could influence our anti-reflux mechanism analyzing the anatomical connection as well as the functional coordination; can we play a part in the post-operative persistence of swallowing and voice alterations and throat discomfort?
Kimura, Yoshihide; Kamiya, Takeshi; Senoo, Kyouji; Tsuchida, Kenji; Hirano, Atsuyuki; Kojima, Hisayo; Yamashita, Hiroaki; Yamakawa, Yoshihiro; Nishigaki, Nobuhiro; Ozeki, Tomonori; Endo, Masatsugu; Nakanishi, Kazuhisa; Sando, Motoki; Inagaki, Yusuke; Shikano, Michiko; Mizoshita, Tsutomu; Kubota, Eiji; Tanida, Satoshi; Kataoka, Hiromi; Katsumi, Kohei; Joh, Takashi
Some patients with gastroesophageal reflux disease experience persistent reflux symptoms despite proton pump inhibitor therapy. These symptoms reduce their health-related quality of life. Our aims were to evaluate the relationship between proton pump inhibitor efficacy and health-related quality of life and to evaluate predictive factors affecting treatment response in Japanese patients. Using the gastroesophageal reflux disease questionnaire, 145 gastroesophageal reflux disease patients undergoing proton pump inhibitor therapy were evaluated and classified as responders or partial-responders. Their health-related quality of life was then evaluated using the 8-item Short Form Health Survey, the Pittsburgh Sleep Quality Index, and the Hospital Anxiety and Depression Scale questionnaires. Sixty-nine patients (47.6%) were partial responders. These patients had significantly lower scores than responders in 5/8 subscales and in the mental health component summary of the 8-item Short Form Health Survey. Partial responders had significantly higher Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale scores, including anxiety and depression scores, than those of responders. Non-erosive reflux disease and double proton pump inhibitor doses were predictive factors of partial responders. Persistent reflux symptoms, despite proton pump inhibitor therapy, caused mental health disorders, sleep disorders, and psychological distress in Japanese gastroesophageal reflux disease patients.
Kimura, Yoshihide; Kamiya, Takeshi; Senoo, Kyouji; Tsuchida, Kenji; Hirano, Atsuyuki; Kojima, Hisayo; Yamashita, Hiroaki; Yamakawa, Yoshihiro; Nishigaki, Nobuhiro; Ozeki, Tomonori; Endo, Masatsugu; Nakanishi, Kazuhisa; Sando, Motoki; Inagaki, Yusuke; Shikano, Michiko; Mizoshita, Tsutomu; Kubota, Eiji; Tanida, Satoshi; Kataoka, Hiromi; Katsumi, Kohei; Joh, Takashi
Some patients with gastroesophageal reflux disease experience persistent reflux symptoms despite proton pump inhibitor therapy. These symptoms reduce their health-related quality of life. Our aims were to evaluate the relationship between proton pump inhibitor efficacy and health-related quality of life and to evaluate predictive factors affecting treatment response in Japanese patients. Using the gastroesophageal reflux disease questionnaire, 145 gastroesophageal reflux disease patients undergoing proton pump inhibitor therapy were evaluated and classified as responders or partial-responders. Their health-related quality of life was then evaluated using the 8-item Short Form Health Survey, the Pittsburgh Sleep Quality Index, and the Hospital Anxiety and Depression Scale questionnaires. Sixty-nine patients (47.6%) were partial responders. These patients had significantly lower scores than responders in 5/8 subscales and in the mental health component summary of the 8-item Short Form Health Survey. Partial responders had significantly higher Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale scores, including anxiety and depression scores, than those of responders. Non-erosive reflux disease and double proton pump inhibitor doses were predictive factors of partial responders. Persistent reflux symptoms, despite proton pump inhibitor therapy, caused mental health disorders, sleep disorders, and psychological distress in Japanese gastroesophageal reflux disease patients. PMID:27499583
... examines the inside of the esophagus) • Ambulatory acid (pH) test (monitors the amount of acid in the ... H2 blockers may help decrease the effects of stomach acid. Proton pump inhibitors block acid production and ...
Kang, Minyong; Lee, Jung Keun; Im, Young Jae; Choi, Hwang; Park, Kwanjin
We delineated clinical features and determined predictors of chronic kidney disease during long-term postpubertal followup in patients with vesicoureteral reflux treated surgically. We analyzed the data of 101 patients who were surgically treated for vesicoureteral reflux and had gone through puberty. Patients underwent preoperative and postoperative voiding cystourethrography to assess reflux status, and dimercaptosuccinic acid scan to assess renal cortical defects. We compared several variables preoperatively and postpubertally, including body mass index; blood urea nitrogen, creatinine and uric acid levels; estimated glomerular filtration rate; microalbuminuria; blood pressure; renal function and renal scarring. Kaplan-Meier analysis was used to predict chronic kidney disease-free survival rates throughout the followup periods. Cox regression model was adopted to identify independent predictors of chronic kidney disease. We defined chronic kidney disease as estimated glomerular filtration rate less than 60 ml/minute/1.73 m(2). Median followup was 100.0 months (IQR 69.0 to 136.5). Median age was 16 years at last followup (IQR 14 to 18). A total of 11 patients (10.9%) were diagnosed with de novo chronic kidney disease during postpubertal followup. It is noteworthy that serum uric acid levels (HR 1.96) and presence of high grade reflux (HR 7.40) were significant predictors of chronic kidney disease on multivariate analysis. In children who were treated surgically for vesicoureteral reflux preoperative uric acid levels and high grade reflux were independent predictors of de novo chronic kidney disease during postpubertal followup. Our results offer valuable information for predicting long-term renal outcomes in patients with vesicoureteral reflux treated surgically. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Chitkara, Denesh K; Fortunato, Christine; Nurko, Samuel
To evaluate esophageal body motor contractions occurring during esophageal reflux in pediatric patients with gastro-esophageal reflux disease (GERD). Patients referred for the evaluation of GERD who were evaluated with combined 24-hour pH probe and esophageal manometry test (MP24) were included. Patients were separated into the following groups: Group C -- normal pH probe and normal EGD; Group 1 -- abnormal pH probe and normal EGD; and Group 2 -- abnormal pH probe and EGD with histologic esophagitis. Esophageal motor function during reflux episodes was analyzed. Twenty-five patients were included. All had a normal stationary esophageal manometry. Patients in Groups 1 and 2 had significantly more gastroesophageal reflux by pH probe than Group C (P < 0.01). During the MP24, patients in Group 1 and 2 had significantly fewer contractions per minute pre-, during, and post-GER (P < 0.05). There were significant differences in the number of isolated and prolonged contractions (>7 sec) during prolonged GERD episodes >5 minutes (P < 0.05). Children with GERD have a decreased number and abnormal esophageal body contractions with esophageal reflux. This suggests that children with GERD with and without esophagitis have impaired esophageal body acid clearance.
Nam, Su Youn; Park, Bum Joon; Cho, Yeong-Ah; Ryu, Kum Hei; Choi, Il Ju; Park, Sohee; Kim, Young-Woo
Although dietary factors seem to be associated with gastroesophageal reflux symptoms, their effects on reflux esophagitis and non-erosive reflux disease (NERD) are unclear. We evaluate dietary effects on NERD and reflux esophagitis. A total of 11,690 health check-up persons completed questionnaires for reflux symptoms and 3-day recordings for dietary intake and underwent esophagogastroduodenoscopy from 2004 to 2008. Multiple logistic regression with odds ratio (OR) and 95% confidence interval (CI) was used to evaluate the relationship of dietary components with NERD or reflux esophagitis. Prevalence of NERD and reflux esophagitis was 7.7 and 7.2%, respectively. In adjusted analysis, highest quartile of beans (OR 0.78, 95% CI 0.64-0.95), 3rd quartile of vegetables (OR 0.74, 95% CI 0.60-0.91), 4th quartile of fruit (OR 0.78, 95% CI 0.64-0.95), 4th quartile of egg (OR 0.78, 95% CI 0.64-0.96), and 3rd quartile of fish (OR 0.80, 95% CI 0.66-0.98), and 4th quartile of milk (OR 0.78, 95% CI 0.65-0.94) reduced NERD. Reflux esophagitis had no association with food groups, whereas it was related with men, absence of H. pylori, hiatal hernia, BMI, and total energy intake. Furthermore, dietary effect on NERD was similar in men and women, whereas highest tertile of potato (OR 1.91) and milk (OR 1.87) increased reflux esophagitis only in women. While many food groups affected NERD, reflux esophagitis was associated with BMI and total energy intake rather than dietary component. These results may suggest different approaches toward dietary management of NERD and reflux esophagitis.
Molina-Infante, Javier; van Rhijn, Bram D
Gastro-oesophageal reflux disease (GORD) is the most common oesophageal disorder, whereas eosinophilic oesophagitis (EoE) is an emerging disease unresponsive to PPI therapy. Updated guidelines in 2011 described proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE), a novel phenotype in EoE patients who were responsive to PPIs. This article aims to update the complex interplay between GORD, EoE and PPIs. Oesophageal mucosal integrity is diffusely impaired in EoE and PPI-REE patients. PPI-REE might occur with either normal or pathological pH monitoring. The genetic hallmark of EoE is overlapped in PPI-REE, but not in GORD. PPIs can partially restore epithelial integrity and reverse allergic inflammation gene expression in PPI-REE. Acid hypersensitivity in EoE patients may explain symptomatic but not histological response on PPIs. Unsolved issues with PPI-REE are whether oesophageal barrier impairment is the cause or the effect of oesophageal eosinophilia and whether PPIs primarily targets barrier integrity or oesophageal inflammation. Copyright © 2015 Elsevier Ltd. All rights reserved.
Beaumont, Hanneke; Bennink, Roelof J; de Jong, Jan; Boeckxstaens, Guy E
Gastro-oesophageal reflux occurs twice as much during transient lower oesophageal sphincter relaxations (TLOSRs) in patients with gastro-oesophageal reflux disease (GORD) compared to healthy volunteers (HVs). Our aim was to assess whether the localisation of the postprandial acid pocket and its interaction with a hiatal hernia (HH) play a role in the occurrence of acidic reflux during TLOSRs. Ten HVs and 22 patients with GORD (12 with HH<3 cm (s-HH), 10 with HH > or =3 cm (l-HH)) were studied. The squamocolumnar junction and diaphragmatic impression were marked with a radioactively labelled clip. To visualise the acid pocket, (99m)Tc-pertechnetate was injected intravenously and images were acquired up to 2 h postprandial. Concurrently, combined manometry/impedance and four-channel pH-metry were performed, with pH pull-through at multiple time-points. The rate of TLOSRs and the per cent associated with reflux was comparable between all groups. However, acidic reflux was significantly increased in patients, especially in patients with l-HH. Acid pocket length was significantly enlarged in patients. Moreover, immediately before a TLOSR, the acid pocket was more frequently located within the hiatus or above the diaphragm in patients with GORD (s-HH, 54%; l-HH, 77%) compared to HVs (22% of TLOSRs). Acidic reflux was significantly increased when the acid pocket was located above the diaphragm in all groups compared to a sub-diaphragmatic localisation. The position of the acid pocket is largely determined by the presence of a HH. Entrapment of the pocket above the diaphragm, especially in patients with l-HH, is a major risk factor underlying the increased occurrence of acidic reflux during a TLOSR in patients with GORD.
Conchillo, J M; Selimah, M; Bredenoord, A J; Samsom, M; Smout, A J P M
Frequent belching is a common symptom in patients with functional dyspepsia with a reported incidence up to 80%. We hypothesized that patients with functional dyspepsia possibly have a higher frequency of belching than healthy subjects secondary to frequent air swallowing. To assess air swallowing, belching, acid and non-acid reflux patterns of patients with functional dyspepsia. Combined 24-h oesophageal impedance and pH monitoring was performed in 10 functional dyspepsia patients and 10 controls. Analysis of the impedance-pH signals included incidence of air swallows, belching, acid and non-acid reflux. The incidence of air swallows in functional dyspepsia patients were significantly higher compared with controls (153 +/- 15 vs. 79 +/- 10, P < 0.001), while the incidence of liquid-only swallows were not significantly increased. The proportions of gas-containing reflux episodes (belches) and non-acid reflux episodes in functional dyspepsia patients were significantly higher when compared with controls (66.4 vs. 44.4%, P = 0.04 and 70.1 vs. 45.9%, P = 0.009, respectively). Patients with functional dyspepsia swallow air more frequently than controls and this is associated with an increased incidence of non-acid gaseous gastro-oesophageal reflux.
Aragona, S E; Mereghetti, G; Bianchetti, M; Mangiavillano, B; Zurlo, T; Lotti, J; La Mantia, I; França, K; Lotti, T
We present our observational study on 40 patients treated with the medical device containing sodium hyaluronic acid and magnesium alginate, performing a lubricating and hydrating action. This device is in the form of a gel, with topical action to contrast gastroesophageal reflux and to exert a mechanical role of protection of the mucosal tissues (mouth-pharyngo-esophageal mucosa and gastric mucose.). Forty patients were recruited aged between 22- and 72-years-old with painful dyspeptic Gastro Esophageal Reflux Disease (GERD) symptomatology in acute or in clinical phase (25 patients) and with pharyngolaryngo- tracheal symptomatology (15 patients). Patients were divided into two clinical groups: Group A was treated with the medical device, while Group B with conventional treatments without the medical device. Subjects of both groups were also treated with proton pump inhibitors (PPIs). Follow-up was at 10, 20 and 30 days and patients were evaluated for reduction of their subjective symptoms, reduction of symptomatic and occasional therapies, reduction of inflammatory process or disappearance of epithelial lesions of the examined mucosa, healing process. The reduction of subjective symptoms was observed at 10 days in the patient with food bolus (disappearance after 5 days) and in patients with a reduction of 70%. A relevant reduction in the use of symptomatic drugs was noted. Our data are relevant considering symptom relief (heartburn, reflux and dyspepsia). New scenarios for the treatment of inflammatory diseases of the digestive and respiratory tract mucosa are at the horizon. Interdisciplinary translational research brings to the development of novel medical devices (as the one described in this study) with a high safety profile, and extremely active on the inflammation-repair-regeneration complex of different tissues and organs.
Kahrilas, Peter J; Smith, Jaclyn A; Dicpinigaitis, Peter V
Along with upper airway cough syndrome (formerly, postnasal drip syndrome) and eosinophilic airway inflammation (asthma, nonasthmatic eosinophilic bronchitis), gastroesophageal reflux disease (GERD) is generally considered among the most common etiologies of chronic cough. Indeed, cough management guidelines published by numerous respiratory societies worldwide recommend evaluation and treatment of GERD as an integral component of the diagnostic/therapeutic algorithm for the management of chronic cough. However, a significant number of patients with chronic cough presumed due to GERD do not report improvement despite aggressive acid-suppressive therapy. Some of these refractory cases may be due to the recently appreciated entity of nonacid or weakly acidic reflux. Further contributing to the controversy are recent studies that demonstrate that patients with chronic cough do not have excessive reflux events relative to healthy volunteers. Although a temporal relationship between cough and reflux events has been suggested by studies utilizing impedance-pH monitoring of reflux events and objective cough recording, consensus is lacking in terms of whether this temporal relationship proves a causal link between reflux and cough. The fourth American Cough Conference (New York, June 2013) provided an ideal forum for the debate of this issue between two internationally recognized experts in the field of reflux and chronic cough.
Daum, C; Sweis, R; Kaufman, E; Fuellemann, A; Anggiansah, A; Fried, M; Fox, M
Non-specific esophageal dysmotility with impaired clearance is often present in patients with gastro-esophageal reflux disease (GERD), especially those with erosive disease; however the physio-mechanic basis of esophageal dysfunction is not well defined. Retrospective assessment of patients with erosive reflux disease (ERD; n=20) and endoscopy negative reflux disease (ENRD; n=20) with pathologic acid exposure on pH studies (>4.2% time/24 h) and also healthy controls (n=20) studied by high resolution manometry. Esophageal motility in response to liquid and solid bolus swallows and multiple water swallows (MWS) was analyzed. Peristaltic dysfunction was defined as failed peristalsis, spasm, weak or poorly coordinated esophageal contraction (>3cm break in 30 mmHg isocontour). Peristaltic dysfunction was present in 33% of water swallows in controls, 56% ENRD and 76% ERD respectively (P<0.023 vs controls, P=0.185 vs ENRD). The proportion of effective peristaltic contractions improved with solid compared to liquid bolus in controls (18%vs 33%, P=0.082) and ENRD (22%vs 54%, P=0.046) but not ERD (62%vs 76%, P=0.438). Similarly, MWS was followed by effective peristalsis in 83% of controls and 70% ENRD but only 30% ERD patients (P<0.017 vs controls and P<0.031 vs ENRD). The association between acid exposure and dysmotility was closer for solid than liquid swallows (r=0.52 vs 0.27). Peristaltic dysfunction is common in GERD. ERD patients are characterized by a failure to respond to the physiologic challenge of solid bolus and MWS that is likely also to impair clearance following reflux events and increase exposure to gastric refluxate. © 2011 Blackwell Publishing Ltd.
Wu, W; Wang, G; Wang, L; Liu, H D; Wang, Q; Xu, X H; Ding, R Y; Xu, B X; Han, H L; Zhou, Y; Gong, J; Wang, H N; Li, B W; Sun, Z Z
Objective: To explore the utility of pharyngeal pH monitoring which positive standard is Ryan index in diagnosis of laryngopharyngeal reflux disease. Methods: In a retrospective study, clinical data of 590 patients who had symptoms laryngopharyngeal reflux disease from February 2016 to March 2017 were analyzed. All patients were received electronic laryngoscopy, assessment of reflux symptom index(RSI) and reflux finding score(RFS), and pharyngeal pH monitoring. SPSS 19.0 software was used to analyze the date. Results: There were 94 patients whose Ryan index were positive(15.93%). Among the 94 patients, 70 were positive during upright, 12 during supine and 12 during both upright and supine. There were 40 patients(6.78%)with pH decline events related to symptoms, while those Ryan index were normal. There were 536(90.85%), 417(70.68%), 233(39.49%) and 117(19.83%) patients with pH<6.5, pH<6.0, pH<5.5 and pH<5.0 events respectively. The positive rate of RSI, RFS, RSI and RFS, RSI or RFS were 44.24%, 16.78%, 7.12%, 53.90% respectively. The RFS score in Ryan index positive group was higher than that in Ryan index negative group[(8.2±2.4) vs (4.0±2.9), u =5.424, P <0.05], while the RSI score in Ryan index positive group was not statistically different from that in Ryan index negative group[(11.3±6.2) vs (12.7±5.8), t =1.247, P =0.167]. Conclusions: Pharyngeal pH monitoring is an objective and non-invasive method which can reflect laryngopharyngeal reflux directly. However, with the Ryan index as a criterion for the diagnosis of laryngopharyngeal reflux disease, partial patients may be missed. Further studies are needed to obtain more accurate and objective laryngopharyngeal pH statistical index for diagnosis of laryngopharyngeal reflux disease.
Ethnic and geographical differences are important factors in studying disease frequencies, because they may highlight the environmental or genetic influences in the etiology. We retrieved the studies which have been published regarding the epidemiologic features of gastroesophageal reflux disease (GERD) in Asia, based on the definitions of GERD, study settings, publication years and geographical regions. From the population-based studies, the prevalence of symptom-based GERD in Eastern Asia was found to be 2.5%-4.8% before 2005 and 5.2%-8.5% from 2005 to 2010. In Southeast and Western Asia, it was 6.3%-18.3% after 2005, which was much higher than those in Eastern Asia. There were robust epidemiologic data of endoscopic reflux esophagitis in medical check-up participants. The prevalence of endoscopic reflux esophagitis in Eastern Asia increased from 3.4%-5.0% before 2000, to 4.3%-15.7% after 2005. Although there were only limited studies, the prevalence of extra-esophageal syndromes in Asia was higher in GERD group than in controls. The prevalence of Barrett's esophagus was 0.06%-0.84% in the health check-up participants, whereas it was 0.31%-2.00% in the referral hospital settings. In summary, the prevalence of symptom-based GERD and endoscopic reflux esophagitis has increased in Asian countries. However, the prevalence of Barrett's esophagus in Asia has not changed and also still rare. PMID:21369488
Ganesh, Meenakshi; Hertzberg, Anne; Nurko, Samuel; Needleman, Howard; Rosen, Rachel
The relation between tooth erosion (TE) and gastroesophageal reflux in children has not been clearly established, and there are no studies to determine the relation with refluxate height, nonacid reflux, and erosions. The aim of this study was to determine the relation between TE and acid and nonacid gastroesophageal refluxes measured using combined pH and multichannel intraluminal impedance (pH-MII). We conducted a prospective cohort study of children presenting for pH-MII testing. Once informed consent was obtained, patients completed questionnaires about their reflux symptoms and diet, and then underwent pH-MII catheter placement and a dental examination. The Keels-Coffield erosion index was used to score the extent and severity of TE. Reflux parameters of patients with and without TE were compared using Student t test and correlations were performed using Spearman correlations. A total of 27 patients participated in the study, all of whom were on acid suppression at the time of pH-MII testing. Of the 27 patients, 10 (37%) had TE. There were significant positive correlations between acid reflux episodes (r = 0.44, P = 0.02), the percentage of time that acid reflux was present in the distal esophagus (r = 0.44, P = 0.02), and reflux index (r = 0.54, P = 0.004) with the number of TE in a given patient. The percentage of time that acid reflux was present in the proximal esophagus was positively correlated with the number of teeth erosions per patient with borderline significance (r = 0.38, P = 0.05). There was a positive correlation between acid reflux parameters and TE. Acid, rather than nonacid reflux, seems to have a significant role in the pathogenesis of TE.
Parisi, Pasquale; Pacchiarotti, Claudia; Ferretti, Alessandro; Bianchi, Simona; Paolino, Maria Chiara; Barreto, Mario; Principessa, Luigi; Villa, Maria Pia
Autonomic signs and symptoms could be of epileptic or nonepileptic origin, and the differential diagnosis depends on a number of factors which include the nature of the autonomic manifestations themselves, the occurrence of other nonictal autonomic signs/symptoms, and the age of the patient. Here, we describe twelve children (aged from ten months to six years at the onset of the symptoms) with Panayiotopoulos syndrome misdiagnosed as gastroesophageal reflux disease. Gastroesophageal reflux disease and Panayiotopoulos syndrome may represent an underestimated diagnostic challenge. When the signs/symptoms occur mainly during sleep, a sleep EEG or, if available, a polysomnographic evaluation may be the most useful investigation to make a differential diagnosis between autonomic epileptic and nonepileptic disorders. An early detection can reduce both the high morbidity related to mismanagement and the high costs to the national health service related to the incorrect diagnostic and therapeutic approaches. To decide if antiseizure therapy is required, one should take into account both the frequency and severity of epileptic seizures and the tendency to have potentially lethal autonomic cardiorespiratory involvement. In conclusion, we would emphasize the need to make a differential diagnosis between gastroesophageal reflux disease and Panayiotopoulos syndrome in patients with "an unusual" late-onset picture of GERD and acid therapy-resistant gastroesophageal reflux, especially if associated with other autonomic symptoms and signs. Copyright © 2014 Elsevier Inc. All rights reserved.
Sugimoto, Mitsushige; Hasegawa, Tomohiko; Nishino, Masafumi; Sahara, Shu; Uotani, Takahiro; Ichikawa, Hitomi; Kagami, Takuma; Sugimoto, Ken; Yamato, Yu; Togawa, Daisuke; Kobayashi, Sho; Hoshino, Hironobu; Matsuyama, Yukihiro; Furuta, Takahisa
Spinal kyphotic deformity occasionally results in gastroesophageal reflux disease (GERD). The effects of acid reflux on the esophagus in kyphotic patients are unclear, however, and it is unknown whether acid reflux, endoscopic GERD, and reflux-related symptoms improve following surgical spinal correction in these patients. Herein, we investigated the characteristics of GERD in kyphotic patients and the improvement in GERD following surgical correction. In 48 patients with severe kyphotic deformity scheduled for surgical spinal correction, we conducted esophagogastroduodenoscopy, 24-h pH monitoring and three questionnaire surveys, including the frequency scale for the symptoms of GERD (FSSG). We repeated these measurements after surgical correction and compared pre- and post-surgery values. Of 48 patients, 70.8% [95% CI: 55.9-83.0%, 34/48] had endoscopically evaluated esophageal mucosal injury. Regarding pH before surgery, 64.9% (CI: 47.5-79.8%, 24/37) had abnormal acid reflux (intraesophageal pH < 4 more than 5% of the time). FSSG score was significantly associated with the severity of GERD, and the positive rate was 52.6% (CI: 35.8-69.0%, 20/38). Following surgical correction, esophageal mucosal injury improved endoscopically in 90% of patients, and median total FSSG score significantly decreased from 8 (0-30) to 5 (0-19) (P = 0.005). Regarding pH after surgery, prevalence of abnormal acid reflux decreased from 66.7% (95% CI: 41.0-86.7%) to 33.3% (95% CI: 13.3-59.0%) (P = 0.045). Surgical spinal correction in kyphosis patients improves not only kyphotic deformity-related disorders but also esophageal mucosal injury, abnormal acid reflux, and reflux-related symptoms. © 2015 Japan Gastroenterological Endoscopy Society.
Frazzoni, Marzio; Conigliaro, Rita; Colli, Giovanni; Melotti, Gianluigi
Laparoscopic Nissen fundoplication (LNF) is a technically demanding surgical procedure designed to cure gastroesophageal reflux disease (GERD). It represents an alternative to life-long medical therapy and the only recommended treatment modality to overcome refractoriness to proton pump inhibitor (PPI) therapy. The recent development of robotic systems prompted evaluation of their use in antireflux surgery. Between 1997 and 2000, in a PPI-responsive series we found postoperative normalization of esophageal acid exposure time (EAET) in most but not all cases. Between 2007 and 2009, in a PPI-refractory series we found postoperative normalization of EAET in all cases. We decided to analyze retrospectively our prospectively collected data to evaluate whether differences other than the conventional or robot-assisted technique could justify postoperative differences in acid reflux parameters. Baseline demographic, endoscopic, and manometric parameters were compared between the two series of patients, as well as postoperative manometric and acid reflux parameters. There were no significant differences in the baseline demographic, endoscopic, and manometric characteristics between the two groups of patients. The median lower esophageal sphincter tone increased significantly, and the median EAET decreased significantly after conventional as well as after robot-assisted LNF. The median postoperative EAET was significantly lower in the robot-assisted (0.2%) than in the conventional LNF group (1%; P = 0.001). Abnormal EAET values were found in 6 of 44 (14%) and in 0 of 44 cases after conventional and robot-assisted LNF, respectively (P = 0.026). Robot-assisted LNF provided a significant gain in postoperative acid reflux parameters compared with the conventional technique. In a challenging clinical setting, such as PPI-refractoriness, in which the efficacy of endoscopic or pharmacological treatment modalities is only moderate, even a small therapeutic gain can be clinically
The diagnostic value of gastroesophageal reflux disease (GERD) symptoms and detection of pepsin and bile acids in bronchoalveolar lavage fluid and exhaled breath condensate for identifying lung transplantation patients with GERD-induced aspiration.
Reder, Nicholas P; Davis, Christopher S; Kovacs, Elizabeth J; Fisichella, P Marco
Gastroesophageal reflux disease (GERD) is thought to lead to aspiration and bronchiolitis obliterans syndrome after lung transplantation. Unfortunately, the identification of patients with GERD who aspirate still lacks clear diagnostic indicators. The authors hypothesized that symptoms of GERD and detection of pepsin and bile acids in the bronchoalveolar lavage fluid (BAL) and exhaled breath condensate (EBC) are effective for identifying lung transplantation patients with GERD-induced aspiration. From November 2009 to November 2010, 85 lung transplantation patients undergoing surveillance bronchoscopy were prospectively enrolled. For these patients, self-reported symptoms of GERD were correlated with levels of pepsin and bile acids in BAL and EBC and with GERD status assessed by 24-h pH monitoring. The sensitivity and specificity of pepsin and bile acids in BAL and EBC also were compared with the presence of GERD in 24-h pH monitoring. The typical symptoms of GERD (heartburn and regurgitation) had modest sensitivity and specificity for detecting GERD and aspiration. The atypical symptoms of GERD (aspiration and bronchitis) showed better identification of aspiration as measured by detection of pepsin and bile acids in BAL. The sensitivity and specificity of pepsin in BAL compared with GERD by 24-h pH monitoring were respectively 60 and 45 %, whereas the sensitivity and specificity of bile acids in BAL were 67 and 80 %. These data indicate that the measurement of pepsin and bile acids in BAL can provide additional data for identifying lung transplantation patients at risk for GERD-induced aspiration compared with symptoms or 24-h pH monitoring alone. These results support a diagnostic role for detecting markers of aspiration in BAL, but this must be validated in larger studies.
Chandrasoma, Parakrama T
To review recent data supporting the development of new histology-based definitions of gastro-esophageal reflux disease (GERD). Three precisely definable columnar epithelial types--cardiac, oxyntocardiac and intestinal--may be interposed between esophageal squamous epithelium and gastric oxyntic (acid secreting) mucosa. This enables definition of a new histologic concept: the squamo-oxyntic gap. The squamo-oxyntic gap is zero or very small in autopsies performed on patients without evidence of GERD. The gap progressively increases in length with the severity of GERD, indicating that the squamo-oxyntic gap is a marker for chronic GERD. The distal part of the gap lines gastric-type rugal folds and, therefore, is distal to the present endoscopic definition of the gastro-esophageal junction. I contend that this distal gap segment (which has esophageal submucosal glands) is actually the dilated distal esophagus; this is the pathologic correlate of destruction of the abdominal segment of the lower esophageal sphincter. The dilated distal esophagus is mistaken for 'gastric cardia' by present endoscopic definitions. I believe that these data support the adoption of novel histologic definitions of GERD as follows: the presence of any squamo-oxyntic gap defines GERD; the length of the gap is a measure of severity of chronic GERD; and the presence of intestinal metaplasia in the gap defines Barrett esophagus and cancer risk.
Yüksel, Fatih; Doğan, Mansur; Karataş, Duran; Yüce, Salim; Şentürk, Mehmet; Külahli, Ismail
We aimed to evaluate a possible relation between gastroesophageal reflux disease and middle ear effusion in children. Children who came to ear, nose, and throat (ENT) department with the symptoms of hearing loss or aural fullness and diagnosed as OME by examination and tympanometry were included into the study. Children were reviewed gastroesophageal reflux disease symptoms including the following: (a) airway symptoms: stridor, frequent cough, recurrent croup, wheezing, nasal congestion, obstructive apnea, hoarseness, and throat clearing; (b) feeding symptoms: frequent emesis, dysphagia, choking: gagging, sore throat, halitosis, food refusal, regurgitation, pyrosis, irritability, failure to thrive, and anemia. Diagnosis is made with at least one positive test of radionuclide gastroesophageal scintigraphy or 24 h pH probe in the patients with reflux. ENT findings were also examined between gastroesophageal reflux disease positive and gastroesophageal reflux disease negative groups. Approximately 39 (54.9%) of 71 children had at least 1 positive test for gastroesophageal reflux disease. Between the gastroesophageal reflux disease-positive and gastroesophageal reflux disease-negative groups, symptoms of reflux were not significantly different. Two pooled variables were created: airway complex (stridor, frequent cough, throat clearing), and feeding complex (irritability, pyrosis, failure to thrive). Percentage of positive symptom complexes were no statistically different between gastroesophageal reflux disease-positive and gastroesophageal reflux disease-negative groups (>0.05). Ear, nose, and throat disorders (including rhinitis/sinusitis, adenoid hypertrophy, tonsillitis/pharyngitis, and laryngitis) were more frequent in gastroesophageal reflux disease-positive group. Tonsillitis/pharyngitis was significantly different between the gastroesophageal reflux disease positive and gastroesophageal reflux disease-negative groups. Upper respiratory tract infections were seen
Etemadi, Arash; Gandomkar, Abdullah; Freedman, Neal D; Moghadami, Mohsen; Fattahi, Mohammad Reza; Poustchi, Hossein; Islami, Farhad; Boffetta, Paolo; Dawsey, Sanford M; Abnet, Christian C; Malekzadeh, Reza
Unlike cigarettes, there is little information about the association between other tobacco products and the risk of gastroesophageal reflux disease (GERD) and esophageal adenocarcinoma. We used the baseline data from the Pars Cohort Study conducted in southern Iran. In 2012, 9264 local residents between 40 and 75 years old were enrolled, with detailed information about lifestyle, including duration and frequency of tobacco use. GERD was defined based on questions assessing heartburn and regurgitation in the past 12 months, frequency and severity. Associations were calculated by logistic regression models adjusted for age, sex, education, cigarettes and body mass index. In the study, 25.4% of the participants had severe GERD (interfering with participants' routines), 25.1% had frequent GERD (at least once a week) and 11.2% had both severe and frequent GERD, all more common among women (p < 0.001); 45.6% of women and 28.3% of men smoked waterpipes. Among people not using medications against reflux symptoms, there was an association between waterpipe smoking and severe [odds ratio (OR) = 1.18; 95% confidence interval (CI):1.04-1.35], frequent (OR = 1.16; 95% CI: 1.02-1.32) and severe and frequent reflux (OR = 1.30; 95% CI: 1.08-1.56). The associations increased with the duration of use, intensity and cumulative waterpipe-years, reaching an OR of 1.44 (95% CI: 1.12-1.86) for severe and frequent reflux in those who had smoked more than 48 waterpipe-years. There was effect modification by sex, and all the associations were only seen among women. The increasing trend in the association between cumulative waterpipe use and reflux disease among women is particularly important given the growing waterpipe tobacco epidemic in many populations. Published by Oxford University Press on behalf of the International Epidemiological Association 2017. This work is written by US Government employees and is in the public domain in the United States.
Solidoro, Paolo; Patrucco, Filippo; Fagoonee, Sharmila; Pellicano, Rinaldo
Asthma and gastroesophageal reflux (GORD) are widespread and potentially coexisting diseases. Incidence and prevalence of concomitant asthma and GORD are highly variable among studies. This is mainly due to the heterogeneity of study designs. To explain a potential link, some pathophysiological anomaly has been proposed such as the altered pressure gradient between thorax and abdomen, the parasympathetic reflex, the heightened bronchial reactivity and chemical effects of microaspired gastric juice. An accurate diagnosis of asthma and GORD is pivotal in order to lead effective treatment and to reach a significant positive outcome, in terms of quality of life and respiratory function amelioration. Gastroenterological evaluation of GORD includes the empiric proton pump-inhibitors (PPIs) trial, the esophageal pH monitoring and endoscopic evaluation. Besides spirometric investigations, pulmonologist have more specific examens such as bronchoalveolar lavage and exhaled breath condensate. Actually, international recommendations regarding the management of asthma suggest the assessment of potential comorbidities, including the presence of GORD, mostly in children, only in patients with normal pulmonary functional tests with frequent respiratory symptoms, and in case of uncontrolled asthma. Symptomatic gastro-esophageal reflux patients should be treated, but those with uncontrolled asthma should not be treated with anti-reflux drugs unless they are symptomatic for reflux. This review explores the state of the art about the pathogenesis and the management of the relationship between asthma and GORD.
Bresadola, Vittorio; Adani, Gian Luigi; Londero, Francesco; Leo, Cosimo Alex; Cherchi, Vittorio; Lorenzin, Dario; Rossetto, Anna; Vit, Gianmatteo; Baccarani, Umberto; Terrosu, Giovanni; Anna, Dino De
AIM: To investigate differences in the physiopathological findings (manometry and pH monitoring) and symptoms between cases of non-erosive reflux disease (NERD) and erosive reflux disease (ERD) found positive at 24 h pH monitoring. METHODS: For a total of 670 patients who underwent 24 h pH monitoring, esophageal manometry and upper endoscopy were retrospectively evaluated, assessing the reflux symptoms, manometric characteristics of the lower esophageal sphincter (LES) and esophageal body and the presence or absence of esophagitis and hiatal hernia. Typical and atypical symptoms were also evaluated. For inclusion in the study, patients had to have NERD or ERD and be found positive on pH monitoring (NERD+). Patients with Gastroesophageal reflux disease (GERD) complicated by stenosis, ulcers or Barrett's esophagus were ruled out. RESULTS: 214 patients were involved in the study, i.e. 107 cases of NERD+ and 107 of ERD. There were no significant gender- or age-related differences between the two groups. The ERD group had more cases of hiatal hernia (P = 0.02) and more acid reflux, both in terms of number of reflux episodes (P = 0.01) and as a percentage of the total time with a pH < 4 (P = 0.00), when upright (P = 0.007) and supine (P = 0.00). The NERD+ cases had more reflux episodes while upright (P = 0.02) and the ERD cases while supine (P = 0.01). The LES pressure was higher in cases of NERD+ (P = 0.03) while the amplitude and duration of their esophageal peristaltic waves tended to be better than in the ERD group (P >0.05). The NERD+ patients presented more often with atypical symptoms (P = 0.01). CONCLUSION: The NERD+ patients’ fewer reflux episodes and the fact that they occurred mainly while in the upright position (unlike the cases of ERD) may be two factors that do not favor the onset of esophagitis. The frequently atypical symptoms seen in patients with NERD+ need to be accurately evaluated for therapeutic purposes because patients with GERD and atypical
Gong, Eun Jeong; Choi, Kee Don; Jung, Hye-Kyung; Youn, Young Hoon; Min, Byung-Hoon; Song, Kyung Ho; Huh, Kyu Chan
Patients with gastroesophageal reflux disease (GERD) have decreased health-related quality of life (HRQL). The quality of life in patients with laryngopharyngeal reflux (LPR) symptoms is also significantly impaired. However, the impact of LPR symptoms on HRQL in GERD patients has not been studied. A nationwide, random-sample, and face-to-face survey of 300 Korean patients with GERD was conducted from January to March 2013. Gastroesophageal reflux symptoms were assessed using the Rome III questionnaire, LPR symptoms using the reflux symptom index, and HRQL using the EuroQol five dimensions (EQ-5D) questionnaire. A structured questionnaire on patient satisfaction, sickness-related absences, and health-related work productivity was also used. Among the 300 patients with GERD, 150 had LPR symptoms. The mean EQ-5D index was lower in patients with GERD and LPR symptoms than in those without LPR (0.88 vs 0.91, P = 0.002). A linear regression model showed that the severity of LPR symptoms was related to decreased HRQL and was independent of age, marital status, body mass index, or household income. The overall satisfaction rate regarding treatment was lower in patients with GERD and LPR (40.0% vs 69.1%, P = 0.040). GERD patients with LPR symptoms reported greater sickness-related absent hours per week (0.36 vs 0.02 h, P = 0.016) and greater percentages of overall work impairment than those without LPR (31.1% vs 20.8%, P < 0.001). Gastroesophageal reflux disease patients with LPR symptoms have a poorer HRQL, a lower satisfaction rate, and a greater disease burden than those without LPR. © 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.
Lee, B S; Lee, S H; Jang, D K; Chung, K H; Hwang, J H; Jang, S E; Cha, B H; Ryu, J K; Kim, Y-T
Belching may result from transient lower esophageal sphincter relaxation; therefore, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). This study was conducted to investigate the frequency of belching during esophagogastroduodenoscopy (EGD) and its association with GERD. A retrospective review was performed on prospectively collected clinical and endoscopic data from 404 subjects who underwent EGD without sedation from December 2012 to May 2013 in a training hospital in Korea. All detectable belching events during endoscopy were counted. Frequency and severity of belching events were compared between the group with and without GERD using an ordinal logistic regression model. There were 145 GERD patients (26 erosive reflux disease and 119 nonerosive reflux disease [NERD]). In the multivariable analysis, GERD was significantly associated with a higher frequency of belching events (odds ratio = 6.59, P < 0.001). Central obesity, female, and younger age were also risk factors for frequent belching during EGD. Subgroup analyses were performed in subjects without erosive reflux disease (n = 378) and NERD (n = 293). NERD was also a predictive factor for frequent belching during EGD (odds ratio = 6.61, P < 0.001), and the frequency of belching was significantly correlated with GERD severity according to the Los Angeles classification (P < 0.05). Frequent belching during EGD was associated with GERD, including NERD. Future research should focus on its adjuvant role in the diagnosis of GERD/NERD and the necessity for applying differentiated endoscopy strategies for GERD patients, leading to less discomfort during EGD in patients at risk for intolerability. © 2015 International Society for Diseases of the Esophagus.
Kandil, Tharwat S; Mousa, Amany A; El-Gendy, Ahmed A; Abbas, Amr M
Gastro-Esophageal Reflux Disease (GERD) defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Many drugs are used for the treatment of GERD such as omeprazole (a proton pump inhibitor) which is a widely used antiulcer drug demonstrated to protect against esophageal mucosal injury. Melatonin has been found to protect the gastrointestinal mucosa from oxidative damage caused by reactive oxygen species in different experimental ulcer models. The aim of this study is to evaluate the role of exogenous melatonin in the treatment of reflux disease in humans either alone or in combination with omeprazole therapy. 36 persons were divided into 4 groups (control subjects, patients with reflux disease treated with melatonin alone, omeprazole alone and a combination of melatonin and omeprazole for 4 and 8 weeks) Each group consisted of 9 persons. Persons were subjected to thorough history taking, clinical examination, and investigations including laboratory, endoscopic, record of esophageal motility, pH-metry, basal acid output and serum gastrin. Melatonin has a role in the improvement of Gastro-esophageal reflux disease when used alone or in combination with omeprazole. Meanwhile, omeprazole alone is better used in the treatment of GERD than melatonin alone. The present study showed that oral melatonin is a promising therapeutic agent for the treatment of GERD. It is an effective line of treatment in relieving epigastric pain and heartburn. However, further studies are required to confirm the efficacy and long-term safety of melatonin before being recommended for routine clinical use. QA13NCT00915616.
Wang, L; Wu, W; Wang, G
Objective: To investigate the significance of the detection of pepsin in saliva and the pharyngeal pH monitoring in the diagnosis of laryngopharyngeal reflux disease(LPRD). Methods: A total of 176 patients (140 patients with simple pharyngitis and 36 patients with space-occupying lesions of larynx) who were suspected to have laryngopharyngeal reflux between February and December 2016 were retrospectively reviewed. All the patients were evaluated with reflux symptom index (RSI), reflux finding score (RFS) and 24-hour pharyngeal pH monitoring(Dx-pH). Saliva of patients was collected and the pepsin in the saliva was measured by enzyme-linked immunosorbent assay (ELISA). Results: The positive rate of RSI (RSI>13) and/or RFS (RFS>7) was 56.8% (100/176). The positive rate of pepsin in saliva was 40.9% (72/176) and pepsin in saliva collected at the time of onset of symptom was much higher than that at other time points ( P <0.001). The positive rate of pepsin in saliva, Ryan score and the pH<6.0 laryngopharyngeal reflux in space-occupying lesions group [55.6%(20/36), 27.8% (10/36), 69.4%(25/36), respectively] were all higher than simple pharyngitis group [37.1% (52/140), 5.0% (7/140), 50% (70/140), respectively] ( P =0.045, P <0.001, P =0.037, respectively). Conclusions: The detection of pepsin in saliva and the pharyngeal pH monitoring reflected different reflux agents, and there was great significance for the diagnosis of LPRD by using two methods together. We found that the weak acid state and consequent pepsin damage played an important role in the occurrence and development of space-occupying lesions of larynx.
Orlando, Roy C
Chronic cough is one of the extra-oesophageal manifestations of gastrooesophageal reflux disease (GORD). It is presumed to occur either directly by microaspiration of acidic gastric contents into the airway or indirectly by a reflex triggered by contact of acidic refluxates with the oesophageal epithelium in GORD. How contact of the oesophageal epithelium with acidic refluxates promotes sensitization for chronic cough is unknown, but like heartburn, which is a necessary accompaniment, it requires acid activation of nociceptors within the oesophageal mucosa. Dilated intercellular spaces within the oesophageal epithelium, a reflection of an increase in paracellular permeability, is a histopathologic feature of both erosive and non-erosive forms of GORD. Since it correlates with the symptom of heartburn, it is hypothesized herein that the increase in paracellular permeability to acid reflected by dilated intercellular spaces in oesophageal epithelium also serves as mediator of the signals that produce the reflex-induced sensitization for cough--a sensitization that can occur centrally within the medullary Nucleus Tractus Solitarius or peripherally within the tracheobronchial tree. Copyright © 2010 Elsevier Ltd. All rights reserved.
Ammari, Mohamed; Djeddi, Djamal; Léké, André; Delanaud, Stéphane; Stéphan-Blanchard, Erwan; Bach, Véronique; Telliez, Frédéric
The aim of the present study was to investigate the impact of gastro-oesophageal acid reflux on sleep in neonates and, reciprocally, the influence of wakefulness (W) and sleep stages on the characteristics of the reflux (including the retrograde bolus migration of oesophageal acid contents). The pH and multichannel intraluminal impedance were measured during nocturnal polysomnography in 25 infants hospitalised for suspicion of gastro-oesophageal reflux. Two groups were constituted according to whether or not the infants displayed gastro-oesophageal reflux (i.e. a reflux group and a control group). There were no differences between the reflux and control groups in terms of sleep duration, sleep structure and sleep state change frequency. Vigilance states significantly influenced the gastro-oesophageal reflux pattern: the occurrence of gastro-oesophageal reflux episodes was greater during W (59 ± 32%) and active sleep (AS; 35 ± 30%) than during quiet sleep (QS; 6 ± 11%), whereas the mean duration of gastro-oesophageal reflux episodes was higher in QS than in W and AS. The percentage of retrograde bolus migrations of distal oesophageal acid content was significantly higher in AS (62 ± 26%) than in W (42 ± 26%) and QS (4.5 ± 9%). In neonates, gastro-oesophageal reflux occurred more frequently during W, whereas the physiological changes associated with sleep state increase the physiopathological impact of the gastro-oesophageal reflux. The duration of oesophagus-acid contact was greater during sleep; AS facilitated the retrograde migration of oesophageal acid content, and QS was characterised by the risk of prolonged acid mucosal contact. © 2011 European Sleep Research Society.
Jonasson, C; Wernersson, B; Hoff, D A L; Hatlebakk, J G
The diagnosis of gastro-oesophageal reflux disease (GERD) remains a challenge as both invasive methods and symptom-based strategies have limitations. The symptom-based management of GERD in primary care may be further optimised with the use of a questionnaire. To assess the diagnostic validity of the GerdQ questionnaire in patients with symptoms suggestive of GERD. Patients with symptoms suggestive of GERD without alarm features, underwent upper endoscopy, and if normal, pH-metry. Patients were followed for 4 weeks and GerdQ was completed blinded to the investigator at both visits. Reflux oesophagitis or pathological acid exposure was used as diagnostic references for GERD. The diagnostic accuracy for GERD on symptom response to proton pump inhibitor (PPI) was assessed. Among the 169 patients, a GerdQ cutoff ≥9 gave the best balance with regard to sensitivity, 66% (95% CI: 58-74), and specificity, 64% (95% CI: 41-83), for GERD. The high prevalence of reflux oesophagitis (81%) resulted in a high proportion of true positives, but at the same time a high proportion of false-negatives. Consequently, GerdQ had a high positive predictive value, 92% (95% CI: 86-97), but a low negative predictive value, 22% (95% CI: 13-34), for GERD. Symptom resolution on PPI therapy had high sensitivity, 76% (95% CI: 66-84), but low specificity, 33% (95% CI: 17-53), for GERD. GerdQ is a useful complementary tool for the diagnosis of gastro-oesophageal reflux disease in primary care. The implementation of GerdQ could reduce the need for upper endoscopy and improve resource utilisation. Symptom resolution on proton pump inhibitor did not predict gastro-oesophageal reflux disease. © 2013 Blackwell Publishing Ltd.
Kandulski, Arne; Weigt, Jochen; Caro, Carlos; Jechorek, Doerthe; Wex, Thomas; Malfertheiner, Peter
Mucosal integrity can be assessed in patients with gastroesophageal reflux disease (GERD) by measuring intraluminal baseline impedance (BI). However, it is not clear whether BI is abnormal in patients with functional heartburn (FH), or can be used to distinguish them from patients with GERD. We compared differences in BI between patients with FH vs GERD. We performed a prospective study of 52 patients (16 men; mean age, 55 y; range, 23-78 y) seen at a tertiary university hospital from February 2009 through December 2012. Thirty-five patients had GERD (19 had nonerosive reflux disease [NERD], 16 had erosive reflux disease [ERD]) and 17 had FH. All patients discontinued proton pump inhibitor therapy and then underwent esophagogastroduodenoscopy and multichannel intraluminal impedance and pH monitoring. BI was assessed at 3, 5, 7, 9, 15, and 17 cm proximal to the lower esophageal sphincter in recumbent patients. Biopsy specimens were taken from 3 cm above the gastroesophageal junction; histology analysis was performed to identify and semiquantitatively score (scale, 0-3) dilated intercellular spaces. Baseline impedance in the distal esophagus was significantly lower in patients with NERD or erosive reflux disease (ERD) than FH (P = .0006). At a cut-off value of less than 2100 Ω, BI measurements identified patients with GERD with 78% sensitivity and 71% specificity, with positive and negative predictive values of 75%. Also in the proximal esophagus, reduced levels of BI levels were found only in patients with ERD. There were negative correlations between level of BI and acid exposure time (r = -0.45; P = .0008), number of acidic reflux episodes (r = -0.45; P = .001), and proximal extent (r = -0.40; P = .004). Biopsy specimens from patients with NERD or ERD had significant increases in dilation of intercellular spaces, compared with those from patients with FH; there was an inverse association between dilated intercellular spaces and BI in the distal esophagus
Avner, D L
Pantoprazole is a new proton pump inhibitor indicated for the treatment of erosive esophagitis associated with gastroesophageal reflux disease (GERD) and is available in both oral and intravenous (IV) formulations. This paper reviews the pharmacologic properties of pantoprazole and summarizes the findings from clinical studies of this drug. This review was compiled from the published literature, abstracts from clinical trials, and data on file with the manufacturer of pantoprazole. Pantoprazole selectively accumulates in the acidic environment of gastric parietal cells and acts at the final step of acid secretion by binding 2 key cysteine residues of the proton pump involved in gastric acid production. The bioavailability of pantoprazole is not altered by concomitant administration of food or antacids or with repeated dosing. Both oral and IV formulations of pantoprazole exhibit linear pharmacokinetics. Several clinical trials have proved pantoprazole superior to histamine-2-receptor antagonists (H2RAs) in reducing acid secretion and elevating gastric pH levels. Pantoprazole has been shown to be more effective than ranitidine (P < 0.05), famotidine (P < 0.001), and nizatidine (P < 0.05), and at least as effective as omeprazole, in healing erosive esophagitis and relieving associated symptoms of GERD, including regurgitation. Pantoprazole is also more effective than the H2RA nizatidine for the treatment of nighttime heartburn (P < 0.05). Studies have shown pantoprazole to be well tolerated; adverse events, including headache, diarrhea, flatulence, abdominal pain, eructation, nausea, and rash, occurred in < or = 6% of patients. The oral and IV formulations of pantoprazole are equally potent in inhibiting gastric acid secretion; thus, switching between formulations requires no dosage adjustments. Special patient populations, including the elderly and patients with renal or mild to moderate hepatic impairment, can take pantoprazole without an adjustment in dosage
Barbieri, C L A; Troncon, L E A; Herculano, J R L; Aprile, L R O; Moraes, E R; Secaf, M; Dantas, R O
Disturbed gastric contractility has been found in manometric studies in patients with gastro-oesophageal reflux disease (GORD), but the pathophysiological role of this abnormality is unclear. We aimed at assessing postprandial gastric antral contractions and its relationships with gastric emptying and gastro-oesophageal reflux in GORD patients. Fasted GORD patients (n = 13) and healthy volunteers (n = 13) ingested a liquid meal labelled with 72 MBq of 99mTechnetium-phytate. Gastric images were acquired every 10 min for 2 h, for measuring gastric emptying half time. Dynamic antral scintigraphy (one frame per second), performed for 4 min at 30-min intervals, allowed estimation of both mean dominant frequency and amplitude of antral contractions. In GORD patients (n = 10), acidic reflux episodes occurring 2 h after the ingestion of the same test meal were determined by ambulatory 24-h oesophageal pH monitoring. Gastric emptying was similar in GORD patients and controls (median; range: 82 min; 58-126 vs 80 min; 44-122 min; P = 0.38). Frequency of antral contractions was also similar in both groups (3.1 cpm; 2.8-3.6 vs 3.2 cpm; 2.4-3.8 cpm; P = 0.15). In GORD patients, amplitude of antral contractions was significantly higher than in controls (32.7%; 17-44%vs 23.3%; 16-43%; P = 0.01), and correlated positively with gastric emptying time (R(s) = 0.58; P = 0.03) and inversely with the number of reflux episodes (R(s) = -0.68; P = 0.02). Increased amplitude of postprandial gastric antral contractions in GORD may comprise a compensatory mechanism against delayed gastric emptying and a defensive factor against acidic gastro-oesophageal reflux.
Menon, Shyam; Prew, Sandra; Parkes, Gill; Evans, Stephanie; Smith, Lynne; Nightingale, Peter; Trudgill, Nigel
Hormone replacement therapy is associated with both reflux symptoms and oesophagitis. During pregnancy, elevated sex hormones are thought to contribute to the high prevalence of reflux symptoms. Increased female sex hormone levels may thus contribute to the aetiology of gastro-oesophageal reflux disease (GORD). To determine if female sex hormone levels are associated with symptomatic acid reflux. Women with GORD symptoms undergoing oesophageal pH monitoring were prospectively recruited. 'Cases' and 'controls' were defined by normal and excess total acid exposure on pH monitoring and were age-matched and BMI-matched. Case and control groups were further stratified into premenopausal and postmenopausal groups. Demographic data were collected, body morphological parameters were measured and oestradiol, oestrone, progesterone and sex hormone-binding globulin were measured. One hundred and twenty-one women [mean age 52 (SD 11.6) years] were recruited and 104 [mean age 51 (SD 11.6) years] were matched for age and BMI. Increasing BMI, as expected, correlated with increasing acid exposure [premenopausal (r=0.404, P=0.02), postmenopausal (r=0.401, P=0.01)]. Increasing BMI also correlated with sex hormone levels [premenopausal oestradiol (r=0.52, P=0.004), postmenopausal oestrone (r=0.364, P=0.01)]. In premenopausal women, sex hormone binding globulin (r=-0.27, P=0.05) and testosterone (r=0.29, P=0.05) correlated with increasing acid exposure, but oestradiol fell just short of significance (r=0.26, P=0.06). However, on matching for BMI, no association between sex hormones and increased acid exposure on pH monitoring was found on multivariate logistic regression analysis. Female sex hormone levels do not appear to contribute to GORD, once adjustment is made for the influence of increasing BMI.
Emken, Birgitte-Elise G; Lundell, Lars R; Wallin, Lene; Myrvold, Helge E; Engström, Cecilia; Montgomery, Madeleine; Malm, Anders R; Lind, Tore; Hatlebakk, Jan G
To compare the effect of anti-reflux surgery (ARS) versus proton pump inhibitor therapy on lower oesophageal sphincter (LOS) function and oesophageal acid exposure in patients with chronic gastro-oesophageal reflux disease (GORD) over a decade of follow-up. In this randomised, prospective, multicentre study we compared LOS pressure profiles, as well as oesophageal exposure to acid, at baseline and at 1 and 10 years after randomisation to either open ARS (n = 137) or long-term treatment with omeprazole (OME) 20-60 mg daily (n = 108). Median LOS resting pressure and abdominal length increased significantly and remained elevated in patients operated on with ARS, as opposed to those on OME. The proportion of total time (%) with oesophageal pH <4.0 decreased significantly in both the surgical and medical groups, and was significantly lower after 1 year in patients treated with ARS versus OME. After 10 years, oesophageal acid exposure was normalised in both groups, with no significant differences, and bilirubin exposure was within normal limits. After 10 years, patients with or without Barrett's oesophagus did not differ in acid reflux control between the two treatment options. Open ARS and OME were both effective in normalising acid reflux into the oesophagus even when studied over a period of 10 years. Anatomically and functionally the LOS was repaired durably by surgery, with increased resting pressure and abdominal length.
... and a pitcher of soda — a well-deserved reward after hours of shooting free throws and running ... and teens who have diseases of the gastrointestinal system (the esophagus, stomach, intestines, and other organs that ...
Lødrup, A; Pottegård, A; Hallas, J; Bytzer, P
Guidelines recommend that patients with gastro-oesophageal reflux disease are adequately treated with acid-suppressive therapy before undergoing anti-reflux surgery. Little is known of the use of acid-suppressive drugs before anti-reflux surgery. To determine the use of proton pump inhibitors and H2 -receptor antagonists in the year before anti-reflux surgery. A nationwide retrospective study of all patients aged ≥18 undergoing first-time anti-reflux surgery in Denmark during 2000-2012 using data from three different sources: the Danish National Register of Patients, the Danish National Prescription Register, and the Danish Person Register. The study population thus included 2922 patients (median age: 48 years, 55.7% male). The annual proportion of patients redeeming ≥180 DDD of acid-suppressive therapy increased from 17.0% 5 years before anti-reflux surgery to 64.9% 1 year before. The probability for inadequate dosing 1 year before surgery (<180 DDD) was significantly increased for younger patients, patients operated in the period 2000-2003, patients who had not undergone pre-surgical manometry, pH- or impedance monitoring, and patients who had not redeemed prescriptions on NSAID or anti-platelet drugs. Compliance with medical therapy should be evaluated thoroughly before planning anti-reflux surgery, as a high proportion of patients receive inadequate dosing of acid-suppressive therapy prior to the operation. © 2015 John Wiley & Sons Ltd.
Hoffman, Ilse; De Greef, Toon; Haesendonck, Nancy; Tack, Jan
Motility abnormalities in adults with gastroesophageal reflux disease (GERD) include nontransmitted contractions, reduced distal esophageal contraction amplitude, and simultaneous contractions. Information on esophageal body motility in children with GERD is scarce. Our aim was to study esophageal motility patterns in children with GERD, taking into account the presence of anatomical abnormalities and neurological impairment, the effect of age on esophageal motility in GERD, and the relation between esophageal manometry and GERD severity parameters (acid exposure and presence of esophagitis). Consecutive children referred for severe GER(D) symptoms underwent a barium swallow, upper endoscopy, pH monitoring, and stationary water-perfused esophageal manometry. Mean lower esophageal sphincter (LES) pressure and velocity of propagation in the proximal and distal esophagus decreased with age in this group of children with GERD (all P < 0.01). Severely disturbed esophageal motility was found in children with previous esophageal atresia. Patients with psychomotor retardation had significantly lower occurrence of peristaltic waves (94% +/- 21% vs 79% +/- 38%; P = 0.001), distal propagation velocity (0.8 +/- 0.4 vs 0.6 +/- 0.5 cm/s; P = 0.05), and distal contraction duration (3.1 +/- 0.8 vs 3.4 +/- 1 seconds; P = 0.05). None of the manometric characteristics differed between patients with normal or abnormal esophageal pH monitoring or with or without erosive esophagitis. LES pressure and esophageal velocity decreased with increasing age. Esophageal manometry is severely impaired in children with esophageal atresia and psychomotor retardation. No specific esophageal motor abnormalities related to the presence of endoscopic esophagitis or abnormal pH monitoring were found.
Pilic, Denisa; Hankel, Saskia; Koerner-Rettberg, Cordula; Hamelmann, Eckard; Schmidt-Choudhury, Anjona
Diagnosis of gastro esophageal reflux disease (GERD) in children is challenging. 24-h-pH-multichannel-intraluminal-impedance measurement (pH-MII) is the best diagnostic tool to display gastro esophageal reflux whereas esophageal endoscopy indicates mucosal lesions. The aim of this study was to compare esophageal endoscopy results with reflux parameters such as acid exposure time (reflux index RI), bolus exposure time (bolus index BI), baseline impedance level (BIL) detected by pH-MII in children with suspected GERD. Analysis of data from 285 children (38 infants) referred to our hospital with suspected GERD. Division into three 'reflux esophagitis' (RE)-stages depending on the severity of endoscopic and histological findings and comparison with reflux parameters in these stages. Further categorization into four groups based on the pH-MII-results. Children with high-grade esophagitis had a significantly lower BIL; otherwise there was no significant association between elevated reflux parameters and esophagitis. Pathological pH-MII results (RI and BI) were associated with lower BIL in the distal impedance channel. The BIL was significantly lower in infants compared to children >1 year regardless of the RI or BI. The main difference between these groups regarding reflux parameters was a longer BI and a higher number of retrograde bolus movements. Pathologic pH-MII results are not predictive for an erosive esophagitis and vice versa. Therefore, these two procedures cannot replace each other. A lower BIL is associated with esophagitis ≥ LA-grade B and may be caused by longer acid but also by longer bolus exposure and thus may be another useful parameter in GERD monitoring.
Cicala, Michele; Emerenziani, Sara; Guarino, Michele Pier Luca; Ribolsi, Mentore
Gastro-esophageal reflux disease (GERD) is one of the most prevalent chronic diseases. Although proton pump inhibitors (PPIs) represent the mainstay of treatment both for healing erosive esophagitis and for symptom relief, several studies have shown that up to 40% of GERD patients reported either partial or complete lack of response of their symptoms to a standard PPI dose once daily. Several mechanisms have been proposed as involved in PPIs resistance, including ineffective control of gastric acid secretion, esophageal hypersensitivity, ultrastructural and functional changes in the esophageal epithelium. The diagnostic evaluation of a refractory GERD patients should include an accurate clinical evaluation, upper endoscopy, esophageal manometry and ambulatory pH-impedance monitoring, which allows to discriminate non-erosive reflux disease patients from those presenting esophageal hypersensitivity or functional heartburn. Treatment has been primarily based on doubling the PPI dose or switching to another PPI. Patients with proven disease, not responding to PPI twice daily, are eligible for anti-reflux surgery.
Ranaldo, Nunzio; Losurdo, Giuseppe; Iannone, Andrea; Principi, Mariabeatrice; Barone, Michele; De Carne, Massimo; Ierardi, Enzo; Di Leo, Alfredo
A relevant percentage of non-erosive reflux disease (NERD) is refractory to proton pump inhibitors (PPIs) treatment. Multichannel intraluminal impedance pH (MII-pH) monitoring should give useful pathophysiological information about refractoriness. Therefore, our aim was to assess whether this technique could be useful to guide a 'tailored' therapy in refractory NERD. We retrospectively recruited NERD patients undergoing MII-pH monitoring for unsuccessful treatment. All patients had undergone upper endoscopy, and those with erosive esophagitis were excluded. No patient received PPI during MII-pH monitoring. Subjects were subgrouped into three categories: acid reflux, non-acid reflux and functional heartburn. MII-pH-guided therapy was performed for 4 weeks as follows: patients with acid reflux received PPI at double dose, patients with non-acid reflux PPI at full dose plus alginate four times a day and patients with functional heartburn levosulpiride 75 mg per day. A visual analog scale (VAS) ranging from 0 to 100 mm was administered before and after such tailored therapy to evaluate overall symptoms. Responders were defined by VAS improvement of at least 40%. Sixty-nine patients with refractory NERD were selected (female-male ratio 43 : 26, mean age 47.6±15.2 years). Overall effectiveness of tailored therapy was 84% without statistical difference among subgroups (88.5% acid reflux, 92% non-acid reflux, 66.6% functional heartburn; P=0.06). Univariate analysis showed that therapy failure directly correlated with functional heartburn diagnosis (OR=4.60) and suggested a trend toward a negative correlation with smoking and a positive one with nausea. However, at multivariate analysis, these parameters were not significant. Functional heartburn experienced a lower median percent VAS reduction than acid reflux (52.5% versus 66.6%, P<0.01) even if equal to non-acid reflux (66.6%). In conclusion, a tailored approach to refractory NERD, guided by MII-pH monitoring
Wernersson, Börje; Ohlsson, Lis; Dent, John
Background: Symptomatically ‘silent’ gastro-oesophageal reflux disease (GORD) may be underdiagnosed. Objective: To determine the prevalence of untreated GORD without heartburn and/or regurgitation in primary care. Methods: Patients were included if they had frequent upper gastrointestinal symptoms and had not taken a proton pump inhibitor in the previous 2 months (Diamond study: NCT00291746). GORD was diagnosed based on the presence of reflux oesophagitis, pathological oesophageal acid exposure, and/or a positive symptom–acid association probability. Patients completed the Reflux Disease Questionnaire (RDQ) and were interviewed by physicians using a prespecified symptom checklist. Results: GORD was diagnosed in 197 of 336 patients investigated. Heartburn and/or regurgitation were reported in 84.3% of patients with GORD during the physician interviews and in 93.4% of patients with GORD when using the RDQ. Of patients with heartburn and/or regurgitation not identified at physician interview, 58.1% (18/31) reported them at a ‘troublesome’ frequency and severity on the RDQ. Nine patients with GORD did not report heartburn or regurgitation either at interview or on the RDQ. Conclusions: Structured patient-completed questionnaires may help to identify patients with GORD not identified during physician interview. In a small proportion of consulting patients, heartburn and regurgitation may not be present in those with GORD. PMID:25360300
Vakil, Nimish; Wernersson, Börje; Ohlsson, Lis; Dent, John
Symptomatically 'silent' gastro-oesophageal reflux disease (GORD) may be underdiagnosed. To determine the prevalence of untreated GORD without heartburn and/or regurgitation in primary care. Patients were included if they had frequent upper gastrointestinal symptoms and had not taken a proton pump inhibitor in the previous 2 months (Diamond study: NCT00291746). GORD was diagnosed based on the presence of reflux oesophagitis, pathological oesophageal acid exposure, and/or a positive symptom-acid association probability. Patients completed the Reflux Disease Questionnaire (RDQ) and were interviewed by physicians using a prespecified symptom checklist. GORD was diagnosed in 197 of 336 patients investigated. Heartburn and/or regurgitation were reported in 84.3% of patients with GORD during the physician interviews and in 93.4% of patients with GORD when using the RDQ. Of patients with heartburn and/or regurgitation not identified at physician interview, 58.1% (18/31) reported them at a 'troublesome' frequency and severity on the RDQ. Nine patients with GORD did not report heartburn or regurgitation either at interview or on the RDQ. Structured patient-completed questionnaires may help to identify patients with GORD not identified during physician interview. In a small proportion of consulting patients, heartburn and regurgitation may not be present in those with GORD.
Khan, Abraham; Kim, Aram; Sanossian, Cassandra; Francois, Fritz
Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD. PMID:26819528
Spechler, S J
Epidemiological studies of gastro-oesophageal reflux disease (GORD) are confounded by the lack of a standardized definition and a diagnostic 'gold-standard' for the disorder. In Western countries, 20-40% of the adult population experience heartburn, which is the cardinal symptom of GORD, but only some 2% of adults have objective evidence of reflux oesophagitis. The incidence of GORD increases with age, rising dramatically after 40 years of age. There is also wide geographical variation in prevalence. Complications, including oesophageal ulcer and stricture, and Barrett's oesophagus, are found in up to 20% of patients with verified reflux oesophagitis. The signs and symptoms of GORD often wax and wane in intensity, and spontaneous remissions have been reported. In most cases, however, GORD is a chronic condition that returns shortly after discontinuing therapy. Although GORD causes substantial morbidity, the annual mortality rate due to GORD is very low (approximately 1 death per 100,000 patients), and even severe GORD has no apparent effect on longevity, although the quality of life can be significantly impaired. There are data to suggest that the use of non-steroidal anti-inflammatory drugs (NSAIDs) contributes to oesophagitis and stricture formation in patients with GORD. Although these data are not conclusive, it seems prudent, if possible, to avoid the use of NSAIDs in patients with GORD, particularly those with oesophageal stricture.
Naik, Rishi D; Vaezi, Michael F
Gastroesophageal reflux disease (GERD) has a large economic burden with important complications that include esophagitis, Barrett's esophagus, and adenocarcinoma. Despite endoscopy, validated patient questionnaires, and traditional ambulatory pH monitoring, the diagnosis of GERD continues to be challenging. Areas covered: This review will explore the difficulties in diagnosing GERD with a focus on new developments, ranging from basic fundamental changes (histology and immunohistochemistry) to direct patient care (narrow-band imaging, impedance, and response to anti-reflux surgery). We searched PubMed using the noted keywords. We included data from full-text articles published in English. Further relevant articles were identified from the reference lists of review articles. Expert commentary: Important advances in novel parameters in intraluminal impedance monitoring such as baseline impedance monitoring has created some insight into alternative diagnostic strategies in GERD. Recent advances in endoscopic assessment of esophageal epithelial integrity via mucosal impedance measurement is questioning the paradigm of prolonged ambulatory testing for GERD. The future of reflux diagnosis may very well be without the need for currently employed technologies and could be as simple as assessing changes in epithelia integrity as a surrogate marker for GERD. However, future studies must validate such an approach.
Khan, Abraham; Kim, Aram; Sanossian, Cassandra; Francois, Fritz
Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD.
Fock, Kwong Ming; Talley, Nicholas; Goh, Khean Lee; Sugano, Kentaro; Katelaris, Peter; Holtmann, Gerald; Pandolfino, John E; Sharma, Prateek; Ang, Tiing Leong; Hongo, Michio; Wu, Justin; Chen, Minhu; Choi, Myung-Gyu; Law, Ngai Moh; Sheu, Bor-Shyang; Zhang, Jun; Ho, Khek Yu; Sollano, Jose; Rani, Abdul Aziz; Kositchaiwat, Chomsri; Bhatia, Shobna
Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus. A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations. A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer. These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Butt, Arshad Kamal; Hashemy, Irfan
To determine the frequency of the use of proton-pump inhibitor therapy in patients with typical symptoms of gastroesophageal reflux disease and evaluate its risk factors. The cross-sectional study was conducted between June 2010 and February 2011 across 10 cities of Pakistan. Adult patients giving a current history of typical gastroesophageal reflux disease symptoms were included. Information on patient demography, medical history, family history, prescription patterns, lifestyle factors and dietary habits were collected. SPSS 18 was used for statistical analysis and descriptive statistics were used for the analysis of categorical and continuous variables. Of the 1010 patients enrolled, 954 (94.45%) formed the study population. Of them, 520 (54.5%) were men. The overall mean age was 41.9 +/- 12.5 years, and 439 (46%) had body mass index > or = 25 kg/m2. Further, 805 (84.4%) reported history of dyspepsia while 692 (72.5%) had gastroesophageal reflux disease during the preceding year. Family history of acid peptic disease was reported by 231 (24.2%) patients. Prior to consultation, 505 (52.9%) patients were on proton-pump inhibitors. Following consultation, 923 (96.8%) patients were prescribed proton-pump inhibitors, with omeprazole being the preferred choice in 577 (60.5%). Associated risk factors included regular use of nonsteroidal anti-inflammatory drugs in 355 (37.2%) and current smoking in 210 (22.0%). Consuming spicy meals was reported by 666 (70.0%). Nearly half the patients with typical gastroesophageal reflux disease symptoms were overweight, and a majority consumed spicy meals. Proton-pump inhibitors were widely prescribed, and omeprazole was the preferred choice of drug.
Amarasiri, Lakmali D; Pathmeswaran, Arunasalam; de Silva, H Janaka; Ranasinha, Channa D
Gastro-oesophageal reflux disease (GORD) symptoms are common in asthma and have been extensively studied, but less so in the Asian continent. Reflux-associated respiratory symptoms (RARS) have, in contrast, been little-studied globally. We report the prevalence of GORD symptoms and RARS in adult asthmatics, and their association with asthma severity and medication use. A cross-sectional analytical study. A validated interviewer-administered GORD scale was used to assess frequency and severity of seven GORD symptoms. Subjects were consecutive asthmatics attending medical clinics. Controls were matched subjects without respiratory symptoms. The mean (SD) composite GORD symptom score of asthmatics was significantly higher than controls (21.8 (17.2) versus 12.0 (7.6); P < 0.001) as was frequency of each symptom and RARS. Prevalence of GORD symptoms in asthmatics was 59.4% (95% CI, 59.1%-59.6%) versus 28.5% in controls (95% CI, 29.0% - 29.4%). 36% of asthmatics experienced respiratory symptoms in association with both typical and atypical GORD symptoms, compared to 10% of controls (P < 0.001). An asthmatic had a 3.5 times higher risk of experiencing a GORD symptom after adjusting for confounders (OR 3.5; 95% CI 2.5-5.3). Severity of asthma had a strong dose-response relationship with GORD symptoms. Asthma medication use did not significantly influence the presence of GORD symptoms. GORD symptoms and RARS were more prevalent in a cohort of Sri Lankan adult asthmatics compared to non-asthmatics. Increased prevalence of RARS is associated with both typical and atypical symptoms of GORD. Asthma disease and its severity, but not asthma medication, appear to influence presence of GORD symptoms.
Background Gastro-oesophageal reflux disease (GORD) symptoms are common in asthma and have been extensively studied, but less so in the Asian continent. Reflux-associated respiratory symptoms (RARS) have, in contrast, been little-studied globally. We report the prevalence of GORD symptoms and RARS in adult asthmatics, and their association with asthma severity and medication use. Methods A cross-sectional analytical study. A validated interviewer-administered GORD scale was used to assess frequency and severity of seven GORD symptoms. Subjects were consecutive asthmatics attending medical clinics. Controls were matched subjects without respiratory symptoms. Results The mean (SD) composite GORD symptom score of asthmatics was significantly higher than controls (21.8 (17.2) versus 12.0 (7.6); P < 0.001) as was frequency of each symptom and RARS. Prevalence of GORD symptoms in asthmatics was 59.4% (95% CI, 59.1%-59.6%) versus 28.5% in controls (95% CI, 29.0% - 29.4%). 36% of asthmatics experienced respiratory symptoms in association with both typical and atypical GORD symptoms, compared to 10% of controls (P < 0.001). An asthmatic had a 3.5 times higher risk of experiencing a GORD symptom after adjusting for confounders (OR 3.5; 95% CI 2.5-5.3). Severity of asthma had a strong dose-response relationship with GORD symptoms. Asthma medication use did not significantly influence the presence of GORD symptoms. Conclusions GORD symptoms and RARS were more prevalent in a cohort of Sri Lankan adult asthmatics compared to non-asthmatics. Increased prevalence of RARS is associated with both typical and atypical symptoms of GORD. Asthma disease and its severity, but not asthma medication, appear to influence presence of GORD symptoms. PMID:20843346
Hölttä, P; Aine, L; Mäki, M; Ruuska, T; Vuento, R; Ashorn, M; Alaluusua, S
It has been suggested that vomiting acid gastric contents in bulimia might favor oral growth of Streptococcus sobrinus. We studied the colonization of Streptococcus sobrinus (serotypes g and d) and Streptococcus mutans (serotypes c, e and f) in sixteen children, ages five to fifteen years, who had suffered for four to eleven years from gastroesophageal reflux, another condition with recurrent acid regurgitation. Our aim was to find out if the prevalence of Streptococcus sobrinus would be higher also in this patient group. Mutants streptococci were detected in twelve out of sixteen (75 percent) study patients of the saliva samples cultured on MSB agar. For the Mutans streptococci positive children healthy controls were matched by salivary levels of mutans streptococci and age as closely as possible. From each child three to six isolates representing both Streptococcus mutans and Streptococcus sobrinus (n = 103) were serotyped by immunodiffusion method. The distribution of serotypes in the study/control group was: c: 7/10; e: 4/2; f: 0/1; g:3/2; d:0/0. One strain in the study group remained untypable. All patients infected with Streptococcus sobrinus were also infected with Streptococcus mutans. Our results indicate the great similarity in the distribution of ms serotypes in the gastroesophageal reflux children and their healthy controls. The data do not suggest that the acid regurgitation would have an influence on the prevalence of Streptococcus sobrinus.
Ang, D; Blondeau, K; Sifrim, D; Tack, J
Barrett's esophagus has traditionally been regarded as the most severe end of the spectrum of gastroesophageal reflux disease and is of great clinical importance in view of the association with esophageal adenocarcinoma. Studies have documented high levels of esophageal acid exposure in Barrett's esophagus. Various pathogenetic mechanisms underlie this phenomenon. These include abnormalities in esophageal peristalsis, defective lower esophageal sphincter pressures, gastric dysmotility and bile reflux. Whilst these factors provide evidence for an acquired cause of Barrett's esophagus, an underlying genetic predisposition cannot be ruled out. Although the past decade has brought about many new discoveries in the pathogenesis of Barrett's esophagus, it has also added further controversy to this complex disorder. A detailed analysis of the gastrointestinal motor abnormalities occurring in Barrett's esophagus follows, with a review of the currently available literature and an update on this condition that continues to be of interest to the gastroenterologist.
Differences in the aetiology as well as patient background of chronic cough have been recognised among US, UK, and Japan. One of the marked differences has been the prevalence of gastro-oesophageal reflux disease (GORD), which has been one of the top three causes in Western countries. It was indeed uncommon or rare in Japan, but, with the increasing prevalence of GOR itself, chronic cough associated with GORD seems to have become more common. In this article, cough associated with GORD will be reviewed based on literature and our Japanese experience. Further, potentially broader relevance of GORD in chronic cough will also be mentioned, highlighting the potential importance of dysmotiliy/non-acid reflux. Copyright © 2017 Elsevier Ltd. All rights reserved.
Gabbard, Scott L; Fass, Ronnie; Maradey-Romero, Carla; Gingold Belfer, Rachel; Dickman, Ram
Gastroesophageal reflux disease has a variable presentation on upper endoscopy. Gastroesophageal reflux disease can be divided into 3 endoscopic categories: Barrett's esophagus, erosive esophagitis, and normal mucosa/nonerosive reflux disease (NERD). Each of these phenotypes behave in a distinct manner, in regards to symptom response to treatment, and risk of development of complications such as esophageal adenocarcinoma. Recently, it has been proposed to further differentiate NERD into 2 categories: those with and those without "minimal changes." These minimal changes include endoscopic abnormalities, such as villous mucosal surface, mucosal islands, microerosions, and increased vascularity at the squamocolumnar junction. Although some studies have shown that patients with minimal changes may have higher rates of esophageal acid exposure compared with those without minimal changes, it is currently unclear if these patients behave differently than those currently categorized as having NERD. The clinical utility of identifying these lesions should be weighed against the cost of the requisite equipment and the additional time required for diagnosis, compared with conventional white light endoscopy.
Gavini, S; Finn, R T; Lo, W-K; Goldberg, H J; Burakoff, R; Feldman, N; Chan, W W
Gastroesophageal reflux (GER) has been associated with idiopathic pulmonary fibrosis (IPF), although the mechanism remains unclear. Gastroesophageal reflux/microaspiration may lead to lung fibrosis, while increased pulmonary workload may also worsen GER. Comparing the GER profile of IPF patients to chronic obstructive pulmonary disease (COPD) patients with similar lung function may help delineate the role of GER in IPF pathogenesis. This was a retrospective cohort study of IPF and COPD patients undergoing pre-lung transplant multichannel intraluminal impedance and pH study (MII-pH) off acid suppression at a tertiary center in 2008-2014. Patients with prior fundoplication were excluded. Baseline demographics, pulmonary function test, and MII-pH results were recorded. Univariate analyses were performed using Fisher's exact (binary variables) and Student's t (continuous variables) tests. Logistic regression was performed to adjust for potential confounders. A total of 90 subjects (54 IPF, 36 COPD) met inclusion criteria. Compared to COPD, IPF patients had increased total reflux episodes (65.9 vs 46.1, p = 0.02), proximal reflux episodes (30.3 vs 20.3, p = 0.04), and prevalence of abnormal total reflux episodes (38.9% vs 16.7%, p = 0.02). On multivariate analyses, abnormal total reflux episodes (OR: 4.9, p = 0.05) and bolus reflux exposure time (OR: 4, p = 0.04) remained significantly associated with IPF. Abnormal reflux was significantly more prevalent among IPF patients after controlling for lung disease severity. Gastroesophageal reflux/microaspiration likely plays a role in fibrosis in IPF. A significant portion of IPF patients had increased non-acid reflux. Therapies aiming to prevent reflux of gastric contents may be more beneficial than antisecretory medications alone in these patients. © 2015 John Wiley & Sons Ltd.
Ke, Mei Yun
Heartburn is a common symptom in gastroesophageal reflux disease. Endoscopic examination can differentiate between reflux esophagitis and non-erosive reflux disease (NERD), but not between NERD and functional heartburn. With the development of new techniques, more NERD patients could be identified among those previously diagnosed with functional heartburn. Most patients with NERD, however, could be identified based on their clinical characteristics and response to proton pump inhibitors and/or integrated anti-gastroesophageal reflux therapy. © 2012 The Author. Journal of Digestive Diseases © 2012 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.
Dehdashti, Hamid; Dehdashtian, Masoud; Rahim, Fakher; Payvasteh, Mehrdad
This study was conducted to provide sonographic measurements of the abdominal esophagus length in neonates and infants with and without gastroesophageal reflux disease (GERD) and to investigate its diagnostic value. GERD severity was also evaluated and correlated with esophageal length. It is a prospective case-control study. This prospective case-control study comprised 235 neonates and infants (120 without reflux and 115 with reflux). There were 40 children without reflux in each of three age categories: less than 1 month, 1-6 months, and 6-12 months. Of the children with reflux, 40 were less than 1 month old; 37, 1-6 months; and 38, 6-12 months. The abdominal esophagus was measured from its entrance into the diaphragm to the base of gastric folds in fed infants. GERD was sonographically diagnosed and confirmed by a barium meal. The number of refluxes during a 10-min period were recorded. Neonates and infants with reflux had a significantly shorter abdominal esophagus than subjects without reflux: the mean difference in neonates, 4.65 mm; 1-6 months, 4.57 mm; 6-12 months, 3.61 mm. Children with severe reflux had a shorter esophagus compared with those with mild and moderate reflux only in the neonate group. Therefore, thinking of GERD and carefully looking for its symptoms is necessary to avoid unnecessary utilization of healthcare resources in children with severe reflux.
Volume, distribution and acidity of gastric secretion on and off proton pump inhibitor treatment: a randomized double-blind controlled study in patients with gastro-esophageal reflux disease (GERD) and healthy subjects.
Steingoetter, Andreas; Sauter, Matthias; Curcic, Jelena; Liu, Dian; Menne, Dieter; Fried, Michael; Fox, Mark; Schwizer, Werner
Postprandial accumulation of gastric secretions in the proximal stomach above the meal adjacent to the esophagogastric junction (EGJ), referred to as the 'acid pocket', has been proposed as a pathophysiological factor in gastro-esophageal reflux disease (GERD) and as a target for GERD treatment. This study assessed the effect of proton pump inhibitor (PPI) therapy on the volume, distribution and acidity of gastric secretions in GERD and healthy subjects (HS). A randomized, double blind, cross-over study in 12 HS and 12 GERD patients pre-treated with 40 mg pantoprazole (PPI) or placebo b.i.d. was performed. Postprandial secretion volume (SV), formation of a secretion layer and contact between the layer and the EGJ were quantified by Magnetic Resonance Imaging (MRI). Multi-channel pH-monitoring assessed intragastric pH. A distinct layer of undiluted acid secretion was present on top of gastric contents in almost all participants on and off high-dose acid suppression. PPI reduced SV (193 ml to 100 ml, in HS, 227 ml to 94 ml in GERD; p < 0.01) and thickness of the acid layer (26 mm to 7 mm, 36 mm to 9 mm respectively, p < 0.01). No differences in secretion volume or layer thickness were observed between groups; however, off treatment, contact time between the secretion layer and EGJ was 2.6 times longer in GERD compared to HS (p = 0.012). This was not the case on PPI. MRI can visualize and quantify the volume and distribution dynamics of gastric secretions that form a layer in the proximal stomach after ingestion of a liquid meal. The secretion volume and the secretion layer on top of gastric contents is similar in GERD patients and HS; however contact between the layer of undiluted secretion and the EGJ is prolonged in patients. High dose PPI reduced secretion volume by about 50% and reduced contact time between secretion and EGJ towards normal levels. NCT01212614.
Richter, Joel E; Rubenstein, Joel H
Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the United States, and leads to substantial morbidity, though associated mortality is rare. The prevalence of GERD symptoms appeared to increase until 1999. Risk factors for complications of GERD include advanced age, male sex, white race, abdominal obesity, and tobacco use. Most patients with GERD present with heartburn and effortless regurgitation. Coexistent dysphagia is considered an alarm symptom, prompting evaluation. There is substantial overlap between symptoms of GERD and those of eosinophilic esophagitis, functional dyspepsia, and gastroparesis, posing a challenge for patient management. Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.
Ho, Khek Yu
Widespread epidemiological changes, rising prevalence and gradual shifts in patterns of disease manifestations: this is the changing face of gastroesophageal reflux disease (GERD) in Asia. Are we witnessing a disease in evolution or merely the result of increased and more accurate case reporting that comes with advancing diagnostic technology, better medical facilities and heightened awareness of the disease? Do the figures reported really reflect the actual scenario or is there more to it than meets the eye? In this article, we take you back in time to review relevant developments over the past decade or so. We will draw on findings from across Asia, take an in-depth look at prevailing trends and patterns and examine some of the most plausible explanations behind the dynamics of this epidemiological transition.
Karbasi, Ashraf; Aliannejad, Rasoul; Ghanei, Mostafa; Sanamy, Mehran Noory; Alaeddini, Farshid; Harandi, Ali Amini
There is no data on the prevalence and the association of gastro esophageal reflux disease (GERD) with toxic fume inhalation. Therefore, we aimed to evaluate the frequency distribution of GERD symptoms among the individuals with mild respiratory disorder due to the past history of toxic fume exposure to sulfur mustard (SM). In a historical cohort study, subjects were randomly selected from 7000 patients in a database of all those who had a history of previous exposure to a single high dose of SM gas during war. The control group was randomly selected from adjacent neighbors of the patients, and two healthy male subjects were chosen per patient. In this study, we used the validated Persian translation of Mayo Gastroesophageal Reflux Questionnaire to assess the frequency distribution of reflux disease. Relative frequency of GERD symptoms, was found to be significantly higher in the inhalation injury patients with an odds ratio of 8.30 (95% confidence interval [CI]: 4.73-14.55), and after adjustment for cigarette smoking, tea consumption, age, and body mass index, aspirin and chronic cough the odds ratio was found to be 4.41 (95% CI: 1.61-12.07). The most important finding of our study was the major GERD symptoms (heartburn and/or acid regurgitation once or more per week) among the individuals with the past history of exposure to SM toxic gas is substantially higher (4.4-fold) than normal populations.
Brar, Tony S; Draganov, Peter V; Yang, Dennis
Gastroesophageal reflux disease (GERD) is a chronic disease characterized by symptoms of heartburn and acid regurgitation. Uncontrolled GERD can significantly impact quality of life, can lead to complications, and increases the risk of esophageal cancer. Over the past few decades, there has been an increasing prevalence of GERD among adults in Western populations. The use of proton pump inhibitors (PPI) in conjunction with lifestyle modifications remains the mainstay therapy. However, the efficacy of this intervention is often hampered by adherence, costs, and the risks of long-term PPI use. Anti-reflux surgery is an option for patients with refractory symptoms or in those in whom medical therapy is contraindicated or not desirable. While conventional surgery has an acceptable safety profile, there has been an increasing interest in alternate treatments that may potentially offer similar results and be associated with a faster recovery. Recent advances in interventional endoluminal techniques have introduced novel incisionless anti-reflux procedures. While the current data are promising, further larger prospective studies are needed in order to assess the long-term efficacy of endoluminal therapies and its place among the treatment options for GERD.
Karbasi, Ashraf; Aliannejad, Rasoul; Ghanei, Mostafa; Sanamy, Mehran Noory; Alaeddini, Farshid; Harandi, Ali Amini
Background: There is no data on the prevalence and the association of gastro esophageal reflux disease (GERD) with toxic fume inhalation. Therefore, we aimed to evaluate the frequency distribution of GERD symptoms among the individuals with mild respiratory disorder due to the past history of toxic fume exposure to sulfur mustard (SM). Materials and Methods: In a historical cohort study, subjects were randomly selected from 7000 patients in a database of all those who had a history of previous exposure to a single high dose of SM gas during war. The control group was randomly selected from adjacent neighbors of the patients, and two healthy male subjects were chosen per patient. In this study, we used the validated Persian translation of Mayo Gastroesophageal Reflux Questionnaire to assess the frequency distribution of reflux disease. Results: Relative frequency of GERD symptoms, was found to be significantly higher in the inhalation injury patients with an odds ratio of 8.30 (95% confidence interval [CI]: 4.73-14.55), and after adjustment for cigarette smoking, tea consumption, age, and body mass index, aspirin and chronic cough the odds ratio was found to be 4.41 (95% CI: 1.61-12.07). Conclusion: The most important finding of our study was the major GERD symptoms (heartburn and/or acid regurgitation once or more per week) among the individuals with the past history of exposure to SM toxic gas is substantially higher (4.4-fold) than normal populations. PMID:26622251
Qureshi, Mahim I; Gohel, Manj; Wing, Louise; MacDonald, Andrew; Lim, Chung S; Ellis, Mary; Franklin, Ian J; Davies, Alun H
This study assessed patterns of superficial reflux in patients with primary chronic venous disease. Retrospective review of all patient venous duplex ultrasonography reports at one institution between 2000 and 2009. Legs with secondary, deep or no superficial reflux were excluded. In total, 8654 limbs were scanned; 2559 legs from 2053 patients (mean age 52.3 years) were included for analysis. Great saphenous vein reflux predominated (68%), followed by combined great saphenous vein/small saphenous vein reflux (20%) and small saphenous vein reflux (7%). The majority of legs with competent saphenofemoral junction had below-knee great saphenous vein reflux (53%); incompetent saphenofemoral junction was associated with combined above and below-knee great saphenous vein reflux (72%). Isolated small saphenous vein reflux was associated with saphenopopliteal junction incompetence (61%), although the majority of all small saphenous vein reflux limbs had a competent saphenopopliteal junction (57%). Superficial venous reflux does not necessarily originate from a saphenous junction. Large prospective studies with interval duplex ultrasonography are required to unravel the natural history of primary chronic venous disease. © The Author(s) 2014.
Hatlebakk, Jan G; Zerbib, Frank; Bruley des Varannes, Stanislas; Attwood, Stephen E; Ell, Christian; Fiocca, Roberto; Galmiche, Jean-Paul; Eklund, Stefan; Långström, Göran; Lind, Tore; Lundell, Lars R
We compared the ability of laparoscopic antireflux surgery (LARS) and esomeprazole to control esophageal acid exposure, over a 5-year period, in patients with chronic gastroesophageal reflux disease (GERD). We also studied whether intraesophageal and intragastric pH parameters off and on therapy were associated with long-term outcomes. We analyzed data from a prospective, randomized, open-label trial comparing the efficacy and safety of LARS vs esomeprazole (20 or 40 mg/d) over 5 years in patients with chronic GERD. Ambulatory intraesophageal and intragastric 24-hour pH monitoring data were compared between groups before LARS or the start of esomeprazole treatment, and 6 months and 5 years afterward. A secondary aim was to evaluate the association between baseline and 6-month pH parameters and esomeprazole dose escalation, reappearance of GERD symptoms, and treatment failure over 5 years in patients receiving LARS or esomeprazole. In the LARS group (n = 116), the median 24-hour esophageal acid exposure was 8.6% at baseline and 0.7% after 6 months and 5 years (P < .001 vs baseline). In the esomeprazole group (n = 151), the median 24-hour esophageal acid exposure was 8.8% at baseline, 2.1% after 6 months, and 1.9% after 5 years (P < .001, therapy vs baseline, and LARS vs esomeprazole). Gastric acidity was stable in both groups. Patients who required a dose increase to 40 mg/d had more severe supine reflux at baseline, and decreased esophageal acid exposure (P < .02) and gastric acidity after dose escalation. Esophageal and intragastric pH parameters, off and on therapy, did not predict long-term symptom breakthrough. In a prospective study of patients with chronic GERD, esophageal acid reflux was reduced greatly by LARS or esomeprazole therapy. However, patients receiving LARS had significantly greater reductions in 24-hour esophageal acid exposure after 6 months and 5 years. Esophageal and gastric pH, off and on therapy, did not predict long-term outcomes of
Frazzoni, Leonardo; Frazzoni, Marzio; de Bortoli, Nicola; Tolone, Salvatore; Martinucci, Irene; Fuccio, Lorenzo; Savarino, Vincenzo; Savarino, Edoardo
The Rome IV Committee introduced a major change in the classification of functional gastrointestinal disorders, proposing a more restrictive definition of gastroesophageal reflux disease (GERD). It was suggested that hypersensitive esophagus (HE) may sit more firmly within the functional realm. It was suggested that GERD diagnosis should be based upon abnormal acid exposure time (AET) only, implying no advantage of impedance-pH over pH monitoring. Symptom association probability (SAP), symptom index (SI) and heartburn relief with proton pump inhibitor (PPI) therapy were regarded as unreliable, whereas a lack of response to PPI was considered as evidence of functional heartburn. These assumptions are contradicted by numerous studies showing the clinical relevance of weakly acidic refluxes and the diagnostic utility of SAP, SI and new impedance parameters, namely the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI). The PSPW index and MNBI provide significant diagnostic advantage, particularly in patients with normal AET who can be classified as HE when both parameters are abnormal, even though SAP and SI are negative. Visceral pain modulators are recommended by the Rome IV Committee despite scanty evidence of efficacy, but a positive outcome with medical or surgical anti-reflux treatment has been reported by several studies of HE patients. Therefore, we believe that patients with endoscopy-negative heartburn should be investigated by means of impedance-pH monitoring with analysis of PSPW index and MNBI: such an approach provides accurate identification of HE cases, who remain, in our opinion, within the realm of GERD and should be treated accordingly. PMID:29333061
Fornari, F; Madalosso, C A S; Callegari-Jacques, S M; Gurski, R R
Gastro-oesophageal reflux disease (GORD) and morbid obesity are entities with increasing prevalence. New clinical strategies are cornerstones for their management. The aim of this study was to assess the prevalence of heartburn during sleep (HDS) and whether this symptom predicts the presence of objective GORD parameters and increased heartburn perception in morbidly obese patients. Ninety-one consecutive morbidly obese patients underwent clinical evaluation, upper gastrointestinal endoscopy and oesophageal pH monitoring. HDS was characterized when patients replied positively to the question, 'Does heartburn wake you from sleep?'. A General Score for Heartburn (GSH) ranging between 0 and 5 was assessed with the question 'How bad is your heartburn?'. HDS was reported by 33 patients (36%). More patients with HDS had abnormal acid contact time or reflux oesophagitis than patients without HDS (94%vs 57%, P < 0.001). HDS had a positive predictive value of 94% (0.95 CI 82-98), sensitivity of 48% (0.95 CI 37-60%) and specificity of 93% (0.95 CI 77-98%) for detection of GORD. A higher proportion of patients with HDS perceived heartburn preceded by acid reflux in diurnal (39%vs 9%; P < 0.001) periods during pH-metry. HDS patients showed higher GSH (2.4 +/- 0.5 vs 1.7 +/- 0.4; P < 0.0001) compared with patients who denied HDS but reported diurnal heartburn. HDS occurs in a significant minority of patients with morbid obesity and has high positive predictive value for GORD. Symptomatic reflux during the sleep seems to be a marker of increased heartburn perception in this population.
Sriratanaviriyakul, Narin; Kivler, Celeste; Vidovszky, Tamas J; Yoneda, Ken Y; Kenyon, Nicholas J; Murin, Susan; Louie, Samuel
Gastroesophageal reflux disease is one of the most common comorbidities in patients with asthma. Gastroesophageal reflux disease can be linked to difficult-to-control asthma. Current management includes gastric acid suppression therapy and surgical antireflux procedures. The LINX® procedure is a novel surgical treatment for patients with gastroesophageal reflux disease refractory to medical therapy. To the best of our knowledge, we report the first case of successful treatment of refractory asthma secondary to gastroesophageal reflux disease using the LINX® procedure. Our patient was a 22-year-old white woman who met the American Thoracic Society criteria for refractory asthma that had remained poorly controlled for 5 years despite progressive escalation to step 6 treatment as recommended by National Institutes of Health-National Asthma Education and Prevention Program guidelines, including high-dose oral corticosteroids, high-dose inhaled corticosteroid plus long-acting β2-agonist, leukotriene receptor antagonist, and monthly omalizumab. Separate trials with azithromycin therapy and roflumilast did not improve her asthma control, nor did bronchial thermoplasty help. Additional consultations with two other university health systems left the patient with few treatment options for asthma, which included cyclophosphamide. Instead, the patient underwent a LINX® procedure after failure of maximal medical therapy for gastroesophageal reflux disease with the additional aim of improving asthma control. After she underwent LINX® treatment, her asthma improved dramatically and was no longer refractory. She had normal exhaled nitric oxide levels and loss of peripheral eosinophilia after LINX® treatment. Prednisone was discontinued without loss of asthma control. The only immediate adverse effects due to the LINX® procedure were bloating, nausea, and vomiting. LINX® is a viable alternative to the Nissen fundoplication procedure for the treatment of patients with
De Oliveira, Patricia Alves Drummond; Paiva, Saul Martins; De Abreu, Mauro Henrique Nogueira Guimarães; Auad, Sheyla Márcia
The purpose of this study was to investigate the impact of gastroesophageal reflux disease (GERD) on dental erosion (DE) in children and analyze the association between dental erosion and diet, oral hygiene, and sociodemographic characteristics. This case-control study encompassed 43 two- to 14-year-olds diagnosed positive for GERD by the 24-hour pH monitoring, paired by age group with 136 healthy controls, in Belo Horizonte, Minas Gerais, Brazil. DE was assessed by one calibrated examiner using the O'Sullivan index. A questionnaire was self-administered by parents collecting information regarding sociodemographics, oral hygiene, and dietary habits. Dental erosion experience was compared between the groups, and a stratified analysis was performed (P<0.05). Dental erosion was diagnosed in 10.6 percent (N equals 19) of all the children; 25.6 percent (N equals 11) of GERD children and 5.9 percent (N equals eight) of children without GERD, P=0.001). Dental erosion was not associated with dietary consumption or sociodemographic characteristics in both groups (P≥0.05). Children who used adult toothpaste had a 5.79 higher chance of having dental erosion in the group with GERD. Children diagnosed with gastroesophageal reflux disease were at an increased risk of having dental erosion when compared to healthy subjects; among the GERD children, dental erosion was associated with the use of adult toothpaste.
Bayram, Ayşe Kaçar; Canpolat, Mehmet; Karacabey, Neslihan; Gumus, Hakan; Kumandas, Sefer; Doğanay, Selim; Arslan, Duran; Per, Hüseyin
Gastroesophageal reflux disease (GERD) can mimic epileptic seizure, and may be misdiagnosed as epilepsy. On the other hand, GERD can be more commonly seen in children with neurological disorders such as cerebral palsy (CP); this co-incidence may complicate the management of patients by mimicking refractory seizures. The purpose of our study was to evaluate the clinical features, definite diagnoses and treatment approaches of the patients with clinically suspected GERD who were referred to the division of pediatric neurology with a suspected diagnosis of epileptic seizure. We also aimed to investigate the occurrence of GERD in children with epilepsy and/or CP. Fifty-seven children who had a final diagnosis of GERD but were initially suspected of having epileptic seizures were assessed prospectively. All patients were assigned to 3 groups according to definite diagnoses as follows: patients with only GERD who were misdiagnosed as having epileptic seizure (group 1: n=16; 28.1%), those with comorbidity of epilepsy and GERD (group 2: n=21; 36.8%), and those with the coexistence of GERD with epilepsy and CP (group 3: n=20; 35.1%). Five patients (8.8%) did not respond to anti-reflux treatment and laparoscopic reflux surgery was performed. The positive effect of GERD therapy on paroxysmal nonepileptic events was observed in 51/57 (89.5%) patients. GERD is one of the important causes of paroxysmal nonepileptic events. In addition, GERD must be kept in mind at the initial diagnosis and also in the long-term management of patients with neurological disorders such as epilepsy and CP. Copyright © 2015 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.
Savarino, Edoardo; de Bortoli, Nicola; Zentilin, Patrizia; Martinucci, Irene; Bruzzone, Luca; Furnari, Manuele; Marchi, Santino; Savarino, Vincenzo
To evaluate the effect of a novel alginate-based compound, Faringel, in modifying reflux characteristics and controlling symptoms. In this prospective, open-label study, 40 patients reporting heartburn and regurgitation with proven reflux disease (i.e., positive impedance-pH test/evidence of erosive esophagitis at upper endoscopy) underwent 2 h impedance-pH testing after eating a refluxogenic meal. They were studied for 1 h under basal conditions and 1 h after taking 10 mL Faringel. In both sessions, measurements were obtained in right lateral and supine decubitus positions. Patients also completed a validated questionnaire consisting of a 2-item 5-point (0-4) Likert scale and a 10-cm visual analogue scale (VAS) in order to evaluate the efficacy of Faringel in symptom relief. Tolerability of the treatment was assessed using a 6-point Likert scale ranging from very good (1) to very poor (6). Faringel decreased significantly (P < 0.001), in both the right lateral and supine decubitus positions, esophageal acid exposure time [median 10 (25th-75th percentil 6-16) vs 5.8 (4-10) and 16 (11-19) vs 7.5 (5-11), respectively] and acid refluxes [5 (3-8) vs 1 (1-1) and 6 (4-8) vs 2 (1-2), respectively], but increased significantly (P < 0.01) the number of nonacid reflux events compared with baseline [2 (1-3) vs 3 (2-5) and 3 (2-4) vs 6 (3-8), respectively]. Percentage of proximal migration decreased in both decubitus positions (60% vs 32% and 64% vs 35%, respectively; P < 0.001). Faringel was significantly effective in controlling heartburn, based on both the Likert scale [3.1 (range 1-4) vs 0.9 (0-2); P < 0.001] and VAS score [7.1 (3-9.8) vs 2 (0.1-4.8); P < 0.001], but it had less success against regurgitation, based on both the Likert scale [2.6 (1-4) vs 2.2 (1-4); P = not significant (NS)] and VAS score [5.6 (2-9.6) vs 3.9 (1-8.8); P = NS]. Overall, the tolerability of Faringel was very good 5 (2-6), with only two patients reporting modest adverse events (i.e., nausea and
Savarino, Edoardo; de Bortoli, Nicola; Zentilin, Patrizia; Martinucci, Irene; Bruzzone, Luca; Furnari, Manuele; Marchi, Santino; Savarino, Vincenzo
AIM: To evaluate the effect of a novel alginate-based compound, Faringel, in modifying reflux characteristics and controlling symptoms. METHODS: In this prospective, open-label study, 40 patients reporting heartburn and regurgitation with proven reflux disease (i.e., positive impedance-pH test/evidence of erosive esophagitis at upper endoscopy) underwent 2 h impedance-pH testing after eating a refluxogenic meal. They were studied for 1 h under basal conditions and 1 h after taking 10 mL Faringel. In both sessions, measurements were obtained in right lateral and supine decubitus positions. Patients also completed a validated questionnaire consisting of a 2-item 5-point (0-4) Likert scale and a 10-cm visual analogue scale (VAS) in order to evaluate the efficacy of Faringel in symptom relief. Tolerability of the treatment was assessed using a 6-point Likert scale ranging from very good (1) to very poor (6). RESULTS: Faringel decreased significantly (P < 0.001), in both the right lateral and supine decubitus positions, esophageal acid exposure time [median 10 (25th-75th percentil 6-16) vs 5.8 (4-10) and 16 (11-19) vs 7.5 (5-11), respectively] and acid refluxes [5 (3-8) vs 1 (1-1) and 6 (4-8) vs 2 (1-2), respectively], but increased significantly (P < 0.01) the number of nonacid reflux events compared with baseline [2 (1-3) vs 3 (2-5) and 3 (2-4) vs 6 (3-8), respectively]. Percentage of proximal migration decreased in both decubitus positions (60% vs 32% and 64% vs 35%, respectively; P < 0.001). Faringel was significantly effective in controlling heartburn, based on both the Likert scale [3.1 (range 1-4) vs 0.9 (0-2); P < 0.001] and VAS score [7.1 (3-9.8) vs 2 (0.1-4.8); P < 0.001], but it had less success against regurgitation, based on both the Likert scale [2.6 (1-4) vs 2.2 (1-4); P = not significant (NS)] and VAS score [5.6 (2-9.6) vs 3.9 (1-8.8); P = NS]. Overall, the tolerability of Faringel was very good 5 (2-6), with only two patients reporting modest adverse
Borrelli, O; Mancini, V; Thapar, N; Ribolsi, M; Emerenziani, S; de'Angelis, G; Bizzarri, B; Lindley, K J; Cicala, M
The diagnostic corroboration of the relationship between gastro-oesophageal reflux disease (GERD) and chronic cough remains challenging. To compare oesophageal mucosal intercellular space diameter (ISD) in children with GERD, children with gastro-oesophageal reflux (GER)-related cough (GrC) and a control group, and to explore the relationship between baseline impedance levels and dilated ISD in children with GER-related cough. Forty children with GERD, 15 children with GrC and 12 controls prospectively underwent oesophagogastroduodenoscopy (EGD) with oesophageal biopsies taken 2-3 cm above squamocolumnar junction. ISD were quantified using transmission electron microscopy. Impedance-pH monitoring with evaluation of baseline impedance in the most distal impedance channel was performed in both patient groups. A significant difference in mean ISD values was found between GrC patients (0.9 ± 0.2 μm) and controls (0.5 ± 0.2 μm, P < 0.001), whereas there was no difference between GrC and GERD group (1 ± 0.3 μm, NS). No difference was found in the mean ISD between GrC children with or without pathological oesophageal acid exposure time (1 ± 0.3 vs. 0.9 ± 0.2 μm), and there was no correlation between ISD and any reflux parameter. Finally, there was no correlation between ISD and distal baseline impedance values (r:-0.35; NS). In children with reflux-related cough, dilated intercellular space diameter appears to be an objective and useful marker of oesophageal mucosal injury regardless of acid exposure, and its evaluation should be considered for those patients where the diagnosis is uncertain. In children with reflux-related cough, baseline impedance levels have no role in identifying reflux-induced oesophageal mucosal ultrastructural changes. © 2014 John Wiley & Sons Ltd.
Sharma, Prateek; Wani, Sachin; Romero, Yvonne; Johnson, David; Hamilton, Frank
Gastroesophageal reflux disease (GERD) is a common chronic disorder that is associated with a huge economic burden in the western countries and significantly decreased quality of life. This review focuses on the various multicultural issues in the epidemiology, pathophysiology, diagnosis, and treatment of GERD. The prevalence of GERD appears to be highest in North America and Europe, whereas epidemiologic data from the Indian subcontinent, Africa, South America, and the Middle East are sparse. A limited number of studies have elucidated ethnic differences in GERD in multiracial populations. African Americans and Asians appear to be at a lower risk for the development of complicated GERD including Barrett's esophagus (BE). Whether the pathophysiology of GERD differs among different populations remains to be answered satisfactorily. It appears that most of the factors involved in the pathogenesis of GERD, as described in western populations, are present in Asians but at a lower scale. The current recommendations for the management of GERD by the American College of Gastroenterology may not meet the need for different ethnic groups or for different geographic regions. Recognition of language barriers in understanding the common terms used to describe reflux symptoms should be borne in mind while treating GERD patients with different ethnic backgrounds. In addition, a universally accepted definition for treatment success in GERD patients is lacking. Given the negative impact on health-related quality of life, significant cost ramifications, and increased risk for BE and esophageal adenocarcinoma, the study of multicultural issues in GERD should be considered.
Analyses of the Post-reflux Swallow-induced Peristaltic Wave Index and Nocturnal Baseline Impedance Parameters Increase the Diagnostic Yield of Impedance-pH Monitoring of Patients With Reflux Disease.
Frazzoni, Marzio; Savarino, Edoardo; de Bortoli, Nicola; Martinucci, Irene; Furnari, Manuele; Frazzoni, Leonardo; Mirante, Vincenzo Giorgio; Bertani, Helga; Marchi, Santino; Conigliaro, Rita; Savarino, Vincenzo
Analyses of impedance parameters such as the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI) have been proposed to increase the accuracy of diagnosis of reflux disease. We assessed whether these improve the diagnostic yield of impedance pH monitoring of reflux disease. We performed a prospective study of consecutive patients with proton pump inhibitor-responsive heartburn who underwent 24-hour impedance pH monitoring at hospitals in Italy from January 2011 through December 2013. Reviewers blindly analyzed off-therapy impedance pH tracings from 289 patients with proton pump inhibitor-responsive heartburn, 68 with erosive reflux disease and 221 with non-erosive reflux disease (NERD), along with 50 healthy individuals (controls). The PSPW index, the MNBI, the esophageal acid exposure time, the number of total refluxes, and the bolus exposure were calculated, as well as the symptom association probability (SAP) and the symptom index (SI). In receiver operating characteristic analysis, the area under curve of the PSPW index (0.977; 95% confidence interval, 0.961-0.993) was significantly greater than that of the other impedance pH parameters in identifying patients with reflux disease (P < .001). The PSPW index and the MNBI identified patients with erosive reflux disease with the highest level of sensitivity (100% and 91%, respectively), as well as the 118 pH-positive (99% and 86%) and 103 pH-negative (77% and 56%) cases of NERD. The PSPW index and the MNBI identified pH-negative NERD with the highest level of sensitivity; values were 82% and 52% for the 65 SAP-positive and/or SI-positive cases and 68% and 63% for the 38 SAP-negative and SI-negative cases. Diagnoses of NERD were confirmed by pH-only criteria, including those that were positive on the basis of the SAP or SI, for 165 of 221 cases (75%) and by impedance pH criteria for 216 of 221 cases (98%) (P = .001). The PSPW index and the MNBI increase the
Zhang, Chaoxian; Guo, Like; Guo, Xiaofeng; Guo, Xiaohe; Li, Guangyan
To study the clinical curative effect, safety and mechanism of action of electroacupuncture combined with Zhizhukuanzhong capsules (ZZKZC) in treating gastroesophageal reflux disease (GERD). A total of 480 patients with confirmed GERD were randomly divided into four groups: the electroacupuncture group, the ZZKZC group, the combined therapy group, and the control group, with 120 cases in each group. Each case in the electroacupuncture group was treated with electroacupuncture on Zusanli (ST 36), Zhongwan (CV 12), Neiguan (PC 6),Taichong (LR 3) and Gongsun (SP 4) once daily for 6 weeks. Each case in the ZZKZC group was treated with oral administration of 1.29 g ZZKZC three times daily. The combined therapy group had electroacupuncture and ZZKZC. The control group was given oral administration of 5 mg mosapride three times and 20 mg pantoprazole twice daily. The 24-hour intraesophageal total number of reflux episodes with pH <4 (or bilirubin absorbance > or = 0.14), the number of long-term (> or = 5 min) reflux episodes, the percentage of upright time, the percentage of supine time, the percentage of total time of pH <4 (or bilirubin absorbance > or = 0.14), endoscopic grading score, symptom score, quality of life score, and adverse reactions were observed before treatment, at the end of treatment and 54 weeks after treatment in the four groups. The 24-hour intraesophageal pH and bile reflux, endoscopic grading score and symptom score were all significantly decreased at the end of treatment in every group, while the scores of 8 dimensions of quality of life were all increased compared with those before treatment (P<0.01). All of these indices were better in the combined therapy group than those in the other groups (P<0.05). These indices did not significantly deteriorate in the combined therapy group and electroacupuncture group 54 weeks after treatment compared with the end of treatment (P>0.05); however, these indices all significantly deteriorated in the ZZKZC and
Orlando, Roy C; Liu, Sherry; Illueca, Marta
Objective: To increase response rates to therapy by increasing the dosage of proton pump inhibitor (PPI) therapy in patients with gastroesophageal reflux disease (GERD) whose symptoms are predominantly associated with acid reflux. Methods: In this double-blind, randomized, proof-of-concept study, 369 patients with GERD and moderate heartburn lasting ≥three days/week, a history of response to antacids/acid suppression therapy, and a positive esophageal acid perfusion test result were randomized to esomeprazole 20 or 40 mg once daily, or to 40 mg twice daily for four weeks. Heartburn symptom relief/resolution was subsequently evaluated. Results: In this study population, no relationship was apparent between esomeprazole dosage and efficacy variables for sustained heartburn resolution (seven days without symptoms) at week 4 (48.0%, 44.0%, and 41.4% for esomeprazole 20 mg once daily, 40 mg once daily, and 40 mg twice daily, respectively). Nocturnal heartburn resolution with esomeprazole 40 mg twice daily showed a numeric improvement trend versus esomeprazole 20 and 40 mg once daily, but this was not statistically significant. Conclusions: Heartburn resolution rates at four weeks were similar for all esomeprazole dosages and comparable with rates reported previously, suggesting a plateau effect in terms of clinical response to acid suppression with PPI therapy in this population of selected GERD patients. PMID:21694855
Savarino, E; de Bortoli, N; De Cassan, C; Della Coletta, M; Bartolo, O; Furnari, M; Ottonello, A; Marabotto, E; Bodini, G; Savarino, V
Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus. © 2016 International Society for Diseases of the Esophagus.
Bolier, E A; Kessing, B F; Smout, A J; Bredenoord, A J
Numerous questionnaires with a wide variety of characteristics have been developed for the assessment of gastroesophageal reflux disease (GERD). Four well-defined dimensions are noticeable in these GERD questionnaires, which are symptoms, response to treatment, diagnosis, and burden on the quality of life of GERD patients. The aim of this review is to develop a complete overview of all available questionnaires, categorized per dimension of the assessment of GERD. A systematic search of the literature up to January 2013 using the Pubmed database and the Embase database, and search of references and conference abstract books were conducted. A total number of 65 questionnaires were extracted and evaluated. Thirty-nine questionnaires were found applicable for the assessment of GERD symptoms, three of which are generic gastrointestinal questionnaires. For the assessment of response to treatment, 14 questionnaires were considered applicable. Seven questionnaires with diagnostic purposes were found. In the assessment of quality of life in GERD patients, 18 questionnaires were found and evaluated. Twenty questionnaires were found to be used for more than one assessment dimension, and eight questionnaires were found for GERD assessment in infants and/or children. A wide variety of GERD questionnaires is available, of which the majority is used for assessment of GERD symptoms. Questionnaires differ in aspects such as design, validation and translations. Also, numerous multidimensional questionnaires are available, of which the Reflux Disease Questionnaire is widely applicable. We provided an overview of GERD questionnaires to aid investigators and clinicians in their search for the most appropriate questionnaire for their specific purposes. © 2013 International Society for Diseases of the Esophagus.
Zelenik, K; Kajzrlikova, I M; Vitek, P; Urban, O; Hanousek, M; Kominek, P
The objective of the present study was to determine if there is correlation between signs of reflux laryngitis (RL) and reflux oesophagitis (RE) in patients with gastro-oesophageal reflux disease (GORD) symptoms. Laryngeal photography obtained from patients during oesophagogastroduodenoscopy were examined by two otolaryngologists experienced in the field of extra-oesophageal reflux regarding the presence and severity of RL. The presence of RE was evaluated by gastroenterologist. Smokers, heavy drinkers and patients with bronchial asthma were excluded from the statistical analysis. A total of 681 patients were analysed. RL was diagnosed in 367 (53.9%) cases, of whom 182 patients had mild, 118 moderate and 67 severe (Reflux Finding Score > 7) RL. RE was diagnosed in 103 (28.1%) patients with RL and in 80 (25.7%) patients without RL. Neither the difference between the overall group of patients with RL and those without (OR 1.141, 95% CI 0.811-1.605, p = 0.448), nor the differences between the respective subgroups of patients with mild, moderate and severe RL and those without RL were statistically significant. The OR and 95% CI for mild, moderate and severe RL were 1.042, 95% CI 0.712-1.526, p = 0.834, 1.182, 95% CI 0.764-1.831, p = 0.453 and 1.0, 95% CI 0.566-1.766, p = 0.999 respectively. It can be concluded that there is no correlation between RL and RE in patients with GORD symptoms. © Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.
Investigation of pretreatment prediction of proton pump inhibitor (PPI)-resistant patients with gastroesophageal reflux disease and the dose escalation challenge of PPIs-TORNADO study: a multicenter prospective study by the Acid-Related Symptom Research Group in Japan.
Furuta, Takahisa; Shimatani, Tomohiko; Sugimoto, Mitsushige; Ishihara, Shunji; Fujiwara, Yasuhiro; Kusano, Motoyasu; Koike, Tomoyuki; Hongo, Michio; Chiba, Tsutomu; Kinoshita, Yoshikazu
Some non-erosive reflux disease (NERD) and reflux esophagitis (RE) patients are unresponsive to a proton pump inhibitor (PPI) at standard dose. We investigated the predictive marker of the efficacy of PPI for GERD patients including NERD and RE treated with standard and increased doses of a PPI. Patients with symptomatic gastroesophageal reflux disease (GERD) (NERD and RE) were treated with rabeprazole (RPZ) 10 mg once daily for 4 weeks. The RPZ dosage was increased to 10 mg twice daily for an additional 2 weeks and again to 20 mg twice daily for another 2 weeks if heartburn was not relieved. Baseline characteristics and efficacy of RPZ were assessed on the basis of a heartburn diary and frequency scale for symptoms of GERD (FSSG). Complete heartburn relief rates after 4 weeks were 42.5% (31/73) and 67.9% (19/28) in NERD and RE groups, respectively, which rose to 68.9 and 91.7% after dose escalation. Multivariate analysis revealed that parameters associated with resistance to RPZ 10 mg once daily were female, non-smoking, frequent heartburn, low score for question 4 (Q4) of the FSSG (subconsciously rubbing the chest), and high scores for Q3 (heavy stomach after meal) and Q7 (unusual sensation in the throat). Frequent heartburn and a high score for Q7 were associated with resistance to RPZ 20 mg twice daily. FSSG scores of patients resistant to RPZ were significantly higher in comparison with responders before and during treatment. FSSG could predict response to a PPI for symptomatic GERD. Increase of RPZ dose is useful for treatment of GERD refractory to the standard dose of RPZ.
Vikneswaran, Namasivayam; Murray, Joseph A
Combined impedance-pH testing (MII) allows for detection of reflux episodes regardless of pH. However impedance-based diagnosis of reflux may not routinely account for duration of the reflux episode. We hypothesize that impedance testing may be less sensitive than pH-testing in detecting acid reflux off therapy as a result of discounting duration of exposure. Baseline characteristics and reflux parameters of MII studies performed off-anti-secretory medications were analyzed. Studies on acid suppressive medication and those with recording times less than 20 h or low baseline impedance were excluded. A total of 73 consecutive MII studies were analyzed of which 31 MII studies had elevated acid exposure while 16 were abnormal by impedance criteria. MII testing off-therapy was more likely to be abnormal by pH criteria (percent time pH < 4) than impedance criteria (total reflux):[42 vs 22 % (p =0.02)]. Acid exposure (percent time pH < 4) identified more studies as abnormal than MII-detected acid reflux episodes [42 vs 34 % (p < 0.01)]. Mean acid clearance time (pH-detected) was significantly longer than median bolus clearance time (impedance-detected) in the total [98.7 s vs 12.6 s (p < 0.01)], upright [58.6 s vs 13.1 s (p < 0.01)], and recumbent positions [136.7 s vs 14.2 s (p < 0.01)] with the greatest difference seen in the recumbent position. The mean ratio of mean acid clearance time (pH-detected) and the median bolus clearance time (impedance-detected) was significantly higher in the recumbent position compared to the upright position [11. vs 5.3 (p = 0.01)]. Ambulatory impedance testing underestimates acid reflux compared to esophageal acid exposure by discounting the prolonged period of mucosal contact with each acid reflux episode, particularly in the recumbent position.
Yang, Hyo-Joon; Chang, Yoosoo; Park, Soo-Kyung; Jung, Yoon Suk; Park, Jung Ho; Park, Dong Il; Cho, Yong Kyun; Ryu, Seungho; Sohn, Chong Il
Reflux esophagitis is associated with obesity and metabolic syndrome; however, the relationship between nonalcoholic fatty liver disease (NAFLD) and reflux esophagitis is unclear. We examined the association between NAFLD and the development of reflux esophagitis. Our cohort consisted of 117,377 Korean adults without reflux esophagitis at baseline who underwent a health checkup program including upper endoscopy between 2002 and 2014 and were followed annually or biennially until December 2014. NAFLD was defined as hepatic steatosis on ultrasonography in the absence of excessive alcohol use or any other identifiable cause. Over 520,843.2 person-years of follow-up, 22,500 participants developed reflux esophagitis (incidence density, 43.2 per 1000 person-years). In models adjusted for age and sex, the adjusted hazard ratio (aHR) (95% confidence interval [CI]) for incident reflux esophagitis in subjects with NAFLD compared to those without was 1.16 (1.13-1.20). After further adjustment for confounders of center, year of visit, smoking status, alcohol intake, regular exercise, education level, and body mass index, the association between NAFLD and incident reflux esophagitis was attenuated, but remained significant (aHR 1.06; 95% CI 1.02-1.10). In this large cohort of Korean men and women, participants with NAFLD exhibited increased incidence of reflux esophagitis independent of possible confounders, suggesting that NAFLD contributes to the development of reflux esophagitis.
What are reflux (GER) and GERD? The esophagus is the tube that carries food from your mouth to your stomach. If your baby has reflux, his or ... into the esophagus. Another name for reflux is gastroesophageal reflux (GER). GERD stands for gastroesophageal reflux disease. It ...
What are reflux (GER) and GERD? The esophagus is the tube that carries food from your mouth to your stomach. If your child has reflux, his or ... into the esophagus. Another name for reflux is gastroesophageal reflux (GER). GERD stands for gastroesophageal reflux disease. It ...
Cheung, Ting K; Wong, Benjamin C Y; Lam, Shiu K
Gastro-oesophageal reflux disease (GORD) is one of the most common gastrointestinal diseases in the Western world and imposes a heavy burden on society. Although its prevalence in Asia is much lower, there is evidence that this is rapidly rising in Asia. The reported population prevalence of GORD in Eastern Asia ranges from 2.5% to 6.7% for at least weekly symptoms of heartburn and/or acid regurgitation. In general, Asians tend to have a milder spectrum of the disease. Most Asian patients have non-erosive GORD; erosive oesophagitis is less commonly seen than in the Western population. Complicated GORD, such as oesophageal stricture and Barrett's oesophagus, is seldom encountered. The mechanisms of GORD may be different in the Chinese population compared with the Western population. Chest pain is the most predominant extra-oesophageal manifestation of GORD in China, whereas an association with asthma has been shown in Japanese patients. The prevalence of GORD appears to be increasing and possible factors for GORD in Asian populations include Helicobacterpylori infection, obesity and increasing dietary fat intake. The adoption of a Western lifestyle in many developing Asian countries may account for the increasing prevalence of GORD. Proton pump inhibitors remain the most effective medical treatment for GORD. GORD will undoubtedly be a great challenge to clinicians both in primary care and in gastroenterology practice in the Asia-Pacific region in the coming years.
Miwa, Hiroto; Kondo, Takashi; Oshima, Tadayuki
Patients who continue to experience heartburn symptoms despite adequate-dose proton pump inhibitor therapy have unmet clinical needs. In this review, we focus on the most recent findings related to the mechanism of heartburn symptom generation, and on the treatment of gastroesophageal reflux disease-related and functional heartburn. The immunological mechanism in the esophageal mucosa has been addressed as a potential mechanism of the onset of esophageal mucosa damage and the generation of heartburn symptoms. Peripheral or central hypersensitivity in viscera is a potentially unifying pathophysiological concept in functional heartburn. Vonoprazan, a novel and potent first-in-class potassium-competitive acid blocker, is expected to prove useful in the treatment of reflux disease. New findings in the mechanisms of heartburn symptom generation are emerging, including the immunological mediation of esophageal mucosal damage and the development of visceral hypersensitivity in functional heartburn. In the future, we anticipate the emergence of new and specific therapeutic options based on these mechanisms, with less dependence on acid-suppressing agents.
Kilduff, Claire E; Counter, Melanie J; Thomas, Gareth A; Harrison, Nicholas K; Hope-Gill, Benjamin D
Chronic cough affects more than 70 percent of patients with Idiopathic Pulmonary Fibrosis and causes significant morbidity. Gastroesophageal reflux is the cause of some cases of chronic cough; and also has a postulated role in the aetiology of Idiopathic Pulmonary Fibrosis. A high prevalence of acid; and more recently non-acid, reflux has been observed in Idiopathic Pulmonary Fibrosis cohorts. Therefore, gastroesophageal reflux may be implicated in the pathogenesis of cough in Idiopathic Pulmonary Fibrosis. Eighteen subjects with Idiopathic Pulmonary Fibrosis underwent 24-hour oesophageal impedance and cough count monitoring after the careful exclusion of causes of chronic cough other than gastroesophageal reflux. All 18 were then treated with high dose acid suppression therapies. Fourteen subjects underwent repeat 24-hour oesophageal impedance and cough count monitoring after eight weeks. Total reflux and acid reflux frequencies were within the normal range in the majority of this cohort. The frequencies of non-acid and proximal reflux events were above the normal range. Following high dose acid suppression therapy there was a significant decrease in the number of acid reflux events (p = 0.02), but an increase in the number of non-acid reflux events (p = 0.01). There was no change in cough frequency (p = 0.70). This study confirms that non-acid reflux is prevalent; and that proximal oesophageal reflux occurs in the majority, of subjects with Idiopathic Pulmonary Fibrosis. It is the first study to investigate the effect of acid suppression therapy on gastroesophageal reflux and cough in patients with Idiopathic Pulmonary Fibrosis. The observation that cough frequency does not improve despite verifiable reductions in oesophageal acid exposure challenges the role of acid reflux in Idiopathic Pulmonary Fibrosis associated cough. The finding that non-acid reflux is increased following the use of acid suppression therapies cautions against the widespread use
Background Chronic cough affects more than 70 percent of patients with Idiopathic Pulmonary Fibrosis and causes significant morbidity. Gastroesophageal reflux is the cause of some cases of chronic cough; and also has a postulated role in the aetiology of Idiopathic Pulmonary Fibrosis. A high prevalence of acid; and more recently non-acid, reflux has been observed in Idiopathic Pulmonary Fibrosis cohorts. Therefore, gastroesophageal reflux may be implicated in the pathogenesis of cough in Idiopathic Pulmonary Fibrosis. Methods Eighteen subjects with Idiopathic Pulmonary Fibrosis underwent 24-hour oesophageal impedance and cough count monitoring after the careful exclusion of causes of chronic cough other than gastroesophageal reflux. All 18 were then treated with high dose acid suppression therapies. Fourteen subjects underwent repeat 24-hour oesophageal impedance and cough count monitoring after eight weeks. Results Total reflux and acid reflux frequencies were within the normal range in the majority of this cohort. The frequencies of non-acid and proximal reflux events were above the normal range. Following high dose acid suppression therapy there was a significant decrease in the number of acid reflux events (p = 0.02), but an increase in the number of non-acid reflux events (p = 0.01). There was no change in cough frequency (p = 0.70). Conclusions This study confirms that non-acid reflux is prevalent; and that proximal oesophageal reflux occurs in the majority, of subjects with Idiopathic Pulmonary Fibrosis. It is the first study to investigate the effect of acid suppression therapy on gastroesophageal reflux and cough in patients with Idiopathic Pulmonary Fibrosis. The observation that cough frequency does not improve despite verifiable reductions in oesophageal acid exposure challenges the role of acid reflux in Idiopathic Pulmonary Fibrosis associated cough. The finding that non-acid reflux is increased following the use of acid suppression
Law, Ruth; Maltepe, Caroline; Bozzo, Pina; Einarson, Adrienne
QUESTION In addition to suffering from nausea and vomiting of pregnancy, which is being treated with antiemetics, some of my pregnant patients complain of heartburn and acid reflux. Should these symptoms also be treated and, if so, which acid-reducing medications are safe for use during pregnancy? ANSWER Increased severity of nausea and vomiting of pregnancy is associated with the presence of heartburn and acid reflux. Antacids, histamine-2 receptor antagonists, and proton pump inhibitors can be used safely during pregnancy, as large studies have been published with no evidence of adverse fetal effects. PMID:20154244
Ganz, Robert A
A magnetic implant for the treatment of gastroesophageal reflux disease (GERD) was Food and Drug Administration-approved in 2012 and has been extensively evaluated. The device is a ring of magnets that are placed around the gastroesophageal junction, augmenting the native lower esophageal sphincter and preventing reflux yet preserving lower esophageal sphincter physiologic function and allowing belching and vomiting. Magnetic force is advantageous, being permanent and precise, and forces between magnets decrease with esophageal displacement. Multiple patient cohorts have been studied using the magnetic device, and trials establish consistent, long-term improvement in pH data, GERD symptom scores, and proton-pump inhibitor use. A 5-year Food and Drug Administration trial demonstrated that most patients achieved normal pH scores, 85% stopped proton-pump inhibitors, and GERD health-related quality of life symptom scores improved from 27 to 4 at 5 years. Seven studies have compared magnetic augmentation with laparoscopic Nissen fundoplication and demonstrated that the magnetic device achieved comparable efficacy with regard to proton-pump inhibitor cessation, GERD symptom score improvement, and heartburn and regurgitation scores. However, to date there have been no randomized, controlled trials comparing the 2 techniques, and the study cohorts are not necessarily comparable regarding hiatal hernia size, severity of reflux, body mass index scores, or esophagitis scores. Dysphagia incidence was similar in both groups. Reoperation rates and safety profiles were also comparable, but the magnetic device demonstrated significant beneficial differences in allowing belching and vomiting. The magnetic device is safe, with the main adverse event being dysphagia with an approximate 3%-5% chronic incidence. Device removals in clinical trials have been between 0% and 7% and were uneventful. There have been no erosions, perforations, or infections in FDA clinical trials
Hu, Hai-Qing; Li, Hui-Kai; Xiong, Ying; Zhang, Xiao-Bin; Zhi, Jun-Li; Wang, Xiao-Xiao; Ling-Hu, En-Qiang
Gastroesophageal reflux disease (GERD) is a major digestive health problem with a high and increasing incidence worldwide. Peroral endoscopic cardial constriction (PECC) was developed by our group to provide a less invasive treatment for GERD.In this preliminary follow-up study, 16 patients were enrolled and 13 patients with GERD were targeted for analysis according to the Los Angeles classification of reflux esophagitis. The GERD health-related quality of life (GERD-HRQL) scale and esophageal pH monitoring were applied to assess clinical efficiency at 3 and 6 months after PECC treatment, respectively.All GERD patients successively received PECC, and no severe treatment-related complication was reported. Before PECC treatment, the GERD-HRQL scale was 19.92 ± 7.89. At 3 and 6 months after treatment, the GERD-HRQL scale was 4.46 ± 4.31 and 5.69 ± 5.07, respectively. DeMeester score was 125.50 ± 89.64 before PECC treatment, and 16.97 ± 12.76 and 20.32 ± 15.22 at 3 and 6 months after PECC treatment. Furthermore, the fraction time of a pH below 4 significantly decreased at 3 and 6 months after PECC treatment. Fraction time at pH <4 was 35.55 ± 26.20 before PECC treatment and 7.96 ± 13.03 and 4.72 ± 3.78 at 3 and 6 months after PECC treatment, respectively. These results suggest that PECC treatment could significantly reduce the GERD-HRQL scale and DeMeester score (P < .01).PECC is a feasible, safe, and effective method to treatment GERD through narrowing the diameter of the cardia and preventing the reflux of stomach contents.
Bardhan, K. D.
Acid-peptic disease is widely considered conquered or controlled, future advances being refinements of existing treatments rather than radical new developments. Yet controversies remain and developments have yet to be made. DUODENAL ULCER: Daily maintenance treatment with the anti-secretory drugs, histamine H2 receptor antagonists and proton pump blockers, controls duodenal ulcer effectively, markedly reducing relapse rate at one year after treatment from about 75 percent to 15 to 20 percent (and to about 10 percent on proton pump blockers). In contrast, Helicobacter pylori eradication with a one to two week course of treatment yields prolonged remission or cure. The consequent reduction in drug costs in individual patients, however, has been exceeded by increasing community use on the more expensive proton pump blockers for the treatment of gastroesophageal reflux disease. The marked decline in elective surgery since the introduction of histamine H2 receptor antagonists is commonly attributed to the power of these drugs. The fall, however, had started much earlier, indicating that the decline is due to changing natural history. In contrast, complication rates remain unaltered. An increasing proportion of newly diagnosed duodenal ulcer patients are elderly, and more of them now present for the first time with complications (in this center, about 40 percent), which consequently cannot be forestalled. Thus, duodenal ulcer disease is likely to remain a problem and in many will be a serious illness. GASTROESOPHAGEAL REFLUX DISEASE: The proton pump blockers have revolutionized the treatment of gastroesophageal reflux disease. In clinical trials they have proven markedly superior to the histamine H2 receptor antagonists in healing (at eight weeks, 80 to 90 percent vs. 50 to 60 percent), symptom relief, prevention of relapse on maintenance therapy and cost-effectiveness. However, several issues remain. The prevalence of gastroesophageal reflux disease seems to be rising
Silva, Renan O; Oliveira, Francisco Fábio B; Bingana, Rudy D; Arruda, Mailton O; Woodland, Philip; Lee, Chung; Souza, Miguel A N; Soares, Pedro M G; Santos, Armênio A; Sifrim, Daniel; Souza, Marcellus H L P
Nonerosive reflux disease (NERD) is a highly prevalent phenotype of the gastroesophageal reflux disease. In this study, we developed a novel murine model of NERD in mice with microscopic inflammation and impairment in the epithelial esophageal barrier. Female Swiss mice were subjected to the following surgical procedure: the transitional region between the forestomach and the glandular portion of the stomach was ligated, and a nontoxic ring was placed around the duodenum near the pylorus. The control group underwent sham surgery. The animals were euthanized at 1, 3, 7, and 14 days after surgery. Survival and body weight were monitored daily. Esophageal wet weight, macroscopic lesion, histopathological alterations, myeloperoxidase (MPO) activity, cytokine levels, transepithelial electrical resistance (TEER), and mucosal permeability were evaluated. The survival rate was 78% at 14 days, with mild loss in body weight. Surgery did not induce erosive esophagitis but instead induced microscopic inflammation and increased esophageal wet weight, IL-6, keratinocyte-derived cytokine (KC) levels, and MPO activity with maximal peak between 3 and 7 days and resolution at 14 days postsurgery. Epithelial esophageal barrier was evaluated in operated mice at 7 and 14 days postsurgery; a decrease in TEER and increase in the esophageal epithelial permeability were observed compared with the sham-operated group. In addition, the inhibition of acid secretion with omeprazole significantly prevented the esophageal inflammation and impairment of barrier function at 7 days postsurgery. Thus we established a novel experimental model of NERD in mice, which can contribute to understanding the pathophysiological events associated with NERD. NEW & NOTEWORTHY In this study, we standardized an experimental model of nonerosive reflux disease (NERD) in mice. This model involves an acute inflammatory response followed by impaired esophageal mucosal integrity, even in the absence of inflammation
Mello, M D; Shriver, A R; Li, Y; Patel, A; Gyawali, C P
Ineffective esophageal motility (IEM) is associated with reflux disease, but its natural history is unclear. We evaluated patients undergoing repeat esophageal high resolution manometry (HRM) for symptomatic presentations after antireflux surgery (ARS) to understand the progression of IEM. Patients with repeat HRM after ARS were included. Ineffective esophageal motility was diagnosed if ≥5 sequences had distal contractile integral (DCI) <450 mmHg cm s. Augmentation of DCI following multiple rapid swallows (MRS) was assessed. The esophagogastric junction (EGJ) was interrogated using the EGJ contractile integral (EGJ-CI). Esophageal motor function was compared between patients with and without IEM. Sixty-eight patients (53.9 ± 1.8 years, 66.2% female) had pre- and post-ARS HRM studies 2.1 ± 0.19 years apart. Esophagogastric junction-CI augmented by a mean of 26.3% following ARS. Four IEM phenotypes were identified: 14.7% had persistent IEM, 8.8% resolved IEM after ARS, 19.1% developed new IEM, and 57.4% had no IEM at any point. Patients with IEM had a lower DCI pre- and post-ARS, lower pre-ARS EGJ CI, and lower pre-ARS-integrated relaxation pressure (p ≤ 0.02 for all comparisons); presenting symptoms and other EGJ metrics were similar (p ≥ 0.08 for all comparisons). The IEM phenotypes could be predicted by MRS DCI response patterns (p = 0.008 across groups); patients with persistent IEM had the least DCI augmentation (p = 0.007 compared to no IEM), while those who resolved IEM had DCI augmentation comparable to no IEM (p = 0.08). Distinct phenotypes of IEM exist among symptomatic reflux patients following ARS. Provocative testing with MRS may help identify these phenotypes pre-ARS. © 2015 John Wiley & Sons Ltd.
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Busch, Evan L; Zevallos, Jose P; Olshan, Andrew F
Exposure to excess gastric acid resulting from gastroesophageal reflux disease, also known as acid reflux or heartburn, might contribute to initiation of head and neck squamous cell carcinoma, particularly laryngeal cancer. Prior epidemiologic studies have reported inconsistent results. We sought to clarify this relationship using an observational study with a larger available sample size and better-characterized exposure information than most prior studies. A population-based case-control study of head and neck cancer in North Carolina with 1,340 newly diagnosed cases and 1,378 controls matched on age, race, and sex. We used unconditional logistic regression to examine associations between self-reported heartburn and development of overall head and neck cancer as well as development of cancer at specific tumor sites. Subgroup analysis by smoking and alcoholic drinking status was used to make comparisons with a previous study that used a similar study design. Overall, an increased odds of head and neck cancer was not associated with either self-reported history of heartburn symptoms (odds ratio = 0.85; 95% confidence interval 0.68, 1.06) or self-reported medical diagnosis of GERD (OR = 0.89; 95% CI 0.71, 1.11). These patterns held for specific tumor sites. For laryngopharyngeal cancer, we did not detect any associations regardless of joint smoking and alcoholic drinking status. Gastroesophageal reflux does not appear to play a role in development of head and neck cancer. 3b. Laryngoscope, 126:1091-1096, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.
Rebecchi, Fabrizio; Allaix, Marco E; Patti, Marco G; Schlottmann, Francisco; Morino, Mario
Laparoscopic sleeve gastrectomy (LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease (GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h pH monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve (both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Roux-en-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX® Reflux Management System procedure and the Stretta® procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of pH monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5th International Consensus
Rebecchi, Fabrizio; Allaix, Marco E; Patti, Marco G; Schlottmann, Francisco; Morino, Mario
Laparoscopic sleeve gastrectomy (LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease (GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h pH monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve (both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Roux-en-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX ® Reflux Management System procedure and the Stretta ® procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of pH monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5 th International
Punjabi, Paawan; Hira, Angela; Prasad, Shanti; Wang, Xiangbing; Chokhavatia, Sita
This article reviews the known pathophysiological mechanisms of comorbid gastroesophageal reflux disease (GERD) in the diabetic patient, discusses therapeutic options in care, and provides an approach to its evaluation and management. We searched for review articles published in the past 10 years through a PubMed search using the filters diabetes mellitus, GERD, pathophysiology, and management. The search only yielded a handful of articles, so we independently included relevant studies from these review articles along with related citations as suggested by PubMed. We found diabetic patients are more prone to developing GERD and may present with atypical manifestations. A number of mechanisms have been proposed to elucidate the connection between these two diseases. Studies involving treatment options for comorbid disease suggest conflicting drug-drug interactions. Currently, there are no published guidelines specifically for the evaluation and management of GERD in the diabetic patient. Although there are several proposed mechanisms for the higher prevalence of GERD in the diabetic patient, this complex interrelationship requires further research. Understanding the pathophysiology will help direct diagnostic evaluation. In our review, we propose a management algorithm for GERD in the diabetic patient. © 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.
Zen Junior, José Hélio; Del Negro, André; Colli Neto, José Alexandre; Araujo, Marina Rachel; Altemani, Albina Maria; Andreollo, Nelson Adami
To develop experimental models to evaluate the effects of hydrochloric acid associated with the pepsin instilled in the mucosa of the upper esophagus and the esophagogastric junction of young male rats Wistar, simulating injury caused by gastroesophageal reflux on the mucosa of aero-digestive tract in humans as well as the action of the risk exposure of mucosa to cigarette smoke. Fifty young male Wistar rats divided in 5 groups with 10 animals each one, respectively simulating pharyngo-laryngeal reflux and gastroesophageal reflux, pharyngo-laryngeal reflux and smoking, smoking only, gastroesophageal reflux and control group. The histopathologic studies no recorded neoplasias, only mild changes and no significant alterations. The hemo-oximetry (carboxyhemoglobin and methemoglobim) and CO2 concentration confirm that the animals were submitted to high intensity of exposure to carcinogens in tobacco and its derivatives. The experimental models were highly efficient, practical, easy to use and economical and can be employed in other similar studies to determine the harmful effects by smoking and reflux.
Kawara, Fumiaki; Fujita, Tsuyoshi; Morita, Yoshinori; Uda, Atsushi; Masuda, Atsuhiro; Saito, Masaya; Ooi, Makoto; Ishida, Tsukasa; Kondo, Yasuyuki; Yoshida, Shiei; Okuno, Tatsuya; Yano, Yoshihiko; Yoshida, Masaru; Kutsumi, Hiromu; Hayakumo, Takanobu; Yamashita, Kazuhiko; Hirano, Takeshi; Hirai, Midori; Azuma, Takeshi
AIM To elucidate the factors associated with residual gastroesophageal reflux disease (GERD) symptoms in patients receiving proton pump inhibitor (PPI) maintenance therapy in clinical practice. METHODS The study included 39 GERD patients receiving maintenance PPI therapy. Residual symptoms were assessed using the Frequency Scale for Symptoms of GERD (FSSG) questionnaire and the Gastrointestinal Symptom Rating Scale (GSRS). The relationships between the FSSG score and patient background factors, including the CYP2C19 genotype, were analyzed. RESULTS The FSSG scores ranged from 1 to 28 points (median score: 7.5 points), and 19 patients (48.7%) had a score of 8 points or more. The patients’ GSRS scores were significantly correlated with their FSSG scores (correlation coefficient = 0.47, P < 0.005). In erosive esophagitis patients, the FSSG scores of the CYP2C19 rapid metabolizers (RMs) were significantly higher than the scores of the poor metabolizers and intermediate metabolizers (total scores: 16.7 ± 8.6 vs 7.8 ± 5.4, P < 0.05; acid reflux-related symptom scores: 12 ± 1.9 vs 2.5 ± 0.8, P < 0.005). In contrast, the FSSG scores of the CYP2C19 RMs in the non-erosive reflux disease patients were significantly lower than those of the other patients (total scores: 5.5 ± 1.0 vs 11.8 ± 6.3, P < 0.05; dysmotility symptom-related scores: 1.0 ± 0.4 vs 6.0 ± 0.8, P < 0.01). CONCLUSION Approximately half of the GERD patients receiving maintenance PPI therapy had residual symptoms associated with a lower quality of life, and the CYP2C19 genotype appeared to be associated with these residual symptoms. PMID:28373773
Kawara, Fumiaki; Fujita, Tsuyoshi; Morita, Yoshinori; Uda, Atsushi; Masuda, Atsuhiro; Saito, Masaya; Ooi, Makoto; Ishida, Tsukasa; Kondo, Yasuyuki; Yoshida, Shiei; Okuno, Tatsuya; Yano, Yoshihiko; Yoshida, Masaru; Kutsumi, Hiromu; Hayakumo, Takanobu; Yamashita, Kazuhiko; Hirano, Takeshi; Hirai, Midori; Azuma, Takeshi
To elucidate the factors associated with residual gastroesophageal reflux disease (GERD) symptoms in patients receiving proton pump inhibitor (PPI) maintenance therapy in clinical practice. The study included 39 GERD patients receiving maintenance PPI therapy. Residual symptoms were assessed using the Frequency Scale for Symptoms of GERD (FSSG) questionnaire and the Gastrointestinal Symptom Rating Scale (GSRS). The relationships between the FSSG score and patient background factors, including the CYP2C19 genotype, were analyzed. The FSSG scores ranged from 1 to 28 points (median score: 7.5 points), and 19 patients (48.7%) had a score of 8 points or more. The patients' GSRS scores were significantly correlated with their FSSG scores (correlation coefficient = 0.47, P < 0.005). In erosive esophagitis patients, the FSSG scores of the CYP2C19 rapid metabolizers (RMs) were significantly higher than the scores of the poor metabolizers and intermediate metabolizers (total scores: 16.7 ± 8.6 vs 7.8 ± 5.4, P < 0.05; acid reflux-related symptom scores: 12 ± 1.9 vs 2.5 ± 0.8, P < 0.005). In contrast, the FSSG scores of the CYP2C19 RMs in the non-erosive reflux disease patients were significantly lower than those of the other patients (total scores: 5.5 ± 1.0 vs 11.8 ± 6.3, P < 0.05; dysmotility symptom-related scores: 1.0 ± 0.4 vs 6.0 ± 0.8, P < 0.01). Approximately half of the GERD patients receiving maintenance PPI therapy had residual symptoms associated with a lower quality of life, and the CYP2C19 genotype appeared to be associated with these residual symptoms.
Li, Yu-Wen; Sifrim, Daniel; Xie, Chenxi; Chen, Minhu; Xiao, Ying-Lian
Increased salivary pepsin could indicate an increase in gastro-esophageal reflux, however, previous studies failed to demonstrate a correlation between salivary pepsin concentrations and 24-hour esophageal acid exposure. This study aims to detect the salivary pepsin and to evaluate the relationship between salivary pepsin concentrations and intercellular spaces (IS) in different gastroesophageal reflux disease phenotypes in patients. A total of 45 patients and 11 healthy volunteers were included in this study. All subjects underwent upper gastrointestinal endoscopy, 24-hour ambulatory multichannel impedance-pH (MII-pH) monitoring, and salivary sampling at 3-time points during the 24-hour MII-pH monitoring. IS were measured by transmission electron microscopy, and salivary pepsin concentrations were determined by enzyme-linked immunosorbent assay. The IS measurements were greater in the esophagitis (EE), non-erosive reflux disease (NERD), and hypersensitive esophagus (HO) groups than in the functional heartburn (FH) and healthy volunteer groups, and significant differences were indicated. Patients with NERD and HO had higher average pepsin concentrations compared with FH patients. A weak correlation was determined between IS and salivary pepsin among patients with NERD ( r = 0.669, P = 0.035). We confirmed the presence of a higher level of salivary pepsin in patients with NERD than in patients with FH. Salivary pepsin concentrations correlated with severity of mucosal integrity impairment in the NERD group. We suggest that in patients with NERD, low levels of salivary pepsin can help identify patients with FH, in addition the higher the pepsin concentration, the more likely the severity of dilated IS.
Yan, Jingliang; Strong, Andrew T; Sharma, Gautam; Gabbard, Scott; Thota, Prashanti; Rodriguez, John; Kroh, Matthew
Systemic sclerosis (scleroderma) is frequently associated with both gastroesophageal reflux disease (GERD) and simultaneous esophageal dysmotility. Anti-reflux procedures in this patient population must account for the existing physiology of each patient and likely disease progression. We aim to compare perioperative and intermediate outcomes of fundoplication versus gastric bypass for the treatment of GERD. After IRB approval, patients with systemic sclerosis undergoing fundoplication or gastric bypass for the treatment of GERD from 2004 to 2016 were identified. Demographics, perioperative data, immediate complications, and symptom improvement were retrieved and analyzed. Fourteen patients with systemic sclerosis underwent surgical treatment of GERD during the defined study period. Average body mass index was 26 kg/m 2 . Seven fundoplications (2 Nissens, 4 Toupets, and 1 Dor) and 7 Roux-en-Y gastric bypasses (RYGB) were performed. No 30-day mortality was observed in either group. Median follow-up was 97 months for the fundoplication group (range 28-204 months), and 19 months for the RYGB group (range 1-164 months). Preoperatively, dysphagia, heartburn, and regurgitation were present in 71% (n = 10), 86% (n = 12), and 64% (n = 9) of patients, respectively. Eleven patients had pH study prior to surgical intervention, and 91% of them had abnormal acid exposure. Esophagitis was evident in 85% (n = 11) of patients during preoperative upper endoscopy, and two patients had Barrett's esophagus. Impaired esophageal motility was present in all RYGB patients and 71% of fundoplication patients. Of the patients who had assessment of their GERD symptoms at follow-up, all five patients in the RYGB group and only 3 (50%) patients in the fundoplication group reported symptom improvement or resolution. Laparoscopic RYGB as an anti-reflux procedure is safe and may provide an alternative to fundoplication in the treatment of GERD for systemic sclerosis patients
Petryszyn, Pawel; Staniak, Aleksandra; Grzegrzolka, Jedrzej
To compare the cost-effectiveness of therapy of gastroesophageal reflux disease with esomeprazole and other proton pump inhibitors (PPIs) in Poland. Studies comparing esomeprazole with other PPIs in the treatment of erosive esophagitis, non-erosive reflux disease and gastroesophageal reflux disease maintenance therapy were systematically reviewed. 9 randomized clinical trials were selected, meta-analyses were conducted. Cost data derived from Polish Ministry of Health and Pharmacies in Wroclaw. In the treatment of erosive esophagitis esomeprazole was significantly more effective than other PPIs. Both for 4- and 8-week therapy respective incremental cost-effectiveness ratio values were acceptably low. Differences in effectiveness of non-erosive reflux disease therapy were not significant. The replacement of pantoprazole 20 mg with more effective esomeprazole 20 mg in the 6-month maintenance therapy was associated with a substantially high incremental cost-effectiveness ratio.
Mahawar, Kamal K; Jennings, Neil; Balupuri, Shlok; Small, Peter K
Sleeve gastrectomy is rapidly becoming popular as a standalone bariatric operation. At the same time, there are valid concerns regarding its long-term durability and postoperative gastro-oesophageal reflux disease. Though gastric bypass remains the gold standard bariatric operation, it is not suitable for all patients. Sleeve gastrectomy is sometimes the only viable option. Patients with inflammatory bowel disease, liver cirrhosis, significant intra-abdominal adhesions involving small bowel and those reluctant to undergo gastric bypass could fall in this category. It is widely recognised that some patients report worsening of their gastro-oesophageal reflux disease after sleeve gastrectomy. Still, others develop de novo reflux. This review examines if it is possible to identify these patients prior to surgery and thus prevent postoperative gastro-oesophageal reflux disease after sleeve gastrectomy.
Surdea-Blaga, Teodora; Băncilă, Ion; Dobru, Daniela; Drug, Vasile; Frățilă, Ovidiu; Goldiș, Adrian; Grad, Simona M; Mureșan, Crina; Nedelcu, Laurențiu; Porr, Paul J; Sporea, Ioan; Dumitrascu, Dan L
Gastroesophageal reflux disease (GERD) therapy is challenging and suppression of acid secretion or prokinetics do not cure all cases. Some drugs with protective action on the esophageal mucosa have been used alternatively or in association with proton pump inhibitors (PPIs) and/or prokinetics. The Romanian Society of Neurogastroenterology undertook an Evidence-Based analysis, from which this position paper evolved. We performed a systematic literature search in PubMed until October 2015, using the terms: sucralfate, guaiazulene, gaiazulene, dimethicone, alginate, antacids and gastroesophageal reflux. Forty-seven papers were included and analyzed. Several statements were elaborated regarding the use of these drugs in GERD. The evidence and recommendations were discussed between the authors. There is evidence in the medical literature suggesting the benefit of these drugs in GERD. In patients with persistent or mild reflux symptoms antacids rapidly relieve heartburn. Alginate-antacid combination is superior both over placebo and antacids to treat mild reflux symptoms, and can be used to treat persistent reflux symptoms despite acid suppressant therapy. Sucralfate is superior over placebo in alleviating GERD symptoms and can be used as maintenance therapy. Guaiazulene-dimethicone improves the quality of life in patients with GERD. Drugs used to protect the esophageal mucosa against acid are useful in alleviating chronic heartburn, especially in patients with mild reflux symptoms.
Raghunath, Anan; Hungin, A Pali S; Wooff, David; Childs, Susan
Objectives To ascertain the prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease and its association with the disease. Design Systematic review of studies reporting the prevalence of H pylori in patients with and without gastro-oesophageal reflux disease. Data sources Four electronic databases, searched to November 2001, experts, pharmaceutical companies, and journals. Main outcome measure Odds ratio for prevalence of H pylori in patients with gastro-oesophageal reflux disease. Results 20 studies were included. The pooled estimate of the odds ratio for prevalence of H pylori was 0.60 (95% confidence interval 0.47 to 0.78), indicating a lower prevalence in patients with gastro-oesophageal reflux disease. Substantial heterogeneity was observed between studies. Location seemed to be an important factor, with a much lower prevalence of H pylori in patients with gastro-oesophageal reflux disease in studies from the Far East, despite a higher overall prevalence of infection than western Europe and North America. Year of study was not a source of heterogeneity. Conclusion The prevalence of H pylori infection was significantly lower in patients with than without gastro-oesophageal reflux, with geographical location being a strong contributor to the heterogeneity between studies. Patients from the Far East with reflux disease had a lower prevalence of H pylori infection than patients from western Europe and North America, despite a higher prevalence in the general population. What is already known on this topicThe relation between H pylori infection and gastro-oesophageal reflux disease is controversialStudies on the prevalence of H pylori in patients with gastro-oesophageal reflux disease have given conflicting resultsRecent guidelines recommend eradication of H pylori in patients requiring long term proton pump inhibitors, essentially for reflux diseaseWhat this study addsDespite heterogeneity between studies, the prevalence of H pylori was
Falcão, Angela; Nasi, Ary; Brandão, Jeovana; Sallum, Rubens; Cecconello, Ivan
Impairment of esophageal motility is a common finding in patients with gastroesophageal reflux disease (GERD) as reduced lower esophageal sphincter (LES) basal pressure. A very low LES pressure might facilitate the occurrence of more gastroesophageal reflux whereas abnormal esophageal peristalsis may contribute to impaired esophageal clearance after reflux. Evaluate the esophageal motor function of the lower esophageal sphincter and esophageal body in the various forms of gastroesophageal reflux disease. The manometrics records of 268 patients, who had evaluation of the esophageal motility as part of the diagnostic gastroesophageal reflux disease were split into four groups, as follows: 33 patients who had no esophagitis; 92 patients who had erosive esophagitis; 101 patients who had short Barrett's esophagus and 42 patients who had long Barrett's esophagus. The group who had long Barrett's esophagus showed smaller mean LES pressure and higher percentage of marked LES hypotonia; in the distal segment of the esophageal body the this group showed higher percentage of marked hypocontractility of the distal segment (<30 mm Hg); this same group showed higher percentage of esophageal motility disorders. The most intense esophageal motility disorders and lower pressure of lower esophageal sphincter were noted in the group with long Barrett's esophagus. Those with reflux esophagitis and short Barrett's esophagus had esophageal motility impairment, intermediate among patients with esophagitis and long Barrett's esophagus. Patients with typical symptoms of gastroesophageal reflux but without esophagitis by endoscopy study showed no impairment of esophageal motility.
Brändén, Lena; Fredriksson, Anita; Harring, Emelie; Jensen, Jörgen; Lehmann, Anders
While patients with symptoms of gastroesophageal reflux disease generally respond well to proton pump inhibitors, 20-30% continue to experience troublesome symptoms. In such cases, agents that target transient lower esophageal sphincter (LES) relaxation may be useful as add-on therapy to proton pump inhibitors. The GABAB receptor agonist baclofen inhibits transient LES relaxation but it is not an ideal agent due to central nervous system activity. Lesogaberan (AZD3355) is a peripherally restricted GABAB receptor agonist with limited central nervous system activity that inhibits transient LES relaxation in dogs. In the present study, the comparative effects of lesogaberan (7 micromol/kg) and baclofen (2.8 micromol/kg) on reflux were studied in dogs using 24-h pHmetry. Drugs (or vehicle control) were administered orally prior to the first meal of the day, and the number of reflux episodes (pH<4 for > or = 5 s) and acid exposure time were computed for the 24-h monitoring period. The mean (S.E.M.) number of reflux episodes/24 h was 4.6 (0.4) and 6.4 (0.6) for lesogaberan and baclofen, respectively, versus 10.7 (0.5) for control (P<0.0001 for both). Acid exposure time was 51.2 (4.5) min for control versus 23.6 (3.8) min for lesogaberan (P<0.0001) and 35.4 (6.5) min with baclofen (P=0.05). It is concluded that lesogaberan significantly reduces acid reflux in dogs, with comparable efficacy to baclofen. Copyright 2010 Elsevier B.V. All rights reserved.
Nobakht, Hossein; Boghratian, Amirhossein; Sohrabi, Masoudreza; Panahian, Mohammad; Rakhshani, Naser; Nikkhah, Mehdi; Ajdarkosh, Hossein; Hemmasi, Gholamreza; Khonsari, Mahmoodreza; Gholami, Ali; Rabiei, Neda; Zamani, Farhad
BACKGROUND Reflux disease is a common gastrointestinal problem. The association between reflux disease and gastritis pattern is controversial. To determine the association between reflux disease and gastritis pattern in patients with Helicobacter pylori (H. pylori) infection. METHODS 470 patients with dyspepsia and reflux disease were enrolled in this study. The inclusion criteria were willing to participate in the study, age over 40 years, and having the criteria of ROME III for at least 3 months. Patients with history of H. pylori eradication therapy during the 3 months before the study, a history of gastric surgery, and gastric cancer were excluded. All of the participants underwent upper endoscopy and two biopsy samples were taken from antrum, body, and fundal areas. RESULTS H. pylori infection rate was 367 (78.1%) with mean age of 59.8 ± 11.4 years. Of them 131 patients (35.7%) were male. Reflux disease was detected in 273 (74.4%) patients. 216 (58.9%) and 102 (27.8%) patients had non-erosive reflux disease (NERD) and gastroesophageal reflux disease (GERD), respectively. Corpus predominant and antral predominant gastritis were seen in 72 (19.6%) and 129 (35.2%) patients, respectively. Antral gastritis was significantly associated with GERD ( p <0.01). In regression analysis, antral predominant gastritis had a significant association with GERD (OR=1.92; 95%CI: 1.22- 3.12). The same result was observed in mild to moderate antral and greater curvature gastritis (OR= 1.26; 95%CI: 0.25-6.40 and OR= 3.0; 95%CI: 0.63-14.17, respectively). CONCLUSION According to these finding ,we could suggest that the pattern of gastritis could be associated with reflux disease and GERD.
Min, Yang Won; Kim, Youngha; Gwak, Geum-Youn; Gu, Seonhye; Kang, Danbee; Cho, Soo Jin; Guallar, Eliseo; Cho, Juhee; Sinn, Dong Hyun
Non-alcoholic fatty liver disease (NAFLD), a hepatic manifestation of the metabolic syndrome, is associated with gastroesophageal reflux disease in cross-sectional studies, but a prospective association has not been evaluated. The current study aimed to determine whether NAFLD increases the risk of incident reflux esophagitis in a large cohort study. We conducted a cohort study of 34 063 men and women without reflux esophagitis or other upper gastrointestinal disease at baseline who underwent health checkup examinations between January 2003 and December 2013. Fatty liver was diagnosed by ultrasound based on standard criteria. Reflux esophagitis was defined by the presence of at least grade A mucosal break on esophagogastroduodenoscopy. The prevalence of NAFLD at baseline was 33.2%. During 153 520.2 person-years of follow-up, the cumulative incidences of reflux esophagitis for participants without and with NAFLD were 9.6% and 13.8%, respectively (P < 0.001). The age-adjusted and sex-adjusted hazard ratio for the risk of reflux esophagitis development in participants with NAFLD compared with those without NAFLD was 1.15 (95% confidence interval 1.07-1.23; P < 0.001). However, this association disappeared after adjusting for body mass index and other metabolic factors (hazard ratio 1.01, 95% confidence interval 0.94-1.09; P = 0.79). Similarly, in multivariable-adjusted models, there was no significant association between NAFLD severity and the risk of developing reflux esophagitis. Non-alcoholic fatty liver disease is not independently associated with the risk of the development of reflux esophagitis, but rather, reflux esophagitis is primarily the consequence of increased body mass index commonly associated with NAFLD. © 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.
Su, Fuzeng; Zhang, Cheng; Ke, Limu; Wang, Zhi; Li, Yiliang; Li, Huiling; Du, Zhi
To compare the efficacy and safety among laparoscopic Nissen, Toupet and Dor fundoplication in the treatment of hiatal hernia complicated with gastroesophageal reflux disease (GERD). Clinical data of 276 patients of hiatal hernia complicated with GERD undergoing operation in our hospital from December 2012 to January 2015 were retrospectively analyzed, including 149 patients of laparoscopic Nissen fundoplication (Nissen group), 41 of laparoscopic Toupet fundoplication (Toupet group), and 86 patients of laparoscopic Dor fundoplication (Dor group). Esophageal reflux status, esophageal manometry, GERD Q rating scale, and postoperative recovery were compare among the three groups. Reflux status was improved significantly in the three groups after operation(all P<0.05),except that the efficacy in reducing reflux episodes and reflux longest time was not obvious in Toupet group(P>0.05). There were no significant differences in postoperative reflux time, acid reflux time ratio, reflux longest time ratio, DeMeester score among the three groups (all P>0.05). Pairwise comparison showed that Dor group was significantly better than Toupet group in reducing the number of reflux episode(14.36±10.58 vs. 29.83±19.71) and long-reflux (0.64±0.21 vs. 6.20±3.48)(both P<0.05), but Nissen group was better than these two groups in reducing the number of long-reflux (0.38±0.16, P<0.05). As compared to pre-operation, the postoperative esophageal sphincter pressure and residual pressure increased significantly, and the relaxation rate reduced significantly (all P<0.05), while the episode of ineffective swallowing increased significantly in Toupet group (11.25±2.04 vs. 6.36±3.26, P<0.05). The contrast in esophageal manometry between Toupet and Dor group showed that Dor group was better than Toupet group in the recovery of lower esophageal sphincter pressure (mean resting breathing) [(20.69±13.95) mmHg vs.(12.91±6.89) mmHg] and the decrease of ineffective swallowing [9.15±6.44 vs. 11
Mahdi, Batool M
Gastro-esophageal reflux disease is a common condition, affecting 25%-40% of the population. Increasing attention has been paid to the relationship between Helicobacter pylori infection and reflux esophagitis. The aim of this study was to investigate the association between CagA+ H. pylori and endoscopically proven gastro-esophageal reflux disease. The study group included 60 hospital patients with gastro-esophageal reflux disease between 2007 and 2009 as compared with 30 healthy patients from a control group that was age and sex matched. Helicobacter pylori CagA+ was identified by an immunological test (Immunochromatography test) (ACON, USA). Helicobacter pyloriCagA+ was present in 42/60 (70%) of the patients with gastro-esophageal reflux disease and in 11/30 (36.6%) patients in the control group (p=0.002). The Odds ratio = 0.8004 with 95% Confidence Interval = from 0.3188 to 2.0094. The relative risk=1.35 that indicates an association between Helicobacter pylori and disease. The presence of Helicobacter pylori is significantly increased in patients with gastro-esophageal reflux disease as compared with the control group.
Rameschandra, Sahoo; Acharya, Vishak; Kunal; Vishwanath, Tantry; Ramkrishna, Anand; Acharya, Preetam
There exists a complex interplay between asthma and gastroesophageal reflux disease. Both these diseases are known to aggravate each other and amelioration of one is necessary for the control of the other. There is a paucity of studies in Indian population on this subject. To evaluate the clinical features and the endoscopic findings of the upper gastrointestinal tract in patients with bronchial asthma. Study was conducted at KMC group of hospitals, Mangalore in the Department of chest medicine in association with Department of gastroenterology. Subjects included 50 cases of bronchial asthma and controls were 58 non asthmatic patients with allergic rhinitis and chronic urticaria. All patients were queried about presence or absence of symptoms of upper gastro intestinal tract disorders by gastro oesophageal reflux disease (GERD) questionnaire and all the included patients underwent upper gastro intestinal endoscopy. The study showed that symptoms of gastroesophageal reflux were significantly more in asthmatics (52%) as compared to the controls (28%). The common presenting features of gastroesophageal reflux in asthmatics were heartburn (40%) retrosternal pain (24%), nocturnal cough (18%), dyspepsia (16%) and regurgitation (14%) and the above symptoms were significantly more common in asthmatics as compared to controls. Gastroesophageal reflux disease was found to be significantly more common in the asthmatics (58%) as compared to the control group where it was present in 32.75% of the subjects. Clinical or endoscopic evidence of any upper gastrointestinal disorder was found in 68% of the asthmatics as compared to 37.93% of the controls. This difference was found to be statistically significant. The study showed that gastroesophageal reflux disease was significantly more in asthmatics as compared to the controls. Upper gastrointestinal symptoms were more common in asthmatics as against controls. Clinical or endoscopic evidence of upper gastrointestinal disorder and
Iovino, P; Mohammed, I; Anggiansah, A; Anggiansah, R; Cherkas, L F; Spector, T D; Trudgill, N J
Differences in lower esophageal sphincter (LES) and peristaltic function and in transient LES relaxations (TLESR) have been described in patients with gastro-esophageal reflux disease (GERD). However, some of these differences may be the result of chronic GERD rather than being an underlying contributory factor. Twins discordant for GERD symptoms, i.e., only one twin had GERD symptoms, underwent standard LES and esophageal body manometry, and then using a sleeve sensor prolonged LES and pH monitoring, 30 min before and 60 min after a 250 mL 1200 kcal lipid meal. Eight monozygotic and 24 dizygotic female twins were studied. Although there was no difference in preprandial LES pressure (symptomatic 13.2 ± 7.1 mmHg vs asymptomatic 15.1 ± 6.2 mmHg, P = 0.4), LES pressure fell further postprandially in symptomatic twins (LES pressure area under the curve 465 ± 126 vs 331 ± 141 mmHg h, P < 0.01). 12/37 (32%) of acid reflux episodes in symptomatic twins occurred due to low LES pressure or deep inspiration/strain and 0/17 in asymptomatic twins (P = 0.01). There was no difference between symptomatic and asymptomatic twins in: peristaltic amplitude, ineffective esophageal body motility, hiatus hernia prevalence, or LES length. There was also no difference in TLESR frequency preprandially (symptomatic median 1(range 0-2) vs asymptomatic 0(0-2), P = 0.08) or postprandially (2.5(1-8) vs 3(1-6), P = 0.81). Twins with GERD symptoms had lower postprandial LES pressure and given the close genetic link between the twins, it is possible that such differences are caused by GERD. Acid reflux episodes associated with a hypotensive LES were seen in symptomatic, but not in asymptomatic twins. © 2013 John Wiley & Sons Ltd.
Niikura, Ryota; Yamada, Atsuo; Hirata, Yoshihiro; Hayakawa, Yoku; Takahashi, Akihiro; Shinozaki, Tomohiro; Takeuchi, Yoshinori; Fujishiro, Mitsuhiro; Koike, Kazuhiko
Objective Clinically, patients with proton pomp inhibitor (PPI)-resistant gastro-esophageal reflux disease (GERD) are very challenging to treat. The aim of this study was to determine the rates of symptom relief and adverse events among PPI-resistant GERD patients that changed their therapy from a PPI to vonoprazan. Methods Patients with severe gastroesophageal reflux symptoms (total GERD-Q score ≥8) without endoscopic findings of mucosal breaks who changed their medication from a PPI to vonoprazan during a 12-week period from 2015 to 2016 at 2 hospitals were selected. The primary outcome was the self-reported relief of gastroesophageal reflux symptoms. The odds ratio (OR) for the improvement of symptoms was calculated based on an exact binomial distribution using a matched-pair analysis. The secondary outcome was the GERD-Q score and adverse events. Results Twenty-six patients (6 men) with a mean age of 67.5 years were analyzed. After the therapy was changed from a PPI to vonoprazan, 18 patients (69.2%) reported an improvement, 6 (23.1%) reported no change, and 2 (7.7%) reported an exacerbation of symptoms. A change in therapy was significantly associated with improved self-reported symptoms (OR 9.0, p<0.001). The mean total GERD-Q score during vonoprazan treatment was significantly lower than that during PPI therapy (11.96 vs. 8.92). There were no significant differences in the incidence of adverse events between the therapies. Conclusion Changing the medication from a PPI to vonoprazan was significantly associated with an improvement in gastroesophageal reflux symptoms. Vonoprazan is one of the most promising treatment options for patients with PPI-resistant GERD.
Chen, Xia; Li, Ping; Wang, Fei; Ji, Guozhong; Miao, Lin; You, Sihong
Gastroesophageal reflux disease (GERD) affects mental state and social activities. On the contrary, mental disorders may also play a crucial role in GERD symptoms. The purpose of the study was to analyze the data of Symptom Checklist 90-Revised (SCL-90-R) questionnaire from patients with persisting GERD and to explore the impact of psychological factors on them. The patients accepted SCL-90-R questionnaire survey, following endoscopy, high-resolution manometry (HRM), and ambulatory impedance-pH monitoring. Based on these results, we divided patients into different groups. The result of SCL-90-R was also compared with degree of acid reflux, symptoms, symptom duration, and gender. The data from 438 patients were analyzed. All patients were divided into reflux esophagitis (RE; 63, 14.38%); nonerosive gastroesophageal reflux disease (NERD; 106, 24.20%); functional heartburn (FH; 123, 28.08%), hypersensitive esophagus (HE; 67, 15.29%), diffuse esophageal spasm (DES; 5: 1.14%), hypertensive (10, 3.42%); weak peristalsis (14, 3.20%); achalasia (50, 11.42%). There were significant differences between different groups regarding depression (DEP), anxiety (ANX), paranoid ideation (PAR), and psychoticism (PSY). The patients with ≥2 years with GERD presented with increased scores in DEP, ANX, and PSY. Women had dramatically higher scores than men in each domain (p < 0.05). Data have shown that GERD patients exhibit differential levels of psychological symptoms. Long duration of GERD was related to typical plus atypical symptoms and females seem to be more prone to develop psychological disorders. How to cite this article: Chen X, Li P, Wang F, Ji G, Miao L, You S. Psychological Results of 438 Patients with persisting Gastroesophageal Reflux Disease Symptoms by Symptom Checklist 90-Revised Questionnaire. Euroasian J Hepato-Gastroenterol 2017;7(2):117-121.
Frazzoni, M; Conigliaro, R; Mirante, V G; Melotti, G
By analysis of symptom-reflux association, endoscopy-negative refractory heartburn can be related to acid/non-acid refluxes with impedance-pH monitoring. Unfortunately, patients frequently do not report symptoms during the test. We aimed to assess the contribution of quantitative analysis of impedance-pH parameters added to symptom-reflux association in evaluating patients with endoscopy-negative heartburn refractory to high-dose proton pump inhibitor therapy. The symptom association probability (SAP), the symptom index (SI), the esophageal acid exposure time and the number of distal and proximal refluxes were assessed at on-therapy impedance-pH monitoring. Relationships with hiatal hernia and manometric findings were also evaluated. Eighty patients were prospectively studied. Refractory heartburn was more frequently related to reflux by a positive SAP/SI and/or abnormal impedance-pH parameters (52/80 cases) (65%) than by a positive SAP/SI only (38/80 cases) (47%) (P = 0.038). In patients with refractory non-erosive reflux disease (NERD) defined by a positive SAP/SI and/or abnormal impedance-pH parameters, the prevalence of hiatal hernia was significantly higher (56%vs 21%, P = 0.007) and the mean lower esophageal sphincter tone was significantly lower (18.7 vs 25.8 mmHg, P = 0.005) than in those (35%) with reflux-unrelated, i.e., functional heartburn (FH). On the contrary, no significant difference was observed subdividing patients according to a positive SAP/SI only. Quantitative analysis of impedance-pH parameters added to symptom-reflux association allows a subdivision of refractory-heartburn patients into refractory NERD and FH which is substantiated by pathophysiological findings and which restricts the diagnosis of FH to one third of cases. © 2011 Blackwell Publishing Ltd.
Akst, Lee M; Haque, Omar J; Clarke, John O; Hillel, Alexander T; Best, Simon R A; Altman, Kenneth W
The National Ambulatory Medical Care Survey (NAMCS) database was utilized to understand evolving national trends in diagnosis and management of reflux. The NAMCS database was queried for visits related to gastroesophageal reflux diagnosis and management. Analysis performed for time periods 1998-2001, 2002-2005, and 2006-2009 was weighted to provide national estimates of care. Results were compared to previously reported time periods from 1990 to 2001 to evaluate patterns in overall visits, age and ethnicity of patients, provider type, and prescriptions provided. The number of ambulatory visits for reflux increased from 8 684 000 in 1998-2001 to 15 750 000 in 2006-2009. Visits increased across each time period for internal medicine, family, and gastroenterology physicians. Among otolaryngologists, absolute visits increased from 1998-2001 to 2002-2005 but decreased in 2006-2009; difference between these time periods did not reach statistical significance. From 1998-2001 to 2006-2009, reflux medication use increased 233%, with continuing trends toward increased proton pump inhibitor use. Reflux visits have increased across all demographic subgroups studied. Knowledge of these trends may inform further paradigm shifts in diagnosis and management of reflux.
Min, Yang Won; Lee, Jin Hee; Min, Byung-Hoon; Lee, Jun Haeng; Kim, Jae J; Rhee, Poong-Lyul
Background/Aims The occurrence of gastroesophageal reflux disease (GERD) is known to be associated with lower post-treatment lower esophageal sphincter pressure in patients with achalasia. This study aimed to elucidate whether GERD after pneumatic balloon dilatation (PD) has a prognostic role and to investigate how the clinical course of GERD is. Methods A total of 79 consecutive patients who were first diagnosed with primary achalasia and underwent PD as an initial treatment were included in this retrospective study. Single PD was performed using a 3.0 cm balloon. The patients were divided into two groups: 1) who developed GERD after PD (GERD group) and 2) who did not develop GERD after PD (non-GERD group). GERD was defined as pathological acid exposure, reflux esophagitis or typical reflux symptoms. Results Twenty one patients (26.6%) developed GERD after PD during follow-up. There were no significant differences between the two groups in demographic or clinical factors including pre- and post-treatment manometric results. All patients in GERD group were well responsive to maintenance proton pump inhibitor therapy including on demand therapy or did not require maintenance. During a median follow-up of 17.8 months (interquartile range, 7.1–42.7 months), achalasia recurred in 15 patients (19.0%). However, the incidence of recurrence did not differ according to the occurrence of GERD after PD. Conclusions GERD often occurs after even a single PD for achalasia. However, GERD after PD is well responsive to PPI therapy. Our data suggest that GERD after PD during follow-up does not appear to have a prognostic role. PMID:24840373
Falk, Gregory L; Beattie, John; Ing, Alvin; Falk, S E; Magee, Michael; Burton, Leticia; Van der Wall, Hans
To investigate the utility of scintigraphic studies in predicting response to laparoscopic fundoplication (LF) for chronic laryngopharyngeal reflux symptoms. Patients with upper aero-digestive symptoms that remained undiagnosed after a period of 2 mo were studied with conventional pH and manometric studies. Patients mainly complained of cough, sore throat, dysphonia and globus. These patients were imaged after ingestion of 99m-technetium diethylene triamine pentaacetic acid. Studies were quantified with time activity curves over the pharynx, upper and lower oesophagus and background. Late studies of the lungs were obtained for aspiration. Patients underwent LF with post-operative review at 3 mo after surgery. Thirty four patients (20 F, 14 M) with an average age of 57 years and average duration of symptoms of 4.8 years were studied. Twenty four hour pH and manometry studies were abnormal in all patients. On scintigraphy, 27/34 patients demonstrated pharyngeal contamination and a rising or flat pharyngeal curve. Lung aspiration was evident in 50% of patients. There was evidence of pulmonary aspiration in 17 of 34 patients in the delayed study (50%). Pharyngeal contamination was found in 27 patients. All patients with aspiration showed pharyngeal contamination. In the 17 patients with aspiration, graphical time activity curve showed rising activity in the pharynx in 9 patients and a flat curve in 8 patients. In those 17 patients without pulmonary aspiration, 29% (5 patients) had either a rising or flat pharyngeal graph. A rising or flat curve predicted aspiration with a positive predictive value of 77% and a negative predictive value of 100%. Over 90% of patients reported a satisfactory symptomatic response to LF with an acceptable side-effect profile. Scintigraphic reflux studies offer a good screening tool for pharyngeal contamination and aspiration in patients with gastroesophageal reflux disease.
Broers, C; Tack, J; Pauwels, A
When gastro-oesophageal reflux is causing symptoms or lesions in the oesophagus, this is referred to as gastro-oesophageal reflux disease (GERD). GERD can manifest itself through typical symptoms (heartburn, regurgitation) or may lead to extra-oesophageal symptoms. Extra-oesophageal manifestations of GERD gained increasing attention over the last decade, especially respiratory disorders, because of the prevalent co-occurrence with GERD. The role of GERD in the pathogenesis of respiratory disorders has become a topic of intense discussion. To provide an overview of the current knowledge on the role of GERD in asthma and chronic obstructive pulmonary disease (COPD). PubMed was searched for relevant articles using the keywords: GERD, asthma, COPD, prevalence, treatment. Case reports were excluded, only English language articles were considered. Estimates for the prevalence of GERD in asthma range from 30% to 90%, compared to an average of 24% in controls. In COPD patients, the prevalence of GERD ranges from 19% to 78% compared to an average of 18% in controls. These data indicate an increased prevalence of GERD in patients with asthma and COPD, although causality is not established and GERD treatment yielded inconsistent effects. Literature supports GERD as a risk factor for COPD-exacerbations and a predictor of the 'frequent-exacerbator'-phenotype. Despite the high prevalence of GERD in asthma and COPD, a causal link is lacking. The results of anti-reflux therapy on pulmonary outcome are inconsistent and contradictory. Future studies will need to identify subgroups of asthmatics and COPD patients that may benefit from anti-reflux therapy (nocturnal or silent reflux). © 2017 John Wiley & Sons Ltd.
Ackermann, C; Margreth, L; Muller, C; Harder, F
10 to 20 years (median 15.1 years) after fundoplication for primary reflux disease 257 patients were questioned about their symptoms. Data of 163 patients could be analyzed. 21.4% of the patients have persistent or recurrent reflux symptoms, about half of them (9.8%) need medical treatment. Adverse side-effects of the fundoplication are frequent: dysphagia in 28.2%, gas-bloat in 50.3%. Using the Visick criteria for classification we found Visick grade I and II for 75.5%, grade III for 17.2%, and IV for 7.4%. Diagnostic and therapeutic concepts in case of failed reflux control are discussed.
Sujatha, S; Jalihal, Umesh; Devi, Yashoda; Rakesh, N; Chauhan, Pallavi; Sharma, Shivani
The aim of this study is to compare surface pH in various parts of the oral cavity between patients with gastroesophageal reflux disease (GERD) and healthy controls. Using a flat pH meter sensor, fixed electrode pen type digital pH meter, oral pH levels were assessed at different mucosal sites among 34 GERD patients and 32 healthy controls. Salivary flow rates and buffering capacity were also assessed in them. A thorough oral examination was performed to screen for any oral and dental changes. A significantly lower pH of 6.65 ± 0.13 (mean ± SD) was found in the GERD group compared to control group 7.23 ± 0.12 (p < 0.05). Least pH was found in the floor of the mouth 6.594 ± 0.17 and highest in the lower labial mucosa among the GERD patients. Salivary flow rate and buffering capacity were low in these patients. Significant changes were noticed in the hard and soft tissues of the oral cavity among the GERD group. Oral mucosal pH is altered in GERD patients and may contribute to effects on the oral cavity.
Savarino, Edoardo; Marabotto, Elisa; Zentilin, Patrizia; Frazzoni, Marzio; Sammito, Giorgio; Bonfanti, Daria; Sconfienza, Luca; Assandri, Lorenzo; Gemignani, Lorenzo; Malesci, Alberto; Savarino, Vincenzo
Functional heartburn is defined by Rome III criteria as an endoscopy-negative condition with normal oesophageal acid exposure time, negative symptom association to acid reflux and unsatisfactory response to proton pump inhibitors. These criteria underestimated the role of non-acid reflux. To assess the contribution of impedance-pH with symptom association probability (SAP) analysis in identifying endoscopy-negative patients with reflux disease and separating them from functional heartburn. Consecutive endoscopy-negative patients treated with proton pump inhibitors (n=219) undergoing impedance-pH monitoring off-therapy were analysed. Distal acid exposure time, reflux episodes, SAP and symptomatic response to proton pump inhibitors were measured. Based on impedance-pH/SAP, 67 (31%) patients were pH+/SAP+, 6 (2%) pH+/SAP-, 83 (38%) hypersensitive oesophagus and 63 (29%) functional heartburn. According to pH-metry alone/response to proton pump inhibitors, 62 (28%) were pH+/SAP+, 11 (5%) pH+/SAP-, 61 (28%) hypersensitive oesophagus and 85 (39%) functional heartburn. In the normal-acid exposure population the contribution of impedance-pH/SAP compared to pH-metry alone/response to proton pump inhibitors in identifying patients with reflux disease and functional heartburn resulted to be 10%. In patients with abnormal-acid exposure, the contribution of impedance-pH/SAP increased by 3%. Comparing impedance-pH testing with pH-metry alone plus the response to proton pump inhibitor therapy demonstrated that the latter ones cause underestimation of reflux disease patients and overestimation of functional heartburn patients. Copyright © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Alsuwat, Obaidallah Buraykan; Alzahrani, Abdulrahman Ahmad; Alzhrani, Mohammed Abdullah; Alkhathami, Ali Mesfer; Mahfouz, Mohammad Eid Mahmoud
Gastroesophageal reflux disease (GERD) is a common chronic gastrointestinal tract disease. The incidence is higher in Asian and Arab countries. In Saudi Arabia, there are few studies that have assessed the prevalence of GERD among some cities' communities. Hence, this study aims to study the prevalence of GERD among the general population of Saudi Arabia. A cross-sectional study was designed to determine the prevalence of GERD among the community of Saudi Arabia. The sample was randomly gathered through self-administered validated GERD questionnaire (GerdQ) to diagnose GERD, during the period from November to December 2016. The sociodemographic data was assessed for all participants. The data were analysed using Statistical Package for Social Sciences version 21.0 (SPSS); the t -test was used to assess the association of GERD and sociodemographic data. The sample was comprised of 2,043 participants. Female and male were 51.8% and 48.2%, respectively. Mean age was 29.6 years with the standard deviation of 10.5 years. The GERD prevalence was 28.7%. It was found statistically significant among divorced/widow (34.9%, P = 0.003). In contrast, there was no association between GERD's prevalence and gender, age, residence status, education level, occupation, and blood group (P > 0.05). The prevalence of GERD among Saudi population is higher than that in Western countries and East Asia. It affects divorced/widow, obese and those with a sedentary lifestyle. It is advocated that national programs and educational campaigns for prevention of this disease and its complications should be established.
Randhawa, Mohammad Akram; Mahfouz, Salah Al-Din Mahmoud; Selim, Noor Ahmed; Yar, Taley; Gillessen, Anton
Treatment of gastro esophageal reflux disease (GERD) is becoming a challenge for medical profession. Proton pump inhibitors (PPIs) are commonly recommended but many disadvantages of these drugs are being reported, particularly when used for long term. Transient lower esophageal sphincter relaxations (TLESRs) are important cause of acid reflux. Gastric distention in upper stomach is the strongest stimulus for generation of TLESRs and is aggravated by intake of food in between meals. In an earlier cases report, two meals a day with intake of only fluids in between was suggested as a remedy for GERD. Present pilot study was conducted on 20 patients with endoscopically proven reflux esophagitis (Los Angles Grade a, b or c), who followed our advice to take meal twice a day with consumption of only soft drinks (fruit juices, tea, coffee, water, etc) in between and no medication for two weeks. On 14th day 15 patients (75%) were free of reflux symptoms, 2 (10%) had partial improvement and 3 (15%) reported no difference. It is concluded that two meals a day with intake of only fluids in between, whenever the patient feels hungry or thirsty, is a useful dietary regimen for the management of GERD. Further investigations are needed to confirm the benefits of this physiological lifestyle change.
Mooney, Peter D; Evans, Kate E; Kurien, Matthew; Hopper, Andrew D; Sanders, David S
Coeliac disease (CD) has been linked to gastro-oesophageal reflux disease (GORD). Previous studies have demonstrated an increased prevalence of reflux in patients with CD. However data on the risk for CD in patients presenting with reflux are conflicting. The aim of this study was to establish the prevalence of CD in patients with GORD and to elucidate the mechanisms for reflux symptoms in newly diagnosed CD patients. Group A: patients who had undergone routine duodenal biopsy were prospectively recruited between 2004 and 2014. Diagnostic yield was compared with that of a screening cohort. Group B: 32 patients with newly diagnosed CD who had undergone oesophageal manometry and 24-h pH studies were prospectively recruited. Group A: 3368 patients (58.7% female, mean age 53.4 years) underwent routine duodenal biopsy. Of these patients, 850 (25.2%) presented with GORD. The prevalence of CD among GORD patients was 1.3% (0.7-2.4%), which was not significantly higher than that in the general population (P=0.53). Within the context of routine duodenal biopsy at endoscopy (when corrected for concurrent symptoms, age and sex), reflux was found to be negatively associated with CD [adjusted odds ratio 0.12 (0.07-0.23), P<0.0001]. In group B, 34% of patients complained of reflux. On manometry, 9% had a hypotensive lower oesophageal sphincter and 40.6% had oesophageal motor abnormalities, with 25% significantly hypocontractile. On pH studies, 33% demonstrated reflux episodes. The prevalence of undiagnosed CD among GORD patients is similar to that in the general population, and routine duodenal biopsy cannot be recommended. A significant number of patients with newly diagnosed CD were found to have reflux and/or oesophageal dysmotility on pH/manometry studies; this may explain the high prevalence of reflux symptoms in CD.
Effectiveness of add-on therapy with domperidone vs alginic acid in proton pump inhibitor partial response gastro-oesophageal reflux disease in systemic sclerosis: randomized placebo-controlled trial.
Foocharoen, Chingching; Chunlertrith, Kitti; Mairiang, Pisaln; Mahakkanukrauh, Ajanee; Suwannaroj, Siraphop; Namvijit, Suwassa; Wantha, Orathai; Nanagara, Ratanavadee
Twice-daily dosing of proton pump inhibitor (PPI), the standard therapy for gastro-oesophageal reflux disease (GERD), is an effective therapy for GERD in SSc. The aim of this study was to compare the efficacy of omeprazole in combination with domperidone vs in combination with algycon in reducing the severity and frequency of reflux symptoms of PPI partial response (PPI-PR) GERD in SSc. Adult SSc patients having PPI-PR GERD were randomly assigned to receive domperidone plus algycon placebo or algycon plus domperidone placebo in a 1:1 ratio plus omeprazole for 4 weeks. The assessment included severity of symptom grading by visual analogue scale, frequency of symptoms by frequency scale for symptoms of GERD and quality of life (QoL) by EuroQol five-dimensions questionnaire scoring. One hundred and forty-eight SSc-GERD patients were enrolled, of whom 88 had PPI-PR. Eighty cases were randomized for either domperidone (n = 38) or algycon (n = 37) therapy. The majority in both groups had the diffuse SSc subset. At the end of the study, no significant difference in symptom grading was found between groups. After treatment and compared with baseline, the severity of symptoms, frequency scale for symptoms of GERD and QoL significantly improved in both groups. Five (13.2%) and 8 (21.6%) respective cases in the domperidone and algycon groups did not respond. The prevalence of PPI-PR GERD is common. Domperidone and algycon are equally effective treatments in combination with omeprazole. However, ∼17% of patients were non-responsive, so the effectiveness of domperidone, algycon and PPI combination therapy should be further investigated. https://clinicaltrials.gov (NCT01878526). © The Author 2016. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Floria, Mariana; Barboi, Oana; Rezus, Ciprian; Ambarus, Valentin; Cijevschi-Prelipcean, Cristina; Balan, Gheorghe; Drug, Vasile Liviu
Atrial fibrillation and gastro-oesophageal reflux are common manifestations in daily practice. The atria and the oesophagus are closely located and have similar nerve innervations. Over the last years, it has been observed that atrial fibrillation development and reflux disease could be related. Atrial fibrillation occurrence could be due to vagal nerve overstimulation. This, in association with vagal nerve-mediated parasympathetic stimulation, has also been observed in patients with gastro-oesophageal reflux. These mechanisms, in addition to inflammation, seem to be implicated in the pathophysiology of both diseases. Despite these associations supported by clinical and experimental studies, this relationship is still considered controversial. This review summarizes critical data regarding the association of gastro-oesophageal reflux and atrial fibrillation as well as their clinical implications.
Sereg-Bahar, M; Jerin, A; Jansa, R; Stabuc, B; Hocevar-Boltezar, I
Laryngopharyngeal reflux (LPR) and biliary duodenogastric reflux can cause damage to the laryngeal mucosa and voice disorders. The aim of this study was to find out whether levels of pepsin and bile acids in the saliva can serve as diagnostic markers of LPR. A prospective comparative study. Twenty-eight patients with LPR proven via high-resolution manometry and combined multichannel intraluminal impedance and 24-h pH monitoring and 48 healthy controls without symptoms of LPR were included in the study. In the patients with LPR symptoms, oesophagogastroscopy with oesophageal biopsy was performed. The levels of total pepsin, active pepsin, bile acids and the pH of the saliva were determined in all participants and compared between the groups. Reflux symptom index (RSI) and reflux finding score (RFS) were also obtained and compared. The groups differed significantly in RSI (P = 0.00), RFS (P = 0.00), the levels of bile acids (P = 0.005) and total pepsin in saliva (P = 0.023). The levels of total pepsin and bile acids were about three times higher in the patients with LPR than in the healthy controls. There was a significant correlation between the RSI and RFS score and the level of total pepsin and bile acids in the saliva. Histopathological examination of the oesophageal biopsy taken 5 cm above the lower oesophageal sphincter confirmed reflux in almost 93% of patients with symptoms. The study results show that the levels of total pepsin and bile acids in saliva are significantly higher in patients with LPR than in the controls, thus suggesting this as a useful tool in the diagnosis of LPR and particularly biliary LPR. © 2014 John Wiley & Sons Ltd.
Jancelewicz, Tim; Lopez, Monica E; Downard, Cynthia D; Islam, Saleem; Baird, Robert; Rangel, Shawn J; Williams, Regan F; Arnold, Meghan A; Lal, Dave; Renaud, Elizabeth; Grabowski, Julia; Dasgupta, Roshni; Austin, Mary; Shelton, Julia; Cameron, Danielle; Goldin, Adam B
The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to derive recommendations from the medical literature regarding the surgical treatment of pediatric gastroesophageal reflux disease (GERD). Five questions were addressed by searching the MEDLINE, Cochrane, Embase, Central, and National Guideline Clearinghouse databases using relevant search terms. Consensus recommendations were derived for each question based on the best available evidence. There was insufficient evidence to formulate recommendations for all questions. Fundoplication does not affect the rate of hospitalization for aspiration pneumonia, apnea, or reflux-related symptoms. Fundoplication is effective in reducing all parameters of esophageal acid exposure without altering esophageal motility. Laparoscopic fundoplication may be comparable to open fundoplication with regard to short-term clinical outcomes. Partial fundoplication and complete fundoplication are comparable in effectiveness for subjective control of GERD. Fundoplication may benefit GERD patients with asthma, but may not improve outcomes in patients with neurologic impairment or esophageal atresia. Overall GERD recurrence rates are likely below 20%. High-quality evidence is lacking regarding the surgical management of GERD in the pediatric population. Definitive conclusions regarding the effectiveness of fundoplication are limited by patient heterogeneity and lack of a standardized outcomes reporting framework. Systematic review of level 1-4 studies. Level 1-4 (mainly level 3-4). Copyright © 2017 Elsevier Inc. All rights reserved.
Gadel, Abil Ali; Mostafa, Mohamed; Younis, Ahmed; Haleem, Magdy
The association of esophageal motility and gastroesophageal reflux symptoms with respiratory symptoms is not well established in patients with chronic obstructive pulmonary disease (COPD). The aim of this work is to study the abnormalities of esophageal function in COPD patients and study its relation to smoking index, body mass index and indices of hyperinflation. This study included 40 male COPD patients and 10 healthy controls. The patients and controls were subjected to spirometry, body plethysmography, esophageal manometry and 24hr pH-metry. Upper gastrointestinal symptoms were found in 55% of patients, hypotensive upper esophageal sphincter pressure in 65% of patients and hypotensive lower esophageal sphincter pressure in 52.5% of patients. Pathological acid reflux was found in 35% of patients. The severity of GERD increased with increased age, smoking index and body mass index, p<0.005. There was negative correlation between LESP and UESP compared with indices of hyperinflation, p<0.001. There was high prevalence of esophageal motility disorders in COPD patients, LESP and UESP were significantly negatively correlated to indices of hyperinflation. There was a high prevalence of GERD in COPD patents especially elderly, severe stage of COPD, high smoking index and high body mass index (BMI).
Ruigómez, Ana; García Rodríguez, Luis Alberto; Wallander, Mari-Ann; Johansson, Saga; Dent, John
It is unclear how gastro-oesophageal reflux disease (GORD) is diagnosed in primary care. The aim of this study is to compare patients given a diagnosis of GORD with those diagnosed with heartburn. Data from the UK General Practice Research Database were extracted for patients newly diagnosed with heartburn (n = 1841) or GORD (n = 5318) in 1996. Patient characteristics, morbidity, healthcare use and prescribed treatments were compared using unconditional logistic regression analysis. GORD was diagnosed more frequently than heartburn (3.2 vs. 1.1 per 1000 patient-years). A diagnosis of GORD was less likely among females (odds ratio (OR): 0.8; confidence interval (CI): 0.7-0.9), smokers (OR: 0.8; CI: 0.7-0.9) and patients who consulted their physician frequently (OR: 0.8; CI: 0.7-0.9). There was a wide distribution in the ratio of GORD-to-heartburn diagnoses between primary care practices (mean 2.9; range 0-infinity). GORD patients were more likely to receive proton pump inhibitors (OR: 2.9; CI: 2.6-3.4), but 24% of GORD patients and 40% of heartburn patients received no acid-suppressive treatment in the month after diagnosis. Several factors influenced the diagnosis of gastro-oesophageal reflux symptoms by primary care physicians. Further research is needed to aid the diagnosis of GORD in primary care.
Barratt, Stephen M; Leeds, John S; Robinson, Kerry; Shah, Premal J; Lobo, Alan J; McAlindon, Mark E; Sanders, David S
An increased prevalence of reflux and irritable bowel syndrome (IBS) symptoms is associated with coeliac disease and inflammatory bowel disease (IBD). We aimed to determine the prevalence of reflux and IBS symptoms in a cohort of patients with coeliac disease and IBD and their relationship with quality of life (QoL) and psychological distress. Histologically proven coeliac disease (n=225), ulcerative colitis (UC) (n=228), Crohn's disease (CD) (n=230) patients and age/sex-matched controls (n=348) completed the Short-Form 36 (SF-36)-Item Health Survey, Hospital Anxiety and Depression Scale (HADS), reflux screen and Rome II criteria. UC patients report higher SF-36 (QoL) scores than coeliac disease; CD fairing worse overall (P≤0.0001). Reflux prevalence: coeliac disease 66%; UC 62%; CD 72%; controls 50%. Patients report reflux of a greater severity: coeliac disease odds ratio=6.8, 95% confidence interval=3.6-12.7, P≤0.001; IBD odds ratio=2.2, 95% confidence interval=1.6-3.2, P≤0.0001. Stepwise reductions in SF-36 scores in association with increasing reflux severity were found (P≤0.0001). IBS prevalence: coeliac disease 22%; UC 16%; CD 24%; controls 6%. Concomitant IBS was associated with reduced SF-36 scores in patients (P≤0.0001). Reflux and IBS are more prevalent in coeliac disease and IBD in comparison with age-matched and sex-matched controls. These additional symptoms are associated with reduced QoL and increasing likelihood of anxiety and depression. QoL may be improved if coeliac disease and IBD patients were assessed for reflux and IBS.
James, M E; Ewer, A K
Acid gastro-oesophageal reflux (GOR) is common in preterm infants but there is a lack of a non-invasive technique to establish the diagnosis. The aim of this study was to identify whether the presence of acid in oro-pharyngeal secretions (OPS) was a valid indicator of clinically significant acid GOR in preterm infants. A total of 23 infants with suspected GOR were studied with 24 h lower-oesophageal pH monitoring and during this period the OPS were tested for acid with litmus paper at 6 hourly intervals. Median (range) gestation was 28 weeks (24-31), birth weight 1023 g (480-1750) and age at study 34 days (11-76). Significant GOR was defined as a reflux index >5%. Of the investigated infants, 18 subjects (78%) had significant GOR. Of this group, 16 infants had acid in the OPS on at least one occasion. Five infants did not demonstrate significant GOR and in four of these acid was not detected in the OPS. Our data indicate that as a predictor for significant GOR, litmus-testing OPS for acid has a sensitivity of 89%, specificity of 80%, positive predictive value of 94% and a negative predictive value of 67%. The difference in the incidence of acid OPS between the GOR and the No GOR group was significant (P<0.03). The presence of acid in the oropharyngeal secretions may help in the prediction of acid gastro-oesophageal reflux in preterm infants. The method is simple, inexpensive cheap and involves minimal disturbance. We suggest that it could aid clinical diagnosis and indicate a need for further investigation of gastro-oesophageal reflux.
Lee, Annemarie L; Goldstein, Roger S
COPD is a long-term condition associated with considerable disability with a clinical course characterized by episodes of worsening respiratory signs and symptoms associated with exacerbations. Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal conditions in the general population and has emerged as a comorbidity of COPD. GERD may be diagnosed by both symptomatic approaches (including both typical and atypical symptoms) and objective measurements. Based on a mix of diagnostic approaches, the prevalence of GERD in COPD ranges from 17% to 78%. Although GERD is usually confined to the lower esophagus in some individuals, it may be associated with pulmonary microaspiration of gastric contents. Possible mechanisms that may contribute to GERD in COPD originate from gastroesophageal dysfunction, including altered pressure in the lower esophageal sphincter (which normally protect against GERD) and changes in esophageal motility. Proposed respiratory contributions to the development of GERD include respiratory medications that may alter esophageal sphincter tone and changes in respiratory mechanics, with increased lung hyperinflation compromising the antireflux barrier. Although the specific cause and effect relationship between GERD and COPD has not been fully elucidated, GERD may influence lung disease severity and has been identified as a significant predictor of acute exacerbations of COPD. Further clinical effects could include a poorer health-related quality of life and an increased cost in health care, although these factors require further clarification. There are both medical and surgical options available for the treatment of GERD in COPD and while extensive studies in this population have not been undertaken, this comorbidity may be amenable to treatment.
Lee, Annemarie L; Goldstein, Roger S
COPD is a long-term condition associated with considerable disability with a clinical course characterized by episodes of worsening respiratory signs and symptoms associated with exacerbations. Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal conditions in the general population and has emerged as a comorbidity of COPD. GERD may be diagnosed by both symptomatic approaches (including both typical and atypical symptoms) and objective measurements. Based on a mix of diagnostic approaches, the prevalence of GERD in COPD ranges from 17% to 78%. Although GERD is usually confined to the lower esophagus in some individuals, it may be associated with pulmonary microaspiration of gastric contents. Possible mechanisms that may contribute to GERD in COPD originate from gastroesophageal dysfunction, including altered pressure in the lower esophageal sphincter (which normally protect against GERD) and changes in esophageal motility. Proposed respiratory contributions to the development of GERD include respiratory medications that may alter esophageal sphincter tone and changes in respiratory mechanics, with increased lung hyperinflation compromising the antireflux barrier. Although the specific cause and effect relationship between GERD and COPD has not been fully elucidated, GERD may influence lung disease severity and has been identified as a significant predictor of acute exacerbations of COPD. Further clinical effects could include a poorer health-related quality of life and an increased cost in health care, although these factors require further clarification. There are both medical and surgical options available for the treatment of GERD in COPD and while extensive studies in this population have not been undertaken, this comorbidity may be amenable to treatment. PMID:26392769
Saberi-Firoozi, Mehdi; Khademolhosseini, Farnaz; Yousefi, Maryam; Mehrabani, Davood; Zare, Najaf; Heydari, Seyed Taghi
AIM: To determine the prevalence and symptoms of gastroesophageal reflux disease (GERD) in a healthy general population in relation to demographic, lifestyle and health-seeking behaviors in Shiraz, southern Iran. METHODS: A total of 1978 subjects aged > 35 years who referred to Gastroenterohepatology Research Center and who completed a questionnaire consisting of 27 questions for GERD in relation to demographic, lifestyle and health-seeking behaviors were included in this study for a period of five months. The validity and reliability of the questionnaire were determined. RESULTS: The prevalence of GERD was 15.4%, which was higher in females (17.3%), in rural areas (19.8%), and in illiterate subjects (21.5%) and those with a mean age of 50.25 years. The prevalence was significantly lower in subjects having fried food (14.8%), and fruit and vegetables (14.6%). More symptoms were noticed in subjects consuming pickles (22.1%), taking aspirin (21%) and in subjects with psychological distresses (27.2%) and headaches (22%). The correlation was statistically significant between GERD and halitosis (18.3%), dyspepsia (30.6%), anxiety (19.5%), nightmares (23.9%) and restlessness (18.5%). Their health seeking behavior showed that there was a significant restriction of diet (20%), consumption of herbal medicine (19%), using over-the-counter drugs (29.9%) and consulting with physicians (24.8%). Presence of GERD symptoms was also significantly related to a previous family history of the disease (22.3%). CONCLUSION: GERD is more common in females, rural and illiterate subjects and correlated with consumption of pickles, occurrence of headache, psychological distress, dyspepsia, halitosis, anxiety, nightmare and restlessness, and a family history of GERD and aspirin intake, but the correlation was negative with consumption of fat and fiber intake. PMID:17907293
Masuda, Takahiro; Yano, Fumiaki; Omura, Nobuo; Tsuboi, Kazuto; Hoshino, Masato; Yamamoto, Se Ryung; Akimoto, Shunsuke; Kashiwagi, Hideyuki; Yanaga, Katsuhiko
Clinical role of low-dose aspirin (LDA) in pathogenesis of gastroesophageal reflux disease is by far controversial. This can be attributed to the paucity of basic research detailing the mechanism of LDA-induced esophageal mucosal injury (EI) on underlying chronic acid reflux esophagitis (RE). The aim of this study was to clarify the effect of LDA on chronic RE in rats. Esophagitis was induced in 8-week-old male Wistar rats by ligating the border between forestomach and glandular portion with a 2-0 silk tie and covering the duodenum with a small piece of 18-Fr Nélaton catheter. Seventy-eight chronic RE rat models were divided into five treatment groups, consisting of orally administered vehicle (controls), and aspirin doses of 2, 5, 50 or 100 mg/kg once daily for 28 days. EI was assessed by gross area of macroscopic mucosal injury, severity grade of esophagitis and microscopic depth of infiltration by inflammatory cells. Area of esophagitis in animals with aspirin dose of 100 mg/kg/day showed a 36.5% increase compared with controls, although it failed to achieve statistical significance (p = 0.812). Additionally, the rate of severe EI was increased in animals with aspirin dose of 100 mg/kg/day as compared with controls (p < 0.05). The grade of severity correlated with the depth of inflammation (r s = 0.492, p < 0.001). Maximal dose aspirin (100 mg/kg/day) contributed in exacerbating preexisting EI. LDA (2 and 5 mg/kg/day), on the other hand, did not affect chronic RE in this model. LDA seems to be safe for use in patients with chronic RE.
Johnson, T; Gerson, L; Hershcovici, T; Stave, C; Fass, R
Carbonated beverages have unique properties that may potentially exacerbate gastro-oesophageal reflux disease (GERD), such as high acidity and carbonation. Cessation of carbonated beverage consumption is commonly recommended as part of lifestyle modifications for patients with GERD. To evaluate the relationship of carbonated beverages with oesophageal pH, oesophageal motility, oesophageal damage, GERD symptoms and GERD complications. A systematic review. Carbonated beverage consumption results in a very short decline in intra-oesophageal pH. In addition, carbonated beverages may lead to a transient reduction in lower oesophageal sphincter basal pressure. There is no evidence that carbonated beverages directly cause oesophageal damage. Carbonated beverages have not been consistently shown to cause GERD-related symptoms. Furthermore, there is no evidence that these popular drinks lead to GERD complications or oesophageal cancer. Based on the currently available literature, it appears that there is no direct evidence that carbonated beverages promote or exacerbate GERD.
Soper, Nathaniel J
This article reviews the current literature pertaining to the diagnosis and management of gastroesophageal reflux disease (GERD) and hiatal hernia. GERD is one of the most common gastrointestinal disorders in the USA. For effective management, a conclusive diagnosis must be made. Most patients are effectively managed by acid suppression therapy, whereas others require procedural treatment. Endoluminal treatment of GERD is an option, but long-term results of this therapy are unknown. The "gold standard" surgical treatment of GERD is laparoscopic Nissen fundoplication. Large hiatal hernias are difficult to manage with a relatively high rate of recurrent hiatal hernia. Whether or not to use mesh at the hiatus to decrease this occurrence is currently debatable.
Kawamura, Osamu; Kohata, Yukie; Kawami, Noriyuki; Iida, Hiroshi; Kawada, Akiyo; Hosaka, Hiroko; Shimoyama, Yasuyuki; Kuribayashi, Shiko; Fujiwara, Yasuhiro; Iwakiri, Katsuhiko; Inamori, Masahiko; Kusano, Motoyasu; Hongo, Micho
Background/Aims Twenty-four-hour esophageal impedance and pH monitoring allows detection of all types of reflux episodes and is considered the best technique for identifying gastroesophageal refluxes. However, normative data for the Japanese population are lacking. This multicenter study aimed to establish the normal range of 24-hour esophageal impedance and pH data both in the distal and the proximal esophagus in Japanese subjects. Methods Forty-two healthy volunteers (25 men and 17 women) with a mean ± standard deviation age of 33.3 ± 12.4 years (range: 22–72 years) underwent a combined 24-hour esophageal impedance and pH monitoring. According to the physical and pH properties, distal or proximal esophageal reflux events were categorized. Results Median 45 reflux events occurred in 24 hours, and the 95th percentile was 85 events. Unlike previous reports, liquid-containing reflux events are median 25/24 hours with the 95th percentile of 62/24 hours. Acidic reflux events were median 11/24 hours with the 95th percentile of 39/24 hours. Non-acidic gas reflux events were median 15/24 hours with the 95th percentile of 39/24 hours. Proximal reflux events accounted for 80% of the total reflux events and were mainly non-acidic gas refluxes. About 19% of liquid and mixed refluxes reached the proximal esophagus. Conclusions Unlike previous studies, liquid-containing and acidic reflux events may be less frequent in the Japanese population. Non-acidic gas reflux events may be frequent and a cause of frequent proximal reflux events. This study provides important normative data for 24-hour impedance and pH monitoring in both the distal and the proximal esophagus in the Japanese population. PMID:27247103
Shin, Woon Geon; Kim, Heung Up; Kim, Sang Gyun; Kim, Gwang Ha; Shim, Ki-Nam; Kim, Jeong Wook; Kim, Jin Il; Kim, Jae Gyu; Kim, Jae J; Yim, Da-Hae; Park, Sue K; Park, Soo-Heon
The costs of gastroesophageal reflux disease have not been assessed in Asia, even though the prevalence of gastroesophageal reflux disease is gradually increasing. We evaluated work presenteeism and absenteeism as indirect costs of gastroesophageal reflux disease in Korea. This was a cross-sectional and multicentre study using patient-reported outcome instruments. A total of 1009 full-time employees who visited the gastrointestinal department for any reason (281 patients with gastroesophageal reflux disease and 728 controls) were included. Main outcomes were presenteeism and absenteeism measured as work productivity loss and monetary cost per week. Absenteeism and presenteeism were significantly higher in the gastroesophageal reflux disease than the control group (1.49% vs. 0.46%, P=0.0010; 34.13% vs. 9.23%, P<0.0001). Loss of work productivity was significantly greater in the gastroesophageal reflux disease than the control group (33.09% vs. 9.02%; P<0.0001). This loss of work productivity difference between the two groups represented an additional productivity loss of 11.7h/week in the gastroesophageal reflux disease group compared with the control group. Assuming average hourly wages of $14.12, the weekly burden of gastroesophageal reflux disease reached $165.07 per person. Gastroesophageal reflux disease was associated with substantial work productivity loss, mainly due to presenteeism rather than absenteeism, in Korean full-time employees. Copyright Â© 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Cocuzza, Salvatore; Bonfiglio, Marco; Chiaramonte, Rita; Serra, Agostino
The objective was to analyze the association of radiotherapy with gastroesophageal reflux as determinant of fistula related pathology, in voice prosthesis patients. Retrospective study. Sixty-one laryngectomy patients were enrolled between 2005 and 2012. All patients underwent phonatory rehabilitation with voice prosthesis, along with evidence of gastroesophageal reflux disease, for which proton pump inhibitors (PPIs) were prescribed. We analyzed the occurrence of fistula-related problems among patients who received postoperative radiotherapy and those patients who did not. We observed a higher rate of failure of speech rehabilitation in laryngectomy patients with gastroesphageal reflux: this occurred when they had a history of postoperative radiotherapy (45%) compared with patients who did not (17%) (P < 0.05), although all patients were treated with PPIs. Our results seem to confirm the importance of postoperative radiotherapy with gastroesophageal reflux for the determinism of fistula-related problems. Copyright © 2014 The Voice Foundation. Published by Mosby, Inc. All rights reserved.
Mengatto, Cristiane Machado; Dalberto, Charlene da Silveira; Scheeren, Betina; Barros, Sérgio Gabriel Silva de
Rhythmic masticatory muscle activity, including sleep bruxism (SB), can be induced in healthy individuals by experimental esophageal acidification, which plays an important role in the pathogenesis of gastroesophageal reflux disease (GERD). However, no robust evidence supports the association between SB and GERD. The purpose of this study was to investigate the association between SB and GERD. Forty-five individuals were eligible to participate in this observational transversal study at the Gastroenterology Service of the Clinical Hospital of Porto Alegre, Brazil. The participants were classified into 2 groups, those with and without GERD, according to the Montreal Criteria and pH-metry/endoscopy findings. The diagnosis of SB was not assessed in a sleep laboratory but was based on self-report plus clinical inspection, according to the minimal diagnostic criteria of the American Academy of Sleep Medicine. The Lipp Stress Symptom Inventory was used to evaluate self-perceived stress. Univariate and multiple logistic regression analyses were performed with SB as dependent variable and GERD, sex, age, body mass index, and stress as predictors (α=.05; 90% power). The study population included individuals with SB without GERD (13.3%) and individuals with SB with GERD (31.1%). In participants with GERD, the prevalence of SB was 73.7%. Only the variable GERD was significantly associated with SB (P=.017; odds ratio 6.58; 95% confidence interval 1.40-30.98), although adjusted for stress and age. Sleep bruxism is prevalent in GERD patients, and GERD is highly associated with SB. Copyright © 2013 Editorial Council for the Journal of Prosthetic Dentistry. Published by Mosby, Inc. All rights reserved.
Fujiwara, Mariko; Miwa, Takashi; Kawai, Takashi; Odawara, Masato
Some studies report that complications of gastroesophageal reflux disease (GERD) occur more frequently in patients with diabetes mellitus (DM) than in non-diabetic patients. This study used transnasal endoscopy to elucidate the current status of concurrent GERD in patients with type 2 diabetes mellitus, and to examine the associations between intraesophageal pressure and GERD, as well as other neuropathic conditions. The study included 57 outpatients with type 2 diabetes mellitus. The mean age was 67 years and the duration of DM was 13 years. The mean hemoglobin A1c was 6.8%. Transnasal endoscopic evaluation items were (i) the presence or absence of esophagitis and its severity; (ii) intraesophageal pressure; and (iii) Helicobacter pylori status, which was evaluated by endoscopic findings, such as the presence or absence of gastritis and peptic ulcer, and by urea breath test. Of 57 patients, 24 (42.1%) were given a diagnosis of GERD based on endoscopy. Patients with concurrent GERD were younger, had shorter duration of DM, and were taller and heavier. Interestingly, no difference in body mass index was observed. There was no significant association between the presence of concurrent GERD and diabetic complications, including peripheral neuropathy, and infection or non-infection with H. pylori. Although there was no significant association between the presence of concurrent GERD and intraesophageal pressure values, we found aging, reduced estimated glomerular filtration rate, and the presence of autonomic nerve symptoms to correlate with reduced intraesophageal pressure. The results of this study could be used to answer the question of whether or not endoscopic GERD is a diabetic complication; however, further study is required. © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.
Iwakura, Narika; Fujiwara, Yasuhiro; Shiba, Masatsugu; Ochi, Masahiro; Fukuda, Takashi; Tanigawa, Tetsuya; Yamagami, Hirokazu; Tominaga, Kazunari; Watanabe, Toshio; Arakawa, Tetsuo
Objective Gastroesophageal reflux disease (GERD) is strongly associated with sleep disturbances; however, the detailed differences in the characteristics of sleep disturbances between GERD and non-GERD patients are unknown. The aim of the present study was to analyze the clinical characteristics as well as health-related quality of life in GERD and non-GERD patients with sleep disturbances. Methods Three hundred and fifty patients, including 124 patients with GERD and 226 patients without GERD, completed a self-administered questionnaire that evaluated clinical information. The Pittsburg Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS) and 8-item Short-Form Health Survey (SF-8) were also used. Sleep disturbance was considered to be present if the PSQI was >5.5. Results The prevalence of sleep disturbances was significantly higher in the GERD patients (66/124, 53.9%) than in the non-GERD patients (89/226, 39.3%). Depression and anxiety were significantly more common in the subjects with sleep disturbances than in those without sleep disturbances, although there were no differences between the GERD and non-GERD patients. Among the subjects with sleep disturbances, daytime sleepiness was more common in the GERD patients than in the non-GERD patients. The subjects with sleep disturbances had a poorer health-related quality of life. The physical components of quality of life were impaired, particularly in the GERD patients with sleep disturbances. Conclusion GERD patients with sleep disturbances commonly experience daytime sleepiness and an impaired health-related quality of life, especially in terms of physical components.
Dore, Maria Pina; Maragkoudakis, Emmanouil; Fraley, Ken; Pedroni, Antonietta; Tadeu, Vincenza; Realdi, Giuseppe; Graham, David Y; Delitala, Giuseppe; Malaty, Hoda M
Studies indicate that gastro-esophageal reflux disease (GERD) is associated with obesity, smoking, esophagitis, diet, and lifestyle. To identify risk factors associated with GERD among patients presenting to a tertiary GI clinic in Italy. Patients with a first diagnosis of GERD based on heartburn and/or regurgitation and/or esophagitis at the endoscopic examination were enrolled. A control group with neither GERD symptoms nor esophagitis was enrolled from the same hospital. Each subject completed a questionnaire including demographic information, lifestyle (e.g., exercise, alcohol, coffee, chocolate, and soda consumption, smoking, having large meals), and frequency of bowel movement. For each participant the body mass index (BMI) was calculated. Five hundred subjects were enrolled including 300 GERD patients and 200 controls. Females had significantly higher prevalence of GERD than males (66 vs. 48%, P = 0.001, OR = 2.1, 95% CI = 1.5-3.1). There was an inverse relationship between the level of education and presence of GERD (76% of GERD patients has completed only elementary school (OR = 2.1, 95% CI = 1.7-4.9). Obesity (BMI of > or =95th percentile for their age/gender specific) was significantly related to GERD (OR = 1.8, P = 0.01). None of the other variables studied showed significant associations with GERD. Logistic regression analysis showed that BMI > or =95th percentile, gender, and low education level were significant risk factors for GERD. Understanding the epidemiology and risk factors for GERD in a region is the first step in designing prevention and treatment strategies.
Stanghellini, Vincenzo; Tosetti, Cesare; Benedetto, Edoardo; Condoluci, Mario; De Bastiani, Rudi; Cogliandro, Rosanna; Mastronuzzi, Tecla; De Polo, Manuela; Di Mita, Francesco; Napoli, Luigi; Ubaldi, Enzo; Nebiacolombo, Cristina; Cottone, Carmelo; Grattagliano, Ignazio; Zamparella, Maria; Baldi, Elisabetta; Sanna, Guido
Gastro-esophageal reflux disease (GERD) leads to frequent medical visits, and available therapies fail in up to 40% of patients. Food allergies may be involved in GERD pathogenesis; however, allergens other than food have received little attention. Nickel allergy is common in the general population and some high-nickel foods are associated with GERD. However, the potential relationship between nickel allergy and GERD remains unaddressed. This study aimed to evaluate the prevalence of nickel sensitization in patients with and without GERD and to compare clinical and demographic features. This prospective, multicenter study included 210 adult GERD patients and 140 patients without GERD who presented at the general practitioner. All GERD patients had undergone treatment with proton pump inhibitors and upper digestive endoscopy within the previous five years. Demographic and clinical data were collected by questionnaire and patients underwent a nickel patch allergy test. Patients with and without GERD presented similar characteristics, with the exception of nickel sensitization, which was significantly more prevalent among GERD patients than controls (39.5% vs. 16.4%; p = 0.001). Nickel-positive GERD patients were more frequently female (90.4% vs. 65.4%, p = 0.003) and asthmatic (18.1% vs. 4.7%; p = 0.038), compared to nickel-negative GERD patients. At six-month follow-up, most of the patients, with or without nickel sensitization, reported improved symptoms without differences in drug prescription. Nickel sensitization is particularly prevalent in GERD patients seen in general practice. Whether allergies other than food allergy play a role in GERD remains to be elucidated.
Abel, Cheryl; Desilets, Alicia R; Willett, Kristine
To describe the pharmacology, pharmacokinetics, and efficacy of dexlansoprazole in the treatment of heartburn associated with nonerosive gastroesophageal reflux disease (GERD) and healing and maintenance of healing of all grades of erosive esophagitis (EE). Literature searches were conducted using MEDLINE Ovid (1950-December 2009, week 4) and EMBASE (1980-2009, week 53) using the term dexlansoprazole. References from articles obtained from the search were evaluated for other relevant citations. All articles published in English evaluating the pharmacology, pharmacokinetics, efficacy, and adverse effect profile of dexlansoprazole were selected for inclusion. Dexlansoprazole is the newest addition to the proton pump inhibitor (PPI) class and is approved for the treatment of heartburn associated with nonerosive GERD, healing of all grades of EE, as well as maintenance of healing of EE. Dexlansoprazole has a unique dual delayed-release formulation, which releases drug at 2 points in time; the first peak occurs 1-2 hours after administration and the second occurs within 4-5 hours after administration. In Phase 3 trials conducted in adults, researchers found that dexlansoprazole increases rates of healing of EE, as well as the maintenance of healing, compared to lansoprazole. Relief of heartburn symptoms was comparable among the dexlansoprazole and lansoprazole treatment groups. Common adverse effects of dexlansoprazole are similar to those of the other PPIs, including diarrhea, abdominal pain, nausea, upper respiratory infection, vomiting, and flatulence. Dexlansoprazole provides another treatment option for the management of EE and symptoms of heartburn. Considering that the cost of dexlansoprazole is not favorable, further studies evaluating potential advantages over other agents are necessary to define the role of dexlansoprazole in the treatment of these conditions.
Moore, Katherine; Bolduc, Stéphane
Endoscopic injection of a bulking agent is becoming a first-line treatment for low grade vesicoureteral reflux. We prospectively compared the efficacy of 2 such products commercially available in Canada. A total of 275 patients with documented grade I to V vesicoureteral reflux were prospectively enrolled in a comparative study between April 2005 and February 2011 to be randomly treated endoscopically with either polydimethylsiloxane (Macroplastique®) or dextranomer/hyaluronic acid copolymer (Deflux®). Of the ureters 202 were treated with polydimethylsiloxane and 197 with dextranomer/hyaluronic acid copolymer. Patients were followed with voiding cystourethrography at 3 months and renal ultrasonography at 3 months and at 1 year. Median followup was 4.3 years. The primary outcome was surgical success (resolution vs nonresolution), and secondary outcomes included occurrence of adverse events. Vesicoureteral reflux was fully corrected in 182 of 202 ureters (90%) treated with polydimethylsiloxane, compared to 159 of 197 (81%) treated with dextranomer/hyaluronic acid copolymer (p <0.05). Obstruction was found in 5 ureters. Univariate and multivariate analyses did not allow identification of any characteristics that could explain the significant difference in the success rates except for the type of product used. We present the largest known prospective evaluation comparing 2 bulking agents for the treatment of vesicoureteral reflux. Endoscopic injection of polydimethylsiloxane resulted in a better success rate than dextranomer/hyaluronic acid copolymer. The rate of resolution obtained with the latter is lower than those previously published due to the inclusion of high grade reflux. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Xu, Wenhong; Sun, Changxian; Lin, Zheng; Lin, Lin; Wang, Meifeng; Zhang, Hongjie; Song, Yulei
Gastroesophageal reflux disease is a chronic disease with a high incidence worldwide. The various symptoms have substantial impact on the quality of life of affected individuals. A long-term self-management program can increase the ability of patients to make behavioral changes, and health outcomes can improve as a consequence. This study's aim was to evaluate the effectiveness of a self-management program for gastroesophageal reflux disease. A total of 115 patients with gastroesophageal reflux disease were allocated to the experimental group and the control group. The former received self-management intervention along with conventional drug therapy, whereas the latter received standard outpatient care and conventional drug therapy. After the clinical trial, the control group also received the same self-management intervention. The levels of self-management behaviors, self-efficacy, gastroesophageal reflux disease symptoms, and psychological condition were compared. Those in the experimental group demonstrated significantly higher self-efficacy for managing their illness, showed positive changes in self-management behaviors, and had comparatively better remission of symptoms and improvement in psychological distress. The program helped patients with gastroesophageal reflux disease self-manage their illness as possible.
Xu, Wenhong; Sun, Changxian; Lin, Lin; Wang, Meifeng; Zhang, Hongjie; Song, Yulei
Gastroesophageal reflux disease is a chronic disease with a high incidence worldwide. The various symptoms have substantial impact on the quality of life of affected individuals. A long-term self-management program can increase the ability of patients to make behavioral changes, and health outcomes can improve as a consequence. This study's aim was to evaluate the effectiveness of a self-management program for gastroesophageal reflux disease. A total of 115 patients with gastroesophageal reflux disease were allocated to the experimental group and the control group. The former received self-management intervention along with conventional drug therapy, whereas the latter received standard outpatient care and conventional drug therapy. After the clinical trial, the control group also received the same self-management intervention. The levels of self-management behaviors, self-efficacy, gastroesophageal reflux disease symptoms, and psychological condition were compared. Those in the experimental group demonstrated significantly higher self-efficacy for managing their illness, showed positive changes in self-management behaviors, and had comparatively better remission of symptoms and improvement in psychological distress. The program helped patients with gastroesophageal reflux disease self-manage their illness as possible. PMID:27684637
Nagahama, Kenji; Nishio, Hikaru; Yamato, Masanori; Takeuchi, Koji
Summary Background Reflux esophagitis is caused mainly by excessive exposure of the mucosa to gastric contents. In the present study, we examined the effect of several amino acids on acid reflux esophagitis in rats. Material/Methods After 18 h of fasting, acid reflux esophagitis was induced by ligating both the pylorus and the transitional region between the forestomach and the corpus under ether anesthesia, and the animals were killed 4 h later. The severity of esophagitis was reduced by the oral administration of omeprazole, a proton pump inhibitor, or pepstatin, a specific pepsin inhibitor. Results The development of esophageal lesions was dose-dependently prevented by L-arginine and glycine, given intragastrically (i.g.) after the ligation, with complete inhibition obtained at 250 mg/kg and 750 mg/kg, respectively, and these effects were not influenced by the prior s.c. administration of indomethacin or L-NAME. By contrast, both L-alanine and L-glutamine given i.g. after the ligation aggravated these lesions in a dose-dependent manner. These amino acids had no effect on acid secretion but increased the pH of the gastric contents to 1.8~2.3 due to their buffering action. Conclusions The results confirmed an essential role for acid and pepsin in the pathogenesis of acid reflux esophagitis in the rat model and further suggested that various amino acids affect the severity of esophagitis in different ways, due to yet unidentified mechanisms; L-alanine and L-glutamine exert a deleterious effect on the esophagitis, while L-arginine and glycine are highly protective, independent of endogenous prostaglandins and nitric oxide. PMID:22207112
Martinucci, Irene; Albano, Eleonora; Marchi, Santino; Blandizzi, Corrado
Associations of gastroesophageal reflux disease (GERD) with extraesophageal manifestations, such as chronic cough, asthma, and laryngitis, are reported frequently, and there is a strong evidence of biological plausibility in support of this relationship. On the other hand, extraesophageal reflux disease (EERD) is usually multifactorial in nature with reflux being just one of the several potential contributing cofactors. Moreover, the accuracy of currently available diagnostic tests for EERD is suboptimal, and therefore the causal relationship between GERD and EERD remains far from being conclusively proven. In addition, there is a general paucity of data supporting a beneficial effect of anti-reflux treatments on symptoms of patients with suspected EERD. Therefore, diagnostic as well as therapeutic management of EERD remains largely empirical. Current guidelines suggest an initial empiric trial of proton pump inhibitors in patients without alarm features, who present also typical GERD symptoms. For those patients who improve with PPIs, GERD is presumed to be the etiology. In patients with refractory reflux, combined impedance/pH monitoring might provide the single best strategy for evaluating reflux symptoms. In this context, as symptoms ascribable to GERD may depend on other causes, investigations that excludes GERD can help to redirect the diagnostic and treatment efforts to other pathological conditions. The present review intends to discuss the current state of knowledge regarding the challenging diagnostic and therapeutic management of patients with suspected EERD, emphasizing the points of strengths and limitations of currently available diagnostic options, and to provide an update on major diagnostic innovations in this area.
Ganz, Robert A
Treatment of gastroesophageal reflux disease in the United States today is binary, with the majority of patients with gastroesophageal reflux disease being treated with antisecre-tory medications and a minority of patients, typically those with volume regurgitation, undergoing Nissen fundoplication. However, there has been increasing dissatisfaction with proton pump inhibitor therapy among a significant number of patients with gastroesophageal reflux disease owing to cost, side effects, and refractory symptoms, and there has been a general reluctance to undergo surgical fundoplication due to its attendant side-effect profile. As a result, a therapy gap exists for many patients with gastroesophageal reflux disease. Alternative techniques are available for these gap patients, including 2 endoscopic fundoplication techniques, an endoscopic radiofrequency energy delivery technique, and 2 minimally invasive surgical procedures. These alternative techniques have been extensively evaluated; however, there are limitations to published studies, including arbitrary definitions of success, variable efficacy measurements, deficient reporting tools, inconsistent study designs, inconsistent lengths of follow-up postintervention, and lack of comparison data across techniques. Although all of the techniques appear to be safe, the endoscopic techniques lack demonstrable reflux control and show variable symptom improvement and variable decreases in proton pump inhibitor use. The surgical techniques are more robust, with evidence for adequate reflux control, symptom improvement, and decreased proton pump inhibitor use; however, these techniques are more difficult to perform and are more intrusive. Additionally, these alternative techniques have only been studied in patients with relatively normal anatomy. The field of gastroesophageal reflux disease treatment is in need of consistent definitions of efficacy, standardized study design and outcome measurements, and improved reporting
Gao, Feng; Hobson, Anthony Robert; Shang, Zhan Min; Pei, Yan Xiang; Gao, Yan; Wang, Jian Xin; Huang, Wan Nong
The cause of idiopathic pulmonary fibrosis (IPF) remains unknown, yet gastro-esophageal reflux disease (GERD) is highly prevalent in this population. GERD prevalence was studied, and esophageal function tests (EFT) were assessed in Chinese IPF patients. We prospectively studied 69 IPF patients who undertook both stationary High Resolution esophageal Manometry/Impedance (HRiM) and 24-hour esophageal Multi-Channel Intraluminal Impedance with pH Recordings (MII/pH). Patients were divided into GERD+ and GERD- groups according to pH results. Controls were HRiM treated healthy volunteers, and patients without IPF received HRiM and MII/pH diagnosed with GERD. 69 IPF patients, 62 healthy volunteers, and 88 IPF negative GERD patients were selected. GERD prevalence in IPF was 43/69 (62.3%), and 58.1% of patients presented with at least one typical symptom. Symptoms had a sensitivity of 58.1%, a specificity of 61.6%, a positive predictive value of 71.4% and a negative predictive of 47.1%. Compared with healthy volunteers, IPF patients had significantly decreased lower esophageal sphincter pressure (LESP), upper esophageal sphincter pressure (UESP) and complete bolus transit rate (CBTR). By contrast, IPF patients had increased total bolus transit time and prevalence of weak peristalsis. MII/pH showed that one third of IPF patients had abnormal distal and proximal reflux, especially non-acid reflux. Compared with GERD patients without IPF, GERD patients with IPF had significantly decreased CBTR and UESP with increased bolus exposure time. GERD prevalence in IPF was high, but symptoms alone were an unreliable predictor of reflux. IPF patients had lower LESP and UESP, impaired esophageal peristalsis and bolus clearance function with more proximal reflux events.
Filipi, Kristina; Halackova, Zdenka; Filipi, Vladimir
To present a complex oral health status including salivary factors, microbial analysis and periodontal and hygiene indices in patients with active gastro-oesophageal reflux disease (GORD). Return of stomach contents is quite common in cases of gastro-oesophageal reflux. Pathological acid movement from the stomach into the oesophagus and oral cavity may lead to a development of dental erosion. Long-lasting untreated GORD may damage hard dental and periodontal tissues and alter the oral microbial environment. The quality and amount of the saliva play an important role in hard and soft oral tissues changes. Fifty patients with diagnosed GORD using 24-hour pH manometry underwent dental examination; 24 patients had active GORD and had been waiting for surgical therapy. In this patient group oral health status and salivary analysis were evaluated. Indicated low salivary flow rates and buffering capacity with a low caries risk but a high risk for dental erosion progression. © 2011 FDI World Dental Federation.
Krill, Joseph T; Naik, Rishi D; Higginbotham, Tina; Slaughter, James C; Holzman, Michael D; Francis, David O; Garrett, C Gaelyn; Vaezi, Michael F
The effectiveness of antireflux surgery (ARS) varies among patients with extraesophageal manifestations of gastroesophageal reflux disease (GERD). By studying a cohort of patients with primary extraesophageal symptoms and abnormal physiologic markers for GERD, we aimed to identify factors associated with positive outcomes from surgery, and compare outcomes to those with typical esophageal manifestations of GERD. We performed a retrospective cohort study to compare adult patients with extraesophageal and typical reflux symptoms who underwent de novo ARS from 2004 through 2012 at a tertiary care center. All 115 patients (79 with typical GERD and 36 with extraesophageal manifestations of GERD) had evidence of abnormal distal esophageal acid exposure based on pH testing or endoscopy. The principle outcome was time to primary symptom recurrence after surgery, based on patient reports of partial or total recurrence of symptoms at follow-up visits. Patients were followed up for a median duration of 66 months (interquartile range, 52-77 mo). The median time to recurrence of symptoms in the overall cohort was 68 months (11.5 months in the extraesophageal cohort vs >132 months in the typical cohort). Symptom recurrence after ARS was associated with having primarily extraesophageal symptoms (adjusted hazard ratio, 2.34; 95% confidence interval, 1.31-4.17) and poor preoperative symptom response to acid-suppression therapy (AST) (hazard ratio, 3.85; 95% confidence interval, 2.05-7.22). Patients with primary extraesophageal symptoms who had a full or partial preoperative AST response experienced lower rates of symptom recurrence compared to patients with poor AST response (P < .01). The rate of symptom recurrence was lowest among patients with primary typical reflux symptoms who had a partial or full symptom response to AST (P < .01). The severity of acid reflux on pH testing, symptom indices, severity of esophagitis, and hiatal hernia size were not associated with symptom
Ishii, Shinji; Fukahori, Suguru; Asagiri, Kimio; Tanaka, Yoshiaki; Saikusa, Nobuyuki; Hashizume, Naoki; Yoshida, Motomu; Masui, Daisuke; Komatsuzaki, Naoko; Higashidate, Naruki; Sakamoto, Saki; Kurahachi, Tomohiro; Tsuruhisa, Shiori; Nakahara, Hirotomo; Yagi, Minoru
The aim of this study is to investigate the degree of delayed gastric emptying (DGE) and evaluate how the severity of DGE affects gastroesophageal reflux disease (GERD) in neurologically impaired (NI) patients utilizing 24-hour multichannel intraluminal impedance pH measurements (pH/MII) and 13 C-acetate breath test ( 13 C-ABT) analyses. 13 C-ABT and pH/MII were conducted in 26 NI patients who were referred to our institution due to suspected GERD. At first, correlation analyses were performed to investigate the correlation between the 13 C-ABT parameters and the clinical or pH/MII parameters. Thereafter, all patients were divided into 2 groups (DGE and severe DGE [SDGE] group) according to each cut off half emptying time (t 1/2 , 90-170 minutes). Each pH/MII parameter was compared between the 2 groups in each set-up cutoff t 1/2 . The mean t 1/2 of all patients was 215.5 ± 237.2 minutes and the t 1/2 of 24 (92.3%) patients were > 100 minutes. Significant moderate positive correlations were observed between both t 1/2 and lag phase time and the non-acid reflux related parameters. Furthermore, the patients in the SDGE group demonstrated higher non-acid reflux related parameters than those of the DGE groups when the cutoff was t 1/2 ≥ 140 minutes. The present study demonstrated that GE with t 1/2 ≥ 140 minutes was related to an increase of non-acid exposure reaching up to the proximal esophagus in NI patients, and indicating that NI patients with SDGE might have a high risk of non-acid GERD.
Boltin, Doron; Zvidi, Ibrahim; Raskin, Maria; Kayless, Hen; Schmilovitz-Weiss, Hemda; Gingold-Belfer, Rachel; Niv, Yaron; Dickman, Ram
Esomeprazole is commonly administered with food; however, clinical data to support this practice are lacking. We aimed to determine the effect of postprandial ingestion of esomeprazole on reflux symptoms among patients with gastroesophageal reflux disease (GERD). Consecutive patients with GERD adequately controlled with esomeprazole 40 mg daily, entered a 2-week lead-in period during which esomeprazole was administered 30 min before breakfast. Patients were then randomized to continue preprandial ingestion or to ingest esomeprazole following a standardized meal. Outcomes included GERD frequency and severity indices, GERD-health-related quality of life (GERD-HRQL) questionnaire and Short Form 36 (SF-36). Thirty-two patients (17 [53.1%] men, aged 53.5 ± 17.2 years) were included, and 16 (50%) switched to postprandial ingestion of esomeprazole. GERD frequency and severity decreased in both groups (Δ9.0 ± 7.2 vs. Δ10.0 ± 8.1, p = 0.29; Δ6.6 ± 6.8 vs. Δ10.2 ± 7.4, p = 0.57 in postprandial group vs. controls, for frequency and severity, respectively). GERD-HRQL improved in both study groups to a similar degree (Δ10.7 ± 10.5 vs. Δ10.0 ± 13.8, p = 0.97). All SF-36 subscores increased in both groups to a similar degree. In a mixed linear model, there were no differences between the study groups in the changes observed in GERD frequency (p = 0.49), severity (p = 0.32), and GERD-HRQL (p = 0.98) during the study period. Switching to postprandial administration of esomeprazole is not associated with deterioration in reflux symptoms among patients with GERD. Esomeprazole seems to remain efficacious when administered after meals. © 2018 S. Karger AG, Basel.
Koufman, Jamie A; Johnston, Nikki
At the cellular level, tissue-bound pepsin is fundamental to the pathophysiologic mechanism of reflux disease, and although the thresholds for laryngeal damage in laryngopharyngeal reflux and for esophageal damage in gastroesophageal reflux disease differ, both forms of damage are due to pepsin, which requires acid for its activation. In addition, human pepsin remains stable at pH 7.4 and may be reactivated by hydrogen ions from any source. Thus, most tap and bottled waters (typically pH 6.7 to 7.4) would not be expected to affect pepsin stability. The purposes of these in vitro studies were to investigate whether artesian well water containing natural bicarbonate (pH 8.8) might irreversibly denature (inactivate) human pepsin, and to establish its potential acid-buffering capacity. Laboratory studies were performed to determine whether human pepsin was inactivated by pH 8.8 alkaline water. In addition, the buffering capacity of the alkaline water was measured and compared to that of the two most popular commercially available bottled waters. The pH 8.8 alkaline water irreversibly inactivated human pepsin (in vitro), and its hydrochloric acid-buffering capacity far exceeded that of the conventional-pH waters. Unlike conventional drinking water, pH 8.8 alkaline water instantly denatures pepsin, rendering it permanently inactive. In addition, it has good acid-buffering capacity. Thus, the consumption of alkaline water may have therapeutic benefits for patients with reflux disease.
Witteman, Bart P L; Conchillo, Jose M; Rinsma, Nicolaas F; Betzel, Bark; Peeters, Andrea; Koek, Ger H; Stassen, Laurents P S; Bouvy, Nicole D
Transoral incisionless fundoplication (TIF) was developed in an attempt to create a minimally invasive endoscopic procedure that mimics antireflux surgery. The objective of this trial was to evaluate effectiveness of TIF compared with proton pump inhibition in a population consisting of gastroesophageal reflux disease (GERD) patients controlled with proton pump inhibitors (PPIs) who opted for an endoscopic intervention over lifelong drug dependence. Patients with chronic GERD were randomized (2:1) for TIF or continuation of PPI therapy. American Society of Anesthesiologists >2, body mass index >35 kg/m(2), hiatal hernia >2 cm, and esophageal motility disorders were exclusion criteria. Primary outcome measure was GERD-related quality of life. Secondary outcome measures were esophageal acid exposure, number of reflux episodes, PPI usage, appearance of the gastroesophageal valve, and healing of reflux esophagitis. Crossover for the PPI group was allowed after 6 months. A total of 60 patients (TIF n=40, PPI n=20, mean body mass index 26 kg/m(2), 37 male) were included. At 6 months, GERD symptoms were more improved in the TIF group compared with the PPI group (P<0.001), with a similar improvement of distal esophageal acid exposure (P=0.228) compared with baseline. The pH normalization for TIF group and PPI group was 50% and 63%, respectively. All patients allocated for PPI treatment opted for crossover. At 12 months, quality of life remained improved after TIF compared with baseline (P<0.05), but no improvement in esophageal acid exposure compared with baseline was found (P=0.171) and normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%. Although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.
Abnormal Gastroesophageal Flap Valve Is Associated With High Gastresophageal Reflux Disease Questionnaire Score and the Severity of Gastroesophageal Reflux Disease in Vietnamese Patients With Upper Gastrointestinal Symptoms.
Quach, Duc T; Nguyen, Trang T; Hiyama, Toru
There have been no studies investigating the distribution of abnormal gastroesophageal flap valve (GEFV) among patients with dyspepsia, non-erosive reflux disease (NERD), and reflux esophagitis (RE) in the same set of patients. The aims of this study are to investigate (1) the association between GEFV and gastroesophageal reflux disease questionnaire (GERDQ) score, and (2) the distribution of abnormal GEFV in Vietnamese patients presenting with upper gastrointestinal symptoms. Three hundred and thirty-one patients recruited in this prospective cross-sectional study were classified into 3 groups: reflux esophagitis (RE), non-erosive reflux disease (NERD) (GERDQ score ≥ 8, no endoscopic mucosal injury), and dyspepsia (GERDQ score < 8, no endoscopic mucosal injury). The GEFV was graded endoscopically according to the Hill classification. GEFV grades I and II were regarded as normal, while grades III and IV were regarded as abnormal GEFV. There were 215 (65.0%) patients with dyspepsia, 55 (16.6%) patients with NERD, and 61 (18.4%) patients with RE. Abnormal GEFV was an independent risk factor for GERD (OR, 2.93; CI 95%, 1.76-4.88) and RE (OR, 3.41; CI 95%, 1.78-6.53). The mean GERDQ score of patients with abnormal GEFV was significantly higher than that of patients with normal GEFV (5.7 ± 2.4 vs 4.9 ± 2.7, P = 0.011). The prevalence of abnormal GEFV gradually increased in patients with dyspepsia (27.4%), NERD (43.6%), grade A RE (56.8%), and grades B/C RE (80.0%) ( P ＜ 0.001). Abnormal GEFV was significantly associated with high GERDQ score. Its prevalence gradually increased in patients with dyspepsia, NERD, and RE, respectively.
Bilgin, Huseyin; Eren, Abdulkadir; Kara, Semra
The possible pathophysiology of the relationship between gastro-esophageal reflux disease and apnea of prematurity has been widely investigated. Various physiological protective reflex responses provide a plausible biological link between gastro-esophageal reflux and apnea of prematurity. It is uncertain whether or not there is a causal relationship between the two diseases. PATIENT'S FINDINGS: Twins were admitted to the neonatal intensive care unit due to feeding problems. Physical examination was normal except for reticulated, blueviolet skin changes. Short apneic attacks occurred on the first day in twin 1 and on the second day in twin 2, and these were initially treated by stimulation and increased ambient O2 concentration. Then, we conducted methylxanthine and continuous positive airway pressure treatment. Laboratory and radiological analysis were normal. As gastro-esophageal reflux disease was thought to be the causes of the treatment-refractory apnea, therapy with gaviscon and domperidon was begun for both cases. Apneic attacks did not recur after gaviscon and domperidon therapy. Pharmacological therapy for gastro-esophageal reflux disease has not definitively been shown to be effective in improving symptoms and hence, should be reserved especially for infants with treatment refractory apnea episodes suspected as being gastro-esophageal reflux in premature infants.
The most important novel findings presented on oesophageal disease in DDW 2015 were the following: 1) GERD: a) hypervigilance seems to be a key pathogenic factor in reflux symptoms refractory to PPI; b) post-reflux swallowing-induced peristaltic waves could be an excellent diagnostic criterion for GERD; c) laryngeal pH-metry is not useful in the diagnosis of extra-oesophageal symptoms; d) the recommendation of weight loss adequately recorded in the clinical reports of patients with GERD and obesity or overweight is an excellent quality indicator and is associated with better outcomes. 2) Barrett's oesophagus: a) persistent low-grade dysplasia in more than one endoscopy and a diagnosis of "indefinite for dysplasia" are associated with a high risk of neoplastic progression; b) narrow-band imaging allows areas of dysplasia on Barrett's oesophagus to be identified with high sensitivity and specificity; c) initial endoscopy fails to identify a high percentage of advanced neoplasms in Barrett's oesophagus. Early re-endoscopy should be considered; d) endoscopists specialized in Barret's oesophagus obtain a much higher yield in the diagnosis of advanced lesions. Patients at high risk-men, older patients, smokers and those with long-segment Barrett's oesophagus-could benefit from follow-up in a referral center. 3) Achalasia: POEM seems safe and effective, independently from patient characteristics (age, comorbidity) and the technical variations used. 4) Eosinophilic esophagitis: topical budesonide and exclusion diets are reasonably effective in PPI non-responders. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.
Ju, Gawon; Yoon, In-Young; Lee, Sang Don; Kim, Nayoung
Studies on the association between gastroesophageal reflux