The cost-effectiveness of the omeprazole test in patients with noncardiac chest pain

Helicobacter pylori eradication does not exacerbate reflux symptoms in gastroesophageal reflux disease

BACKGROUND & AIMS

Observational studies have suggested that Helicobacter pylori may protect against gastrointestinal reflux disease (GERD), but these results could be due to bias or confounding factors. We addressed this in a prospective, double blind, randomized, controlled trial.

METHODS

H. pylori-positive patients with at least a 1-year history of heartburn with a normal endoscopy or grade A esophagitis were recruited. Patients were randomized to 20 mg omeprazole, 250 mg clarithromycin, and 500 mg tinidazole twice a day for 1 week or 20 mg omeprazole twice a day and identical placebos. A second concurrently recruited control group of H. pylori-negative patients were given open label 20 mg omeprazole twice a day for 1 week. All patients received 20 mg omeprazole twice a day for the following 3 weeks and 20 mg omeprazole once daily for a further 4 weeks. Omeprazole was discontinued at 8 weeks and patients were followed up for a further 10 months. A relapse was defined as moderate or severe reflux symptoms. H. pylori eradication was determined by 13C-urea breath test.

RESULTS

The H. pylori-positive cases were randomized to antibiotics (n = 93) or placebo (n = 97). Relapse of GERD occurred in 83% of each of the antibiotic, placebo, and H. pylori-negative groups during the 12-month study period. Life tables revealed no statistical difference between the 2 H. pylori-positive groups (log rank test, P = 0.84) or between the 3 groups (log rank test, P = 0.94) in the time to first relapse. Two patients in each group developed grade B esophagitis at 12 months.

CONCLUSIONS

H. pylori eradication therapy does not seem to influence relapse rates in GERD patients.

Gastroesophageal reflux disease. Control of symptoms, prevention of complications

GERD is a common disease that has a significant impact on patients' quality of life. Many surveys have shown that up to 60% of the population suffers from GERD at some time. Heartburn and acid regurgitation are the classic symptoms, but manifestations are variable. Of the several extraesophageal manifestations of GERD, reflux-induced asthma may be the most important. Complications of GERD include peptic strictures of the esophagus and Barrett's metaplasia. Clinical diagnosis of GERD can be confirmed by response to antisecretory therapy. A high-dose trial of a PPI is becoming an accepted diagnostic technique for uncomplicated mild or moderate GERD. Endoscopic examination and ambulatory esophageal pH monitoring still have a role in the evaluation of severe GERD or when other diseases are suspected. Lifestyle changes rarely are beneficial, and antisecretory therapy remains the mainstay of GERD treatment. PPIs have been shown to be more effective than H2 blockers. Antireflux surgery is indicated in some patients. Healing of esophagitis can take up to 8 weeks; failure to control symptoms necessitates the use of higher drug doses. Failure to control symptoms with high-dose PPI treatment raises the likelihood of other causes.

Chest pain of esophageal origin

Chest pain of esophageal origin or noncardiac chest pain is reported by at least a fifth of the general population. Recent literature focused on further understanding mechanisms of chest pain in subset of patients with functional chest pain of presumed esophageal origin. Studies have demonstrated concurrent visceral and somatic pain hypersensitivity, and amplified secondary allodynia, in patients with noncardiac chest pain (NCCP), suggesting central sensitization. Other studies have demonstrated abnormal cerebral processing of intraesophageal stimuli. However, gastroesophageal reflux disease (GERD) has remained the most common esophageal cause of NCCP. The introduction of the proton pump inhibitor test, a highly sensitive and cost-effective diagnostic strategy, simplified our diagnostic approach toward patients with GERD-related NCCP. For patients with positive proton-pump-inhibitor test results, long-term treatment with antireflux medication is warranted. For patients with non-GERD-related NCCP, pain modulators remain the cornerstone of therapy.

Endoscopy-negative reflux disease

Endoscopy-negative reflux disease (ENRD) is more prevalent than reflux esophagitis, especially in a primary care setting. Acid-sensitive esophagus (ie, reflux-related symptoms with normal acid exposure at 24-hour pH monitoring) is part of the gastroesophageal reflux disease spectrum. ENRD is not a mild disease (symptoms return frequently and have an impact on quality of life), but it rarely progresses to the erosive stage. In patients with atypical or extra-esophageal manifestations, pH monitoring remains useful, and symptom analysis (symptom index or symptom-associated probability) is of pivotal importance. A proton pump inhibitor (PPI) test may represent a cost-effective alternative to 24-hour pH monitoring. However, well-designed validation studies are necessary to assess the diagnostic value of PPI tests and improve specificity without reducing sensitivity. Management of ENRD is based on the same principles as that of reflux esophagitis. Restoration of quality of life is the major goal. Proton pump inhibitors are not more (and are sometimes even less) effective in non-erosive reflux disease than in reflux esophagitis. Different long-term strategies (continuous maintenance, intermittent or on-demand therapy) are available, depending on the needs of the patient. Antireflux surgery may be indicated in carefully selected patients. In the future, pharmacologic approaches targeted to transient lower esophageal sphincter relaxation or visceral perception should be developed.

A critical approach to noncardiac chest pain: pathophysiology, diagnosis, and treatment

Approximately 30% of coronary angiograms performed in this country are negative for significant coronary artery disease. These patients are classified as having noncardiac or unexplained chest pain (UCP). Despite the good overall prognosis, this condition has significant morbidity and costs. The pathophysiology of this condition is likely caused by overlapping cardiac, esophageal, and psychiatric abnormalities with visceral hyperalgesia playing a central role. Gastroenterologists are often consulted in the evaluation of these patients because esophageal disorders are among the most common conditions associated with UCP. However, clinical symptoms are unreliable in differentiating between esophageal and cardiac causes of UCP. Gastroesophageal reflux disease, not esophageal motility disorders, is the most common esophageal disorder present in patients with UCP. The most useful diagnostic test in the evaluation of UCP is 24-h pH monitoring. An initial empiric trial of high-dose acid suppression is the most cost-effective intervention in the management of these patients. A clinical algorithm is suggested for the evaluation and treatment of UCP.

Nonerosive reflux disease--current concepts and dilemmas

Nonerosive reflux disease is defined as the presence of typical symptoms of gastroesophageal reflux disease caused by intraesophageal acid in the absence of visible esophageal mucosal injury at endoscopy. Recent studies demonstrate that it is a chronic disease with a significant impact on quality of life, and it is very common in primary care settings. Treatment with acid inhibitory agents is effective, and proton pump inhibitors are the most effective form of therapy.

Diagnosing gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common condition with a variety of clinical manifestations and potentially serious complications. This article reviews available methods for diagnosing GERD. A clinical history of the classic symptoms of GERD, heartburn or acid regurgitation, is sensitive enough to establish the diagnosis in patients without other complications. Esophagogastroduodenoscopy is the best way to evaluate suspected complications of GERD, but endoscopic findings are insensitive for the presence of pathological reflux, and therefore they cannot reliably exclude GERD. The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux is the 24-hour ambulatory esophageal pH monitoring test, and this study should be used for the evaluation of refractory symptoms and extraesophageal manifestations of GERD. A formal acid-suppression test is helpful in the evaluation of the atypical GERD symptom of noncardiac chest pain. Optimal use of currently available tests for GERD may allow for more efficient diagnosis and better characterization of the pathological manifestations associated with GERD.

Diagnosis of reflux disease

There are numerous tests for which a diagnostic value in the context of gastro-oesophageal reflux disease has been claimed. Some of these tests (e.g. the acid perfusion test) have become obsolete after the advent of 24-hour oesophageal pH monitoring. With the latter test not only can excessive reflux be identified, but also, and more importantly, a temporal relationship can be demonstrated between a patient's symptoms and reflux episodes. Radiographical examination of the oesophagus has largely been replaced by endoscopy, although the use of the former test is still indicated in certain circumstances (e.g. in the differentiation of sliding from para-oesophageal hiatus hernia). In clinical practice, the so-called proton pump inhibitor test has gained considerable popularity. Despite several studies on the specificity and sensitivity of this test, its value has not yet been established with sufficient accuracy. Conventional manometric evaluation of lower oesophageal sphincter pressure has been over-emphasized as a diagnostic test in gastro-oesophageal reflux disease.

Proton pump inhibitors in the treatment of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is the most common peptic acid disease in the western world and is the commonest indication for acid suppression therapy. Major advances have been made over the past 30 years in the understanding of lower oesophageal sphincter function and the mechanism of acid secretion. Developments in surgical and pharmacological therapy have paralleled these advances. Pharmacotherapy for GERD has evolved from antacids to H2-receptor antagonists (H2RAs) to prokinetics to proton pump inhibitors (PPIs). The H2RAs, while modestly effective in symptom relief and healing of GERD, are limited by pharmacological tolerance. The prokinetics (metoclopramide and cisapride) are limited by low efficacy, pharmacological tolerance and toxicity. The PPIs have emerged as the most effective therapy for symptom relief, healing and long-term maintenance. They have also proved to be remarkably safe and cost-effective in long-term therapy. This review evaluates the pharmacology, efficacy, tolerability, safety and cost-effectiveness of the four currently available PPIs, lansoprazole, omeprazole, pantoprazole and rabeprazole, in the treatment of GERD.

Recent developments in chest pain of undetermined origin

The syndrome of angina-like pain with normal epicardial coronary vessels is a very common and expensive clinical problem. Patients suffering from this condition frequently present a diagnostic challenge. Cardiac and musculoskeletal disorders must be excluded prior to identifying the esophagus as the source of pain. The term "chest pain of undetermined origin" (UCP) has been proposed to refer to this condition. Esophageal dysmotility was previously considered a major source for chest pain; however, recent studies indicate that esophageal reflux is the most common cause of esophageal pain. Two controlled trials of acid suppressive agents in patients with chest pain have shown that omeprazole provides effective pain relief for the majority of these individuals. Visceral hyperalgesia and psychologic disturbances are also commonly noted in patients with UCP. Much remains to be learned about the etiology of visceral hyperalgesia and the precise role of psychologic abnormalities in these patients. Until further information is available, treatment with imipramine or trazodone has been shown to offer effective relief of chest pain for subgroups of patients with UCP. Psychologic intervention is also valuable in the management of some patients. Studies of other therapeutic regimens continue to be conducted.