Modern diagnosis of GERD: the Lyon Consensus

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.

Clinical and psychological characteristics in gastroesophageal reflux disease patients overlapping with laryngopharyngeal reflux symptoms

BACKGROUND AND AIM

Laryngopharyngeal reflux (LPR) defined as reflux of gastric content reaching above the upper esophageal sphincter is frequently found in patients with gastroesophageal reflux disease (GERD). This study aimed to investigate clinical and psychological differences between GERD patients with or without LPR symptoms.

METHODS

This study enrolled 303 consecutive patients with proton pump inhibitor treatment-naïve scheduled for upper endoscopy because of troublesome reflux symptoms and recognized as GERD by non-dyspepsia reflux disease questionnaire score. Included GERD patients were further categorized into two study groups: with or without LPR by reflux symptoms index score. All participants were also evaluated with questionnaires for depression, anxiety, and sleep disturbances.

RESULTS

There were 132 (43.6%) GERD patients with LPR symptoms and 171 (56.4%) GERD patients without LPR symptoms. GERD patients with LPR symptoms had more depression (P < 0.001), sleep disturbance (P = 0.002), irritable bowel syndrome (P = 0.008), functional dyspepsia (P = 0.005), and reflux symptoms burden (P < 0.001) than those without LPR symptoms. Erosive esophagitis was more in patients without LPR symptoms (P = 0.03). GERD patients with LPR symptoms (28.8%) had more complex psychological distress than those without LPR symptoms (28.8% vs 14%, P < 0.001). Reflux symptoms burden, sleep disturbance, and erosive esophagitis were independently associated with GERD overlapping with LPR symptoms.

CONCLUSIONS

Gastroesophageal reflux disease patients with LPR symptoms appear to have more reflux symptoms, psychological distress, and functional gastrointestinal disturbance but less erosive esophagitis. This work suggests that therapeutic strategy with tailored multidimensional approach is promising for GERD patients overlapping with LPR symptoms.

Role of Reflux in the Pathogenesis of Eosinophilic Esophagitis: Comprehensive Appraisal With Off- and On PPI Impedance-pH Monitoring

OBJECTIVES

Role of reflux and mechanisms of response to proton pump inhibitor (PPI) therapy in eosinophilic esophagitis (EoE) have not yet been fully elucidated. Comprehensive assessment by impedance-pH monitoring could clarify these issues.

METHODS

Prospective multicenter study comparing EoE patients with healthy controls and gastroesophageal reflux disease cases. Patients with EoE were evaluated off- and on PPI; responsiveness was assessed by histology. Impedance-pH appraisal included chemical clearance, assessed with the postreflux swallow-induced peristaltic wave (PSPW) index, and mucosal integrity measured with mean nocturnal baseline impedance (MNBI).

RESULTS

Sixty consecutive patients with EoE were compared with 60 age- and sex-matched healthy controls and 60 subjects with gastroesophageal reflux disease. The number of total refluxes was higher, while the PSPW index was lower in patients with EoE than in healthy controls. Off PPI, a lower MNBI gradient between the mid and distal esophagus distinguished 20 patients with PPI-refractory EoE from 40 patients with PPI-responsive EoE and was a predictor of PPI failure. On PPI, a lower PSPW index was the sole reflux parameter distinguishing PPI-refractory from PPI-responsive EoE; all reflux parameters improved in PPI-responsive patients, whereas the PSPW index was not modified in PPI-refractory cases and was independently associated with PPI-responsiveness. MNBI in the distal and mid esophagus improved much more in PPI-responsive than in PPI-refractory EoE.

DISCUSSION

Reflux plays a role in the pathogenesis of EoE, more relevant in PPI-responsive cases. Low impedance gradient between the mid and distal esophagus may be useful to predict PPI refractoriness. PPIs mainly act by improving chemical clearance, i.e., by an antireflux action supporting long-term prescription in PPI-responsive EoE.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being  < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

Non-Bariatric Roux-en-Y Gastric Bypass

Background: Roux-en-Y gastric bypass (RYGB) is frequently performed for weight loss purposes in the morbidly obese population. The popularity and acceptance of this procedure have increased the knowledge of the physiological (anatomical and functional) changes that this technique produces in the organism. RYGB improves gastric emptying and gastroesophageal reflux symptoms. Materials and Methods: We analyzed 6 patients in whom an RYGB was performed for non-bariatric purposes. Symptom questionnaire was used to evaluate response. Results: None of the patients qualified for bariatric surgery, as all had a body mass index (BMI) <35 kg/m². Five patients were operated on for severe gastroesophageal reflux disease symptoms, and one for gastroparesis. All patients had good to excellent results, with marginal modification of their BMI. Conclusion: Non-bariatric RYGB can be considered in patients with functional diseases of the upper gastrointestinal tract, regardless of their BMI.

Mucosal impedance testing: A new diagnostic testing in gastroesophageal reflux disease

Current diagnostic testing for gastroesophageal reflux disease (GERD) include endoscopy, ambulatory pH and intraluminal impedance monitoring. However, they are suboptimal and do not measure chronicity of reflux. Recently, a mucosal impedance (MI) device has been developed to measure esophageal epithelial conductivity changes, a marker of chronic GERD. The aim of this review is to summarize the use of MI testing (MIT) for the evaluation and management of esophageal disease. MIT is a minimally invasive and simple through-the-scope procedure performed during endoscopy. It allows for a rapid derivation of MI values within seconds without an uncomfortable overnight pH- impedance catheter. The MI values can correlate with histological findings of epithelial barrier dysfunction, normalize with effective treatment, and show promise for differentiating GERD from non-GERD conditions such as eosinophilic esophagitis (EoE). In conclusion, endoscopic MIT measurement can differentiate esophageal disorders instantly during endoscopy. It may not only serve as an important tool in diagnosing of GERD but also help guide therapy in clinically difficult situations as a surrogate to predict the treatment response.

Intra-Esophageal pH Monitoring on Two Consecutive Days in Patients With Gastroesophageal Reflux Symptoms

Background

The best method to measure the frequency and duration of gastroesophageal reflux is 24-h pH or 24-h pH/impedance monitoring. However, the detection of reflux can vary when measured on different days. Our aim was to evaluate the possibility that the severity of gastroesophageal reflux is different even under similar conditions on two consecutive days.

Methods

We performed a 48-h pH monitoring in 12 subjects, aged 25 - 63 years, who complaint of heartburn and regurgitation, ten with esophagitis and two with non-erosive disease. The pH measurement was conducted at 5 cm from the lower esophageal sphincter. The patients stayed at the Clinical Investigation Ward of the hospital for 48 h. On each day, they consumed a 2,000 calorie diet. The results obtained on the first day were compared with those on the second day.

Results

Mean reflux index in the upright position was different between the two days. Results of the pH-monitoring within the 2 h after the meal revealed differences in the number of acidic reflux and reflux index episodes. Three patients had abnormal DeMeester score on one day and normal score on the other day. Considering the upper limit of 6.0% of the test duration with esophageal pH < 4 as indicative of gastroesophageal reflux disease, two patients showed abnormal results on one day and normal results on the other day.

Conclusions

The 24-h pH monitoring, performed on two consecutive days under similar conditions, can lead to different diagnosis of gastroesophageal reflux disease in symptomatic patients.

Reflux esophagitis, functional and non-functional

The pathogenesis of gastroesophageal reflux disease has been explained by acid-peptic model. However, related with the progress of the diagnostic modalities, another phenotypical group of patients were defined and called "functional disorders of the esophagus". These patients are important because diagnosis is particularly difficult, co-morbid disorders especially psychiatric diseases are common, proton pump inhibitor response is low, and surgical results are very poor. Simpler and translational science studies are required in functional groups in order to differentiate from acid-peptic disorders. New and more accurate diagnostic modalities as well as therapeutic approaches are strongly needed in this particularly new and exciting era, especially in the effect of neuromodulators. Current diagnostic modalities should also be evaluated and in fact, normal values should be established. New medications, especially acting at the level of esophageal epithelium and intercellular spaces, might shift the paradigm.

Idiopathic pulmonary fibrosis and GERD: links and risks

Gastroesophageal reflux disease (GERD) and idiopathic pulmonary fibrosis (IPF) are two pathological conditions often strictly related, even if a clear relationship of causality has not been demonstrated. GERD is a frequent comorbidity in IPF patients, as demonstrated using combined multichannel intraluminal impedance-pH, despite being mostly clinically silent. According to that, it has been hypothesized that microaspiration of gastric material may play a fundamental role in the fibrotic transformation of pulmonary parenchyma. In contrast, it cannot be excluded that IPF may favor GERD by increasing the negative intrathoracic pressure. Therefore, this relationship is uncertain as well as not univocal. Nevertheless, the latest international guidelines recommend the use of proton pump inhibitors (PPIs) in IPF based on several data showing that PPIs can stabilize lung function, reduce disease flares and hospitalizations. On the contrary, recent studies not only question the relevance of these results, but also associate the use of PPIs with an increased risk of lung infections and a negative prognostic outcome. The aim of this review is to analyze the possible links between GERD and IPF and their possible therapeutic implications, trying to translate this scientific evidence into useful information for clinical practice.

The importance of pH reflux monitoring test for the management of low-grade esophagitis in Chinese patients

BACKGROUND AND AIMS

Low-grade esophagitis (grade A and B) are no longer believed as confirmatory evidence of gastroesophageal reflux disease, but there were no data about the association of low-grade esophagitis with pathological acid reflux (PAR) in China. This study aimed to summarize the proportion of PAR in the patients with low-grade esophagitis and to explore the differential factors between low-grade esophagitis patients with and without PAR.

METHODS

Database of the patients accepted 24-hour pH monitoring in the motility laboratory of a tertiary center was retrospectively searched, and the patients were diagnosed as low-grade esophagitis before the procedure was recruited. The demographics, symptoms and high-resolution manometry and pH monitoring parameters were compared between the patients with pathological and physiological acid reflux and between patients with grade A and B esophagitis.

RESULTS

About 24% of grade A and 55% of grade B esophagitis patients had pathological acid reflux. The demographics, symptoms, and almost all high-resolution manometry findings were similar in patients with pathological and physiological acid reflux. About two-thirds of the participants with physiological acid reflux reported symptom improvement after PPI administration. All participants with PPI-resistant symptoms were with physiological acid reflux.

CONCLUSION

The proportion of PAR in low-grade esophagitis is not high. For patients with low-grade esophagitis in China, especially the patients with grade A esophagitis, regardless of symptom change, reflux monitoring is possibly needed for the patients whose esophageal mucosa break is not improved after 8 weeks of PPI treatment.

Esophageal mucosal innervation in functional heartburn: Closer to healthy asymptomatic subjects than to non-erosive reflux disease patients

BACKGROUND

Mucosal innervation in non-erosive reflux disease (NERD; pathological esophageal acid exposure, normal macroscopic mucosa) is clearly distinct from that of healthy volunteers (HV) and from patients with esophagitis or Barrett's esophagus: The nerves in NERD are situated much closer to the luminal surface of the mucosa. Patients with functional heartburn (FH) have a similar symptom profile to patients with NERD and indistinguishable macroscopic appearances. However, they have physiological acid exposure and no reflux-symptom association. The aim of our study was to delineate the position of esophageal mucosal nerve fibers in patients with FH and compare it with that in NERD and HV.

METHODS

Distal esophageal biopsies from patients with FH were immunohistochemically stained for CGRP. CGRP-positive nerve fibers were identified, and their position relative to the lumen was determined. These results were compared to our previously published cohort of HV and NERD.

RESULTS

Eleven patients were included in the FH group with a mean age of 46 years (range 33-69); 7F:4M. Nine patients had visible nerve fibers. The location of the afferent nerve fibers in the distal esophageal mucosa (median of 22, range 10.4-28) was similar to the HV group (median 25.5) and significantly deeper than the superficial nerves seen in NERD (median 9.5).

CONCLUSIONS

The mucosal innervation pattern in FH is more alike that of healthy individuals than that of NERD, with afferent nerves lying deep in the mucosa, away from the luminal surface. This supports the theory that heartburn in FH has a distinct nociceptive pathophysiology.

Clinical Characteristics and Outcomes of Patients With Postfundoplication Dysphagia

BACKGROUND & AIMS

Dysphagia is a consequence of antireflux surgery (ARS) for gastroesophageal reflux disease (GERD). We studied patient management and symptomatic outcomes.

METHODS

We performed a retrospective study of 157 consecutive adult patients with GERD (mean age, 65.1 ± 1.0 y; 72% female) who underwent ARS at a tertiary care center from 2003 through 2014. We characterized postfundoplication dysphagia using a self-reported Likert scale, which ranged from a low score of 0 (no dysphagia) to a high score of 4 (severe daily dysphagia); scores of 2 or more indicated clinically significant dysphagia. Postfundoplication dysphagia was categorized as early (≤6 wk after ARS) or late (>6 wk after ARS), and Kaplan-Meier analyses were used to assess the time to development of clinically significant dysphagia. We performed univariate and multivariate analyses to assess management response and identify factors associated with dysphagia. The primary aim was to determine the prevalence and clinical course of postfundoplication dysphagia in patients with GERD treated with ARS.

RESULTS

Of the 157 patients, 54.8% had early postfundoplication dysphagia (clinically significant in 20.4%); only 3.5% required endoscopic intervention. Over 2.1 ± 0.2 years of follow-up evaluation, 29 patients (18.5%) developed late postfundoplication dysphagia. Based on Kaplan-Meier analysis, the median time to clinically significant late postfundoplication dysphagia was 0.75 years (95% CI, 0.26-1.22). Of 13 patients (44.8%) who underwent endoscopic dilation, improvement was reported by 92.3%, with a mean decrease in dysphagia severity of 1.55 ± 0.3, based on the Likert scale. Prefundoplication dysphagia, early postfundoplication dysphagia, recurrent hiatal hernia, and lack of contraction reserve following multiple rapid swallows were univariate predictors of late postfundoplication dysphagia (P ≤ .04); lack of contraction reserve was associated independently with late postfundoplication dysphagia, based on multivariate logistic regression analysis (odds ratio, 3.73; 95% CI, 1.11-12.56).

CONCLUSIONS

Early and late postfundoplication dysphagia can be successfully managed conservatively or with endoscopic dilation, respectively. Lack of contraction reserve on multiple rapid swallows is associated independently with late postfundoplication dysphagia.

Management of supragastric belching with cognitive behavioural therapy: factors determining success and follow-up outcomes at 6-12 months post-therapy

BACKGROUND

Supragastric belching (SGB) has a significant behavioural component. We recently used cognitive behavioural therapy (CBT) to treat SGB. We demonstrated that CBT significantly reduces symptoms and improves quality of life in 50% of patients who had completed treatment.

AIMS

To investigate factors associated with successful CBT for SGB and to assess symptoms 6-12 months after completion of CBT METHODS: Records of 39 patients who had completed the CBT protocol were analysed. Per cent pre- to post-treatment change in symptoms was assessed using a visual analogue scale (VAS) score. We evaluated the association between 'pre-treatment' factors and 'during-treatment' factors, and symptomatic outcomes. Symptoms were also assessed 6-12 months after treatment.

RESULTS

From 'pre-treatment factors', a lower number of SGBs (P < .01) and lower hypervigilance score (P < .04) were significantly associated with a better outcome. From 'during-treatment factors' a higher CBT 'proficiency score' ([a] acceptance of the explanation that SGB is a behavioural phenomenon [b] detection of a warning signal before belching [c] adherence to the exercises treatment) was associated with a better outcome (P = .001). Multiple regression analysis found that number of SGBs, hypervigilance score and CBT proficiency score were independently associated with outcome (P < .01, P = .01, P < .01). VAS score before CBT (267 ± 79) decreased to 151 ± 88 soon after CBT (P < .001), and the effect persisted at 6-12 months follow-up (153 ± 82).

CONCLUSIONS

Lower number of SGBs, lower hypervigilance score and higher proficiency during CBT were associated with better CBT outcome. CBT positive effect lasted for at least 6-12 months post-treatment.

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

BACKGROUND

Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals.

PURPOSE

A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

Updates in the field of non-esophageal gastroesophageal reflux disorder

Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.

[Current advances in the treatment of gastroesophageal reflux disease: a focus on esophageal protection]

Gastroesophageal reflux disease (GERD) is characterized by high morbidity and a significant decrease in the quality of life of patients, and is a major risk factor for esophageal adenocarcinoma. Nowadays, antisecretory therapy with proton pump inhibitors (PPI) is the "gold standard" of conservative treatment of GERD, but in some cases this therapy is unsuccessful. According to various studies, the prevalence of refractory GERD can reach 30-40%. The latest scientific data in the field of genetics and pathophysiology of GERD demonstrate that a disruption of the barrier function of the esophageal mucosa and an increase of its permeability can be the leading causes of refractoriness. Thus, the optimal therapy for patients with GERD should not only suppress the secretion of hydrochloric acid, but also restore the barrier function of the mucous membrane, providing an esophagoprotective effect. To achieve these goals, Alfasoxx was developed, which consists of a mixture of low molecular weight hyaluronic acid and low molecular weight chondroitin sulfate dissolved in a bioadhesive carrier (poloxamer 407). The clinical efficacy of this product has been confirmed by three prospective, randomized, placebo - controlled trials. Alfasoxx has a healing and restorative effect towards the esophageal epithelium and due to high ability for bioadhesion provides long - term protection of the mucous membrane of the esophagus. Combination therapy for GERD with the use of PPI and an esophagoprotector offers new perspectives for the treatment of patients with GERD.

Role and safety of fundoplication in esophageal disease and dysmotility syndromes

Gastroesophageal reflux disease (GERD) is quite prevalent worldwide, especially in the western hemisphere. The pathophysiology of GERD is complex, involving an incompetent esophagogastric junction (EGJ) as an anti-reflux barrier, as well as other co-morbid conditions such as gastroparesis, hiatal herniation or hyper acid secretion. Esophageal dysmotility is also frequently encountered in GERD, further contributing to the disease in the form of fragmented peristalsis, ineffective esophageal motility (IEM) or the more severe aperistalsis. The latter is quite common in systemic connective tissue disorders such as scleroderma. The main stay treatment of GERD is pharmacologic with proton pump inhibitors (PPI), with surgical fundoplication offered to patients who are not responsive to medications or would like to discontinue them for medical or other reasons. The presence of esophageal dysmotility that can worsen or create dysphagia can potentially influence the choice of fundoplication (partial or complete), or whether it is even possible. Most of the existing literature demonstrates that fundoplication may be safe in the setting of ineffective or weak peristalsis, and that post-operative dysphagia cannot be reliably predicted by pre-operative manometry parameters. In cases of complete aperistalsis (scleroderma-like esophagus), partial fundoplication can be offered in select patients who exhibit prominent reflux symptoms after a comprehensive multidisciplinary evaluation. Roux-en-Y gastric bypass is an alternative to fundoplication in patients with this extreme form of esophageal dysmotility, after careful consideration of the nutritional status.

New classifications of gastroesophageal reflux disease: an improvement for patient management?

Introduction: Gastroesophageal reflux disease (GERD) is a very common and often debilitating disease. In the broad spectrum of GERD phenotypes, three main groups may be traditionally distinguished: 1) patients only affected by esophageal and/or extra-esophageal symptoms; 2) patients with erosive esophagitis and 3) patients with further complications. Areas covered: This review provides an overview on the current classifications of GERD patients, and their impact on their management. Expert opinion: In 2017, the GERD Consensus Working Group focused the attention on patients unresponsive to PPIs. In this scenario, a diagnosis of GERD might be confirmed by evident signs of erosive esophagitis and the finding of pH or multichannel intraluminal impedance-pH tests, such as more than 6%. The 'Lyon Consensus' panel of experts confirmed that positive indices of reflux-symptom association, without other altered parameters, represent reflux hypersensitivity. GERD requires a customized management; it is crucial to assess frequency and severity of symptoms and their response to an optimal course of therapy as well as to explore the endoscopic alterations and consider other diagnoses responsible for persistent symptoms.

Acceptable outcomes after fundoplication-different views are held by patients, GPs, and surgeons

Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29-0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95%CI: 1.17-3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.

High-Resolution Manometry Diagnosis of Ineffective Esophageal Motility Is Associated with Higher Reflux Burden

INTRODUCTION

Ineffective esophageal motility (IEM) is the most commonly diagnosed abnormality on high-resolution manometry (HRM). However, the clinical significance of IEM and associated reflux burden remains unclear.

AIM

Our primary aim was to compare reflux patterns between IEM versus normal motility on HRM.

METHODS

HRM and reflux studies in patients with IEM and normal motility were retrospectively reviewed. Esophageal pressure topography parameters, reflux variables, and patient-reported outcome questionnaires were explored.

RESULTS

A total of 239 patients with IEM were explored. Of these, 146 underwent reflux monitoring. Additionally, 100 patients with normal HRM all of whom had undergone reflux monitoring were included. IEM patients were more likely to have an abnormal number of reflux events compared to normal (22.7% vs. 9.0%, p < 0.01). Including only off-proton pump inhibitor (PPI) testing, IEM patients had higher mean total acid exposure time (AET) and total reflux events compared to normal motility (p = 0.02). Within IEM patients, higher AET modestly correlated with increased percentage of impaired swallows. Increased reflux events modestly correlated with higher impaired swallows and decreased lower esophageal sphincter (LES) resting pressure. Reflux burden increased with higher esophagogastric junction (EGJ) subtype, driven mostly by subtype III, although there was no difference in the distribution of EGJ subtypes between the IEM and normal HRM cohorts.

CONCLUSIONS

Patients with HRM diagnosis of IEM may be more prone to acid reflux while off-PPI and non-acid reflux while on-PPI. Reflux burden appears to be worse in IEM patients who have lower resting LES pressure, higher EGJ subtype, or higher percentage of impaired swallows.

Conversion from laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) to one anastomosis gastric bypass (OAGB): preliminary data from a multicenter retrospective study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes.

OBJECTIVES

To retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB.

SETTING

High-volume centers for bariatric surgery.

METHODS

Prospectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded.

RESULTS

Three hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m2 at the time of first intervention, 41.8 ± 6.3 kg/m2 at redo time, and 30.5 ± 5.5 kg/m2 at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6-156) months and overall complications rate was 8.6%.

CONCLUSION

Our data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery.

Persistent Postprandial Regurgitation vs Rumination in Patients With Refractory Gastroesophageal Reflux Disease Symptoms: Identification of a Distinct Rumination Pattern Using Ambulatory Impedance-pH Monitoring

OBJECTIVES

Up to 20% of patients with refractory gastroesophageal reflux disease (GERD) might have postprandial rumination. The aim of this study was to distinguish persistent GERD-related postprandial regurgitation from rumination in patients with refractory GERD undergoing ambulatory multichannel intraluminal impedance-pH (MII-pH) monitoring.

METHODS

We first characterized 24-hour and postprandial MII-pH patterns in 28 consecutive patients with confirmed rumination syndrome (positive clinical and high-resolution manometry/impedance). We compared such MII-pH patterns with those from 30 patients with typical GERD symptoms (10 nonerosive reflux disease, 10 hyperactive esophagus, and 10 functional heartburn) and 27 healthy controls. Using ROC curves, we selected the best MII-pH parameters to prepare an MII-pH rumination score. We prospectively tested the performance of the new MII-pH rumination score in 26 consecutive patients with refractory GERD (predominant regurgitation).

RESULTS

Compared with GERD controls, patients with rumination were more often females, younger, and had significantly more postprandial early nonacid reflux episodes with high proximal extent. Postprandial reflux in ruminators had a distinct nadir pH profile over time (from nonacid to acid). Despite increased reflux events, baseline impedance in ruminators was similar to that in healthy subjects. Ruminators marked postprandial symptoms earlier and much more often than patients with GERD. An MII-pH-based rumination score (using postprandial nonacid reflux/hour and Symptom Index) diagnosed rumination in 46% of patients with refractory GERD and persistent regurgitation (sensitivity 91.7% and specificity 78.6%).

DISCUSSION

Postprandial rumination is very common in refractory GERD with persistent regurgitation. A simple MII-pH score detects rumination in these patients with high sensitivity and specificity.

Predicting factors of recurrence in patients with gastroesophageal reflux disease: a prospective follow-up analysis

BACKGROUND

Recurrence of gastroesophageal reflux disease (GERD) is common among patients who are no longer receiving proton pump inhibitors (PPIs). This study investigated factors associated with GERD recurrence.

METHODS

We included 499 consecutive GERD patients who completed validated reflux and psychological questionnaires before undergoing upper endoscopy. All patients were treated with PPIs and followed up.

RESULTS

Recurrence was observed in 89 (30.4%) of 293 patients during the 1-year follow up. Patients with recurrence had a higher prevalence of diabetes mellitus (p = 0.037), higher baseline GERD Questionnaire (GERDQ) scores (p = 0.002), and higher Pittsburgh Sleep Quality Index scores (p = 0.045). Log-rank analysis showed that a GERDQ score of ⩾8 was independently associated with an increased recurrence risk (p = 0.002). The scores of all psychological questionnaires and health-related quality of life questionnaire worsened more at the end of follow up in patients with recurrence than in those without recurrence. Multivariate analysis revealed that a higher GERDQ score was the only independent risk factor for GERD recurrence (p = 0.024). GERD patients who have greater initial symptom burden will have a higher recurrence rate after discontinuing PPIs.

CONCLUSIONS

GERD patients with greater initial symptom burden are more likely to have recurrence after discontinuing PPIs. This study highlights the importance of developing a new strategy to prevent GERD recurrence in the management of this common disorder.

The Utility of Esophageal Motility Testing in Gastroesophageal Reflux Disease (GERD)

PURPOSE OF REVIEW

Here, we discuss how esophageal motor testing plays important roles in patients with suspected gastroesophageal reflux disease (GERD). In addition to guiding appropriate placement of catheters for ambulatory reflux monitoring, esophageal high-resolution manometry (HRM) rules out confounding diagnoses, such as achalasia spectrum disorders, that can present with symptoms similar to that of GERD, but are managed very differently.

RECENT FINDINGS

HRM performed with impedance in the post-prandial setting (PP-HRIM) can assess for rumination syndrome or supragastric belching, which should be directed towards behavioral interventions. The recent GERD Classification of Motor Function recommends a hierarchical approach, focusing on (1) the esophagogastric junction (EGJ), (2) the esophageal body, and (3) esophageal contraction reserve, which can be assessed with provocative maneuvers at HRM, such as multiple rapid swallows (MRS). This approach can inform the appropriate tailoring of antireflux surgery. Novel esophageal motility metrics, such as the EGJ-contractile integral from HRM, or post-reflux swallow-induced peristaltic wave indices from 24-h pH-impedance monitoring, may also assist with GERD diagnosis. Assessment of esophageal motor function can contribute in a significant manner to the care of patients with suspected GERD, particularly when esophageal symptoms do not improve with antisecretory therapy, and/or when surgical or endoscopic antireflux therapies are under consideration.

The Mexican consensus on non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases.

AIM

To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients.

METHODS

Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system.

RESULTS AND CONCLUSIONS

The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

Overlapping of irritable bowel syndrome with erosive esophagitis and the performance of Rome criteria in diagnosing IBS in a clinical setting

Irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD) overlap. It is not clear whether GERD is caused by non-erosive esophagitis, or erosive esophagitis. The Rome criteria are not widely used for the diagnosis of IBS in the clinic. In total, 1,489 IBS patients without red flags were included in the present retrospective study. They comprised of 1,331 females and 158 males with a mean age of 51 years. The diagnosis of IBS was verified by endoscopic and histopathological examinations. Whereas erosive esophagitis occurred in 97% of patients, only 66% had GERD symptoms. Endoscopy and histopathological examinations revealed that 1.4% of the IBS patients with diarrhea as the predominant symptom had other organic gastrointestinal diseases: 0.3% with celiac disease, 0.2% with Crohn's disease, 0.07% with ulcerative colitis, 0.6% with microscopic colitis, and 0.2% with colon cancer. Applying the Rome III criteria produced a sensitivity of 100% [95% confidence intervals (CI)=99.8–100.0%] a specificity of 98.7% (95% CI=98.0–99.2%), a positive likelihood ratio of 76.9%, and a negative likelihood ratio of 0%. IBS is associated with erosive esophagitis. Applying Rome III criteria without red flags and history, was effective in diagnosing IBS. Celiac disease and microscopic colitis should be considered as alternative diagnoses.

Associations between tooth wear and dental sleep disorders: A narrative overview

Objectives

Tooth wear is a common finding in adult patients with dental sleep disorders. The aim of this paper was to review the literature on the possible associations between tooth wear and the following dental sleep disorders: sleep‐related oro‐facial pain, oral moistening disorders, gastroesophageal reflux disease (GERD), obstructive sleep apnoea syndrome (OSAS) and sleep bruxism.

Methods

A PubMed search was performed on 1 June 2018 using MeSH terms in the following query: Tooth Wear AND (Facial Pain OR Temporomandibular Joint Disorders OR Xerostomia OR Sialorrhea OR Gastroesophageal Reflux OR Sleep Apnea Syndrome OR Sleep Bruxism).

Results

The query yielded 706 reports on tooth wear and the mentioned dental sleep disorders. Several associations between tooth wear and the dental sleep disorders were suggested in the literature. It could be concluded that: (a) tooth wear is associated with dental pain and/or hypersensitivity; (b) oral dryness is associated with tooth wear, oro‐facial pain and sleep bruxism; (c) GERD is associated with tooth wear, oro‐facial pain, oral dryness, OSAS and sleep bruxism; (d) OSAS is associated with oral dryness, GERD and sleep bruxism; and (e) sleep bruxism is associated with tooth wear.

Conclusions

Tooth wear is associated with the dental sleep disorders oro‐facial pain, oral dryness, GERD and sleep bruxism. The dental sleep disorders are interlinked with each other, which leads to indirect associations as well, and makes the consequences of each single condition difficult to disentangle. Knowledge of these associations is clinically relevant, but more research is needed to confirm their validity.

Evaluation of Esophageal Contraction Reserve Using HRM in Symptomatic Esophageal Disease

Esophageal high resolution manometry (HRM) is the gold standard for assessment of esophageal motor disorders, but motor responses to the standard 5 mL water swallow protocol may not provide precision in defining minor motor disorders. Provocative maneuvers, particularly multiple rapid swallows (MRS), have been used to assess deglutitive inhibition during the repetitive swallows, and the contractile response following the final swallow of the sequence. The augmentation of esophageal smooth muscle contraction following MRS is termed contraction reserve. This is determined as the ratio between esophageal body contraction vigor (distal contractile integral, DCI) following MRS to the mean DCI after single swallows, which is ≥1 in the presence of contraction reserve. Reliable assessment of contraction reserve requires the performance of 3 MRS maneuvers during HRM. Absence of contraction reserve is associated with a higher likelihood of late postfundoplication dysphagia and may correlate with higher esophageal reflux burden on ambulatory reflux monitoring. Esophageal motor responses to abdominal compression, functional lumen imaging probe (FLIP) balloon distension, and pharmacologic testing (using edrophonium and cisapride) may correlate with contraction reserve. Other provocative tests useful during HRM include rapid drink challenge, solid and viscous swallows, and standardized test meals, which are more useful in evaluation of esophageal outflow obstruction and dysphagia syndromes than in identification of contraction reserve. Provocative maneuvers have been recommended as part of routine HRM protocols, and while useful clinical information can be gleaned from these maneuvers, further research is necessary to determine the precise role of provocative testing in clinical esophagology.

Advancements in the use of manometry and impedance testing for esophageal functional disorders

The utilization of high-resolution manometry (HRM) has enhanced our understanding and assessment of esophageal motor disorders. Moreover, the combination of impedance technology with HRM (HRIM) has further improved our knowledge of esophageal physiology and the clinical evaluation of dysmotility, thanks to the addition of accurate measurement of bolus transit. Areas covered. This paper provides an overview of current knowledge in the use of HRIM for the study of esophageal functional disorders by reporting mainly the results of many publications and several systematic reviews in this field. Expert opinion. HRIM has represented a relevant improvement in the assessment of esophageal motility and has required the development of new metrics, such as the esophageal impedance integral ratio, the bolus flow time, the nadir impedance pressure and the impedance bolus height, which increase the evaluation of esophageal bolus transit. An extension of impedance is represented by functional lumen imaging probe (FLIP), which determines the biophysical properties and the distensibility of the esophagus and permits to detect contractility patterns not seen on HRM alone. We eagerly wait for a new and fruitful iteration of the Chicago Classification, now in version 3.0, which can cover the ongoing clinical experience of HRIM.

Does DeMeester score still define GERD?

Gastroesophageal reflux disease (GERD) clinical presentation may encompass a myriad of symptoms that may mimic other esophageal and extra-esophageal diseases. Thus, GERD diagnosis by symptoms only may be inaccurate. Upper digestive endoscopy and barium esophagram may also be misleading. pH monitoring must be added often for a definitive diagnosis. The DeMeester score (DMS) is a composite score of the acid exposure during a prolonged ambulatory pH monitoring that has been used since 1970s to categorize patients as GERD+ or GERD-. We showed in this review that DMS has some limitations and strengths. Although there is not a single instrument to precisely diagnose GERD in all of its variances, pH monitoring analyzed at the light of DMS is still a reliable method for scientific purposes as well as for clinical decision making. There are no data that show that acid exposure time is superior-or for that matter inferior-as compared to DMS.

Relationship between esophageal motility and severity of gastroesophageal reflux disease according to the Los Angeles classification

The current study aimed to investigate the relationship between the severity of gastroesophageal reflux disease (GERD) according to the Los Angeles (LA) classification and esophageal motility using high-resolution manometry (HRM) and 24-hour esophageal pH monitoring.We examined 124 patients with GERD from January 2016 to June 2018. The LA classification of each patient was determined by endoscopy. HRM was performed by the intraluminal water infusion method. HRM and 24-hour esophageal pH monitoring parameters of the patients were studied and statistically compared.On HRM examination, GERD symptoms were found to be associated with worsened distal contractile integral (DCI), ineffective esophageal motility (IEM), peristalsis break (PB), lower esophageal sphincter (LES) pressure, and the 4-second integrated relaxation pressure (IRP4s) of LES pressure along with the grade of LA classification, especially in patients having grade C and D GERD who had transverse mucosal breaks. The 24-hour pH monitoring study revealed that patients classified as having grade C or D GERD had an esophageal pH < 4.0 for a longer time than those with grade O, A, or B GERD. Similar results were found regarding the duration of the longest reflux event, the number of reflux episodes longer than 5 minutes, and the number of reflux episodes. Patients with higher grade esophagitis had higher De Meester scores, which suggested greater esophageal acid exposure. Hiatal hernia (HH) was more closely related to LES pressure, IRP4s, and acid exposure, whereas DCI, IEM, and PB were not statistically different between patients with GERD with and without HH.Patients with severe esophagitis may have motor dysfunction not only in the LES but also in the esophageal body, with resulting increased esophageal acid exposure, which causes esophagitis. Low LES pressure might be the main reason that patients with HH develop esophagitis. GERD without HH may be due to a variety of motor dysfunctions.

Predictor of slower gastric emptying in gastroesophageal reflux disease: Survey of an Asian-Pacific cohort

BACKGROUND AND AIM

Asian populations have relatively lower prevalence of gastroesophageal reflux disease and tend to exhibit symptoms of prolonged gastric retention. However, it remains unknown if slower gastric emptying influences its features in Asian countries. We prospectively assessed the potential implications of slower gastric emptying in an Asian-Pacific cohort of gastroesophageal reflux disease by a hospital-based survey.

METHODS

One hundred fifty-two patients of gastroesophageal reflux disease complete the scintigraphic measurement of solid phase of gastric emptying. Clinical symptoms and psychological stress are recorded by self-report questionnaire. The status of Helicobacter pylori infection, blood level of pepsinogen I, and I/II ratio are assessed.

RESULTS

Forty-seven percent and 28% of the patients have slower gastric emptying rate, depending on the incremental defined cut-off values of slower gastric emptying, respectively. Multiple logistic regression analysis indicates that older age and depression score are independently related to slower gastric emptying. Subgroup analysis discloses that patients with slower gastric emptying and higher depression score tend to present with non-erosive esophagitis whereas higher body mass index level and male gender in patients with normal gastric emptying predict the presence of erosive reflux disease.

CONCLUSIONS

Our study cohort of Asian patients indicates distinctive clinical implications of slower gastric emptying in patients with gastroesophageal reflux disease.

Screening for Barrett's Esophagus: Balancing Clinical Value and Cost-effectiveness

In predisposed individuals with long standing gastroesophageal reflux disease (GERD), esophageal squamous mucosa can transform into columnar mucosa with intestinal metaplasia, commonly called Barrett’s esophagus (BE). Barrett’s mucosa can develop dysplasia, which can be a precursor for esophageal adenocarcinoma (EAC). However, most EAC cases are identified when esophageal symptoms develop, without prior BE or GERD diagnoses. While several gastrointestinal societies have published BE screening guidelines, these vary, and many recommendations are not based on high quality evidence. These guidelines are concordant in recommending targeted screening of predisposed individuals (eg, long standing GERD symptoms with age > 50 years, male sex, Caucasian race, obesity, and family history of BE or EAC), and against population based screening, or screening of GERD patients without risk factors. Targeted endoscopic screening programs provide earlier diagnosis of high grade dysplasia and EAC, and offer potential for endoscopic therapy, which can improve prognosis and outcome. On the other hand, endoscopic screening of the general population, unselected GERD patients, patients with significant comorbidities or patients with limited life expectancy is not cost-effective. New screening modalities, some of which do not require endoscopy, have the potential to reduce costs and expand access to screening for BE.

The diagnostic value of GerdQ in subjects with atypical symptoms of gastro-esophageal reflux disease

BACKGROUND

Symptoms are essential in the clinical diagnosis of gastro-esophageal reflux disease (GERD). Questionnaires such as GerdQ have been developed as diagnostic aids. GerdQ has been thoroughly validated in well-characterized GERD patients, but has not yet been fully evaluated in a population that includes subjects with atypical symptoms.

AIM

To evaluate GerdQ in a population with typical and/or atypical symptoms of GERD, defined by 24-h pH monitoring. The secondary aim was to investigate the outcome of GerdQ depending on the response to proton pump inhibitor (PPI) treatment.

METHODS

The study included 646 subjects referred for 24-h pH monitoring due to a clinical suspicion of GERD. All subjects completed GerdQ before performing a 24-h pH monitoring.

RESULTS

In total, 377 (58%) subjects were diagnosed with GERD based on symptoms and 24-h pH monitoring (GERD_pH). Of these, 46% had atypical main symptoms. Overall, GerdQ (at cut-off 8) predicted GERD_pH with a sensitivity and specificity of 62% and 74%, respectively. A high specificity but poor sensitivity for diagnosis of GERD_pH was found for atypical main symptoms such as cough, dysphagia and globus. GerdQ had a relatively high sensitivity and specificity in predicting PPI response and a PPV of 99% at cut-off 8.

CONCLUSIONS

GerdQ has a diagnostic value in an unselected population presenting with typical and/or atypical symptoms of GERD, but a low sensitivity for diagnosis of GERD_pH was found in subjects with predominant symptoms such as cough, dysphagia and globus.

Perspectives on the interlinked nature of systemic sclerosis and reflux disease

Systemic sclerosis (SSc) is a multisystem connective tissue disease, characterized by chronic inflammation and vascular changes that result in esophageal smooth muscle atrophy and fibrosis. Subsequent progressive loss of peristalsis in the distal esophagus and loss of lower esophageal sphincter function lead to problems with the protective barrier and exposure of sensitive tissues to the gastroduodenal contents, a disorder called reflux disease. Areas covered: Depending on the range, nature and symptoms of the disease, the term 'reflux disease' may refer to gastroesophageal reflux, laryngopharyngeal reflux, microaspiration into the airways and silent reflux. Despite the links between these visceral complications, this connection remains controversial. This is due to a lack of complete understanding, the asymptomatic nature of the disease and the limited diagnostic accuracy of tests, which can delay diagnosis. Such delays are problematic, given that the early detection of GERD in SSc patients, the timing of assessment, the treatment of the organs involved are critical aspects of patient prognosis and disease outcome. Expert commentary: This review summarizes the most recent knowledge about the pathophysiology, diagnosis and prospective treatment of GERD in SSc patients and highlights how innovative technologies applied through an integrative, interdisciplinary approach may soon lead to effective treatment strategies.

Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score

BACKGROUND

Peroral endoscopic myotomy (POEM) for achalasia is technically challenging to carry out in patients with type III, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the POEM difficulty score (PDS).

AIM

To demonstrate the application and discuss the utility of PDS and present the feasibility, safety, and efficacy of POEM in complex achalasia patients.

METHODS

Forty consecutive POEM were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score ≤3) at a minimum of 3 months follow-up. Secondary outcomes included adverse events, procedural velocity and PDS.

RESULTS

Twenty-eight complex and 12 non-complex POEM procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15 months (complex) and 8 months (non-complex). Mean velocities for non-complex, type III, prior myotomy, ≥4 procedures and sigmoid type were as follows: 4.4 ± 1.6, 4.8 ± 1.5, 5.9 ± 2.2, 6.9 ± 2.2 and 8.2 ± 3.2 min/cm, respectively. Median PDS for non-complex, type III, prior myotomy, ≥4 treatments and sigmoid type were 1 (0-3), 2 (0-4), 2.5 (1-6), 3 (2-6) and 3.5 (1-6), respectively. PDS was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's P < 0.001).

CONCLUSIONS

PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, ≥4 treatments and sigmoid type.

[Gastroesophageal Reflux Disease]

Gastroesophageal reflux disease (GERD) is a condition that develops when reflux of stomach contents causes troublesome symptoms and/or complications. The prevalence of GERD is increasing worldwide and in Asia-Pacific. The latest Korean guidelines for GERD were published in 2012, and several international guidelines and consensus statements for the management of GERD have also been recently published. Here, we review these guidelines and consensus statements in order to provide a better understanding of the diagnosis and treatment of GERD.

Natural history, pathophysiology and evaluation of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common diseases encountered by both internists and gastroenterologists. GERD can cause a wide variety of symptoms ranging from heartburn and regurgitation to more atypical symptoms such as cough, chest pain, and hoarseness. The diagnosis is often times made on the basis of history and clinical symptomatology. The prevalence of GERD is currently estimated to be 8-33% with the incidence of disease only expected to increase over time. Although most cases of GERD can be diagnosed based on symptoms and clinical presentation, the diagnosis of GERD can be challenging when symptoms are atypical. In this review, we provide a comprehensive summary of the epidemiology, pathophysiology, evaluation and diagnosis of gastroesophageal reflux disease.

Acid exposure in patients with gastroesophageal reflux disease is associated with esophageal dysmotility

OBJECTIVE

To explore the correlation between reflux disease and abnormal esophageal motility in patients with gastroesophageal reflux disease (GERD).

METHODS

Participants (patients with GERD and controls) who underwent 24-h impedance-pH monitoring (MII-pH monitoring) and high-resolution manometry between January 2012 and February 2017 were retrospectively studied. The patients were divided into two groups (acid reflux and nonacid reflux) based on their MII-pH monitoring data. Reflux episodes, endoscopic findings, and esophageal dynamic parameters were assessed and compared.

RESULTS

A total of 142 patients were included (acid reflux [n = 58], nonacid reflux [n = 60], control group [n = 24]). There were more patients with esophagitis and more severe esophageal mucosal injury in the acid reflux group than in the nonacid reflux group. The acid reflux group had reduced lower esophageal sphincter (LES) basal pressure, shorter LES length, lower esophageal pressure and distal contractile integral index than the nonacid reflux group. Patients in the acid reflux group had more large breaks and a higher incidence of type II and III esophagogastric junction morphology than those in the nonacid reflux group. Acid exposure time, the incidence of long-term acid reflux, recumbent acid reflux, and the incidence of acid and nonacid reflux had a significant negative correlation with esophageal body motility or LES function.

CONCLUSION

This study suggests that an increase in esophageal acid exposure is correlated with an increase in esophageal dysmotility in patients with GERD.