Gastroesophageal reflux disease: an Asian perspective

Risk factors for proton pump inhibitor refractoriness in Chinese patients with non-erosive reflux disease

AIM: To analyze risk factors for refractoriness to proton pump inhibitors (PPIs) in patients with non-erosive reflux disease (NERD).

METHODS: A total of 256 NERD patients treated with the PPI esomeprazole were enrolled. They were classified into symptom-free and residual symptoms groups according to Quality of Life in Reflux and Dyspepsia (QolRad) scale. All subjects completed questionnaires on psychological status (self-rating anxiety scale; self-rating depression scale) and quality of life scale (Short Form 36). Multivariate analysis was used to determine the predictive factors for PPI responses.

RESULTS: According to QolRad, 97 patients were confirmed to have residual reflux symptoms, and the remaining 159 patients were considered symptom free. There were no significant differences between the two groups in lifestyle factors (smoking and alcohol consumption), age, Helicobacter pylori infection, and hiatal hernia. There were significant differences between the two groups in relation to sex, psychological distress including anxiety and depression, body mass index (BMI), and irritable bowel syndrome (IBS) (P < 0.05). Logistic regression analysis found that BMI < 23, comorbid IBS, anxiety, and depression were major risk factors for PPI resistance. Symptomatic patients had a lower quality of life compared with symptom-free patients.

CONCLUSION: Some NERD patients are refractory to PPIs and have lower quality of life. Residual symptoms are associated with psychological distress, intestinal disorders, and low BMI.

Association between metabolic syndrome and prevalence of gastroesophageal reflux disease in a health screening facility in Japan

BACKGROUND

Abdominal fat accumulation, which induces high intra-abdominal pressure that causes increase in the gastroesophageal pressure gradient and hiatal hernia, as well as obesity, has been shown to increase the prevalence of gastroesophageal reflux disease (GERD). This study was performed to clarify the association between metabolic syndrome and the prevalence of GERD.

METHODS

The study subjects were an adult population who visited a medical center for annual medical check-ups from April 2010 to March 2011. GERD was diagnosed by the presence of endoscopically proven reflux esophagitis, GERD symptoms (QUEST score ≥6), or current medical therapy for GERD. The presence of metabolic or pre-metabolic syndrome was diagnosed based on the Japanese criteria for metabolic syndrome.

RESULTS

Six hundred four (16.0 %) of 3775 study subjects were positively diagnosed with GERD, with the number of those with metabolic and pre-metabolic syndrome being 477 (12.6 %) and 384 (10.2 %), respectively. Multiple logistic regression analysis showed that male gender, presence of hiatal hernia, and metabolic or pre-metabolic syndrome, as well as absence of gastric mucosal atrophy, were significant predictive factors for the prevalence of GERD, as were visceral fat accumulation and untreated dyslipidemia. Untreated hypertension and untreated hyperglycemia were also considered to be positive risk factors. Subjects undergoing treatment for hypertension showed an increased risk of GERD, while those undergoing treatment for dyslipidemia and diabetes mellitus showed a decreased risk.

CONCLUSION

Metabolic syndrome is a reliable predictive factor for the prevalence of GERD, and medical therapy for metabolic syndrome may modify the risk of GERD occurrence.

Gastroesophageal Reflux Disease Questionnaire (GerdQ) in real-world practice: a national multicenter survey on 8065 patients

BACKGROUND AND AIM

Recently, Gastroesophageal Reflux Disease Questionnaire (GerdQ) has been developed for diagnosis of GERD. However, no study investigated its value in real-world practice. This study aimed to investigate whether GerdQ can be used for diagnosis of GERD in China.

METHODS

A national multicenter survey was undertaken; all patients who underwent first diagnostic upper endoscopy for upper gastrointestinal (GI) symptoms were included. Data including the gender, age, symptoms, and endoscopic findings were prospectively recorded. The GerdQ score was measured before endoscopic procedure.

RESULTS

Totally, 8065 patients were included. One thousand four hundred and thirty-five patients (17.8%) had reflux esophagitis. Among them, 620 (43.2%) patients' GerdQ score was ≥ 8. For 2025 patients with GerdQ ≥ 8, 620 (30.6%) were found to have reflux esophagitis, but the remaining 69.4% (1405/2025) were normal. Proportions of patients with reflux esophagitis increased in cut-off range from 3-18 for GerdQ. However, 22.2% of the patients with a GerdQ score ≤ 2 also had reflux esophagitis. Twenty-eight (0.3%) patients were diagnosed to have upper GI malignancies, and 10 out of these 28 (35.7%) patients' GerdQ score was ≥ 8.

CONCLUSIONS

The study suggests the proportions of Chinese patients with reflux esophagitis rise up with the increase of GerdQ score, and GerdQ may be used for diagnosis of GERD. However, low GerdQ score cannot exclude the possibility of reflux esophagitis. A minority of Chinese patients has high GerdQ score but is diagnosed with malignancies, even in the absence of alarm features.

The Prevalence of Erosive Esophagitis Is Not Significantly Increased in a Healthy Korean Population - Could It Be Explained?: A Multi-center Prospective Study

Background/Aims

Researches on the potential risk factors for the development of erosive esophagitis have been conducted extensively, however, the results are conflicting. The aim of this multicenter study was to identify the prevalence rate and risk factors of erosive esophagitis and their interactions with residency status.

Methods

A total of 4,023 eligible subjects at 8 tertiary health care centers were evaluated using questionnaires, laboratory tests and endoscopy. Univariate and multivariate analyses were conducted to identify independent risk factors for erosive esophagitis.

Results

The prevalence rate of reflux esophagitis was 8.8%. Los Angeles grade A was common type of erosive esophagitis. Residence in a large urban areas was negatively associated with the development of erosive esophagitis (OR, 0.60; 95% CI, 0.40-0.90). The high body mass index (≥ 25 kg/m²) was more frequent in residents of small and medium-sized cities than those in big cities (38.8% and 26.9%, respectively; P < 0.001). Seronegativity of Helicobacter pylori was associated with increased erosive esophagitis (OR, 1.91; 95% CI, 1.48-2.46). Triglyceride ≥ 150 mg/dL (OR, 1.65; 95% CI, 1.08-2.07), fasting glucose level ≥ 126 mg/dL (OR, 1.73; 95% CI, 1.06-2.81), and hiatal hernia (OR, 3.11; 95% CI, 1.87-5.16) were also associated with erosive esophagitis.

Conclusions

The prevalence rate of erosive esophagitis and its risk factors in this study were similar to the result of 8.0% of nationwide study in 2006. Residency and obesity are more important independent risk factors than H. pylori infection status for development of erosive esophagitis in Korea. These results suggest that the prevalence rate of erosive esophagitis in Korea might not increase as in the Western countries.

Non-alcoholic fatty liver disease is associated with high prevalence of gastro-oesophageal reflux symptoms

BACKGROUND

Gastro-oesophageal reflux symptoms are usually reported by patients with obesity and metabolic syndrome. Aim of this study was to assess the prevalence and clinical characteristics of gastro-oesophageal reflux symptoms in subjects with non-alcoholic fatty liver disease.

METHODS

Cross-sectional, case-control study of 185 consecutive patients with non-alcoholic fatty liver disease and an age- and sex-matched control group of 112 healthy volunteers. Participants were interviewed with the aid of a previously validated questionnaire to assess lifestyle and reflux symptoms in the 3 months preceding enrolment. Odds ratios were determined before and after adjustment for body mass index, increased waist circumference, physical activity, metabolic syndrome and proton pump inhibitors and/or antiacid medication.

RESULTS

The prevalence of heartburn and/or regurgitation and of at least one of gastro-oesophageal reflux symptoms was significantly higher in the non-alcoholic fatty liver disease group. Non-alcoholic fatty liver disease subjects were associated to higher prevalence of heartburn (adjusted odds ratios: 2.17, 95% confidence intervals: 1.16-4.04), regurgitation (adjusted odds ratios: 2.61, 95% confidence intervals: 1.24-5.48) and belching (adjusted odds ratios: 2.01, 95% confidence intervals: 1.12-3.59) and had higher prevalence of at least one GER symptom (adjusted odds ratios: 3.34, 95% confidence intervals: 1.76-6.36).

CONCLUSION

Non-alcoholic fatty liver disease is associated with a higher prevalence of gastro-oesophageal reflux symptoms.

Respiratory pathogens adopt a chronic lifestyle in response to bile

Chronic respiratory infections are a major cause of morbidity and mortality, most particularly in Cystic Fibrosis (CF) patients. The recent finding that gastro-esophageal reflux (GER) frequently occurs in CF patients led us to investigate the impact of bile on the behaviour of Pseudomonas aeruginosa and other CF-associated respiratory pathogens. Bile increased biofilm formation, Type Six Secretion, and quorum sensing in P. aeruginosa, all of which are associated with the switch from acute to persistent infection. Furthermore, bile negatively influenced Type Three Secretion and swarming motility in P. aeruginosa, phenotypes associated with acute infection. Bile also modulated biofilm formation in a range of other CF-associated respiratory pathogens, including Burkholderia cepacia and Staphylococcus aureus. Therefore, our results suggest that GER-derived bile may be a host determinant contributing to chronic respiratory infection.

Visceral fat predominance is associated with erosive esophagitis in Japanese men with metabolic syndrome

BACKGROUND AND AIM

Although visceral fat is strongly associated with metabolic syndrome (MS), the association between erosive esophagitis (EE) and visceral and subcutaneous fat types in individuals with MS has remained unclear. In this study, we divided individuals with MS into those with visceral and subcutaneous fat types, and determined the differences in the presence of EE between the types of MS in Japanese men.

METHODS

The participants were 265 men with MS who underwent a medical checkup including upper gastrointestinal endoscopy and abdominal ultrasonography. We made a distinction between visceral and subcutaneous fat types of MS by ultrasonography, and examined for the presence of EE, and the correlation between EE and other data.

RESULTS

Total cholesterol, low-density lipoprotein cholesterol, alanine aminotransferase, and the frequency of EE were significantly higher in visceral fat-type MS than in subcutaneous fat-type MS. On logistic regression analysis with EE as a dependent variable and the significant background factors as the independent variables, visceral fat-type MS and hiatal hernia were significant predictors of an increased prevalence of EE (odds ratios=3.808 and 8.599; 95% confidence intervals=1.710-8.479 and 4.206-17.58; P<0.005 and <0.001, respectively).

CONCLUSION

Japanese men with visceral fat-type MS are more likely to have dyslipidemia and EE than those with subcutaneous fat-type MS. Visceral fat-type MS is one of the most significant predictors of an increased prevalence of EE in Japanese men with MS.

Irritable bowel syndrome and other gastrointestinal disorders: evaluating self-medication in an Asian community setting

BACKGROUND

Gastrointestinal disorders frequently present symptoms which are often self-treated.

OBJECTIVE

To record demographic profile of patients visiting community pharmacies for self-treatment with medications for gastrointestinal disorders, the number of these patients who fulfilled irritable bowel syndrome diagnostic criteria, and to judge the appropriateness of their treatment requests.

SETTING

Singapore community pharmacies.

METHOD

The multicentre study was conducted using ROME III adapted criteria on adults above 18 years who have self-selected medicinal products for treatment of irritable bowel syndrome or gastrointestinal symptoms in the community pharmacy.

RESULTS

Among those seeking self-medication, 36.8 % fulfilled criteria for irritable bowel syndrome, with irritable bowel syndrome-mixed (16.3 %) being the most prevalent subtype. For patients not fulfilling criteria for irritable bowel syndrome diagnosis, rates for other functional gastrointestinal disorders were constipation (20.5 %), dyspepsia (16.3 %), gastroesophageal reflux disease (12.1 %), diarrhoea (8.9 %), bloating (4.2 %), and heartburn (3.2 %). There were more females with gastrointestinal complaints. Overall, 21.6 % of the total participants had recently sought medical attention for their gastrointestinal complaint. 20 % of patients selected inappropriate medication for their gastrointestinal complaints, and the antacids class had the highest incidence of inappropriate medication use. Possible co-existing relationships were seen between gastroesophageal reflux disease with dyspepsia, irritable bowel syndrome with gastroesophageal reflux disease, irritable bowel syndrome with dyspepsia, and diarrhoea with constipation.

CONCLUSION

Patients who fulfilled criteria for irritable bowel syndrome had a high tendency to self-treat their gastrointestinal symptoms. Constipation complaints were also common. Around one in five patients self-medicated gastrointestinal symptoms inappropriately, with antacids being the most common.

Comparison of gastro-oesophageal junction carcinomas in Chinese versus American patients

AIMS

To compare the clinical and pathological features of gastro-oesophageal junction (GEJ) carcinomas in Chinese and American patients.

METHODS AND RESULTS

Eighty consecutive patients with a GEJ carcinoma (43 from mainland China, and 37 from the USA) were evaluated for association with Barrett oesophagus (BO), chronic Helicobacter pylori gastritis, intestinal metaplasia, and outcome. GEJ carcinomas were defined as tumours that were located within 20 mm of, and crossed, the GEJ. Overall, GEJ carcinomas from Chinese patients revealed significantly more frequent location in the proximal stomach, higher pathological stage, larger size, younger patient age, and association with chronic H. pylori gastritis. In contrast, GEJ cancers from American patients showed a strong association with distal oesophageal location, BO, and associated intestinal metaplasia and dysplasia. Pathologically, GEJ carcinomas from American patients were predominantly adenocarcinomas, whereas Chinese patients showed a higher proportion of mucinous, adenosquamous, acinar or neuroendocrine tumours. Overall, 3- and 5-year survival rates were statistically similar between both patient groups, but upon multivariate analysis, Chinese patients showed statistically better survival rates for stage III tumours.

CONCLUSIONS

Most GEJ carcinomas in patients from China represent proximal gastric cancers associated with chronic H. pylori gastritis, and BO-associated carcinomas are rare among this patient population.

Prevalence of gastroesophageal reflux disease in a general population in Taiwan

BACKGROUND AND AIM

To evaluate the prevalence and risk factors of gastroesophageal reflux disease (GERD) in a general population in Taiwan.

METHODS

A validated symptom questionnaire, the Chinese GERD questionnaire, was utilized to determine the prevalence of GERD within a community in Taiwan. A cut-off value for GERD diagnosis was a total score ≥ 12. Additionally, demographic data, including sex, age, body mass index, and consumption of tobacco and alcohol, were recorded, and a logistic regression analysis was conducted to search the independent risk factors for the development of GERD in a general population.

RESULTS

In total, 1238 residents were recruited for this study. The monthly frequencies of heartburn, epigastric acidic discomfort, and acid regurgitation were 4.4%, 3.7%, and 2.9%, respectively. The GERD prevalence was 25% in the community. The multivariate analysis showed that female sex and age of 40-49 years and 50-59 years were independent risk factors related to the development of GERD, with odd ratios of 1.71, 3.65, and 2.41, respectively (95% confidence intervals: 1.26-2.34, 1.62-8.21, and 1.11-2.54, respectively).

CONCLUSIONS

GERD has become a common disorder in the general population in Taiwan. Female sex and age of 40-49 years and 50-59 years are risk factors for the development of GERD within a community.

Treatment of non-erosive reflux disease with a proton pump inhibitor in Chinese patients: a randomized controlled trial

BACKGROUND

Evidence suggests that rates of gastroesophageal reflux disease are increasing in the Asia-Pacific region, where patients tend to have predominantly non-erosive reflux disease as opposed to erosive (reflux) esophagitis. At present, data for the responsiveness of non-erosive reflux disease to proton pump inhibition are scant. We aimed to study esomeprazole for the treatment of non-erosive reflux disease in Chinese patients.

METHODS

Patients with a clinical diagnosis of gastroesophageal reflux, and a locally validated reflux index, the Chinese GerdQ, of equal to or greater than 12 were recruited and randomized to receive esomeprazole 20 mg daily or placebo for 8 weeks. Reflux index scores, quality of life (SF-36), and the hospital anxiety and depression (HAD) scale and symptom relief were evaluated before, during, and after treatment.

RESULTS

A total of 175 patients were randomized. Patients in the esomeprazole group (n = 85) demonstrated statistically significant reductions in their GerdQ index, from 19.45 to 15.37 and to 14.32 (p = 0.013, p = 0.005) at weeks 4 and 8, respectively. Compared to placebo at week 8, 57.1% of patients on esomeprazole found that their symptoms had resolved or were acceptable compared with 37.2% in the placebo group (p = 0.001). There were no statistically significant differences in overall quality-of-life measures or the HAD scale related to treatment.

CONCLUSIONS

This study suggests that esomeprazole is efficacious in treating Chinese patients with non-erosive reflux disease.

Endoscopic findings in patients presenting with dysphagia: analysis of a national endoscopy database

Dysphagia is a common problem and an indication for upper endoscopy. There is no data on the frequency of the different endoscopic findings and whether they change according to demographics or by single versus repeat endoscopy. To determine the prevalence of endoscopic findings in patients with dysphagia and whether findings differ in regard to age, gender, ethnicity, and repeat procedure. This was a retrospective study using a national endoscopic database (CORI). A total of 30,377 patients underwent esophagogastroduodenoscopy (EGD) for dysphagia of which 4,202 patients were repeat endoscopies. Overall frequency of endoscopic findings was determined by gender, age, ethnicity, and single vs. repeat procedures. Esophageal stricture was the most common finding followed by normal, esophagitis/ulcer (EU), Schatzki ring (SR), esophageal food impaction (EFI), and suspected malignancy. Males were more likely to undergo repeat endoscopies and more likely to have stricture, EU, EFI, and suspected malignancy (P = 0.001). Patients 60 years or older had a higher prevalence of stricture, EU, SR, and suspected malignancy (P < 0.0001). Esophageal stricture was most common in white non-Hispanic patients compared to other ethnic groups. In patients undergoing repeat EGD, stricture, SR, EFI, and suspected malignancy were more common (P < 0.0001). The prevalence of endoscopic findings differs significantly by gender, age, and repeat procedure. The most common findings in descending order were stricture, normal, EU, SR, EFI, and suspected malignancy. For patients undergoing a repeat procedure, normal and EU were less common and all other abnormal findings were significantly more common.

Prevalence and risk factors for gastroesophageal reflux in pregnancy

BACKGROUND AND AIM

Prevalence of gastroesophageal reflux (GER) increases during pregnancy, due to several factors like decreased lower esophageal sphincter pressure, increased intra-abdominal pressure secondary to the enlarged gravid uterus and alteration in gastrointestinal transit. The present study aimed to determine the prevalence of GER in pregnancy in a southern State of the Indian subcontinent and determine the risk factors associated with it.

METHODS

Consecutive pregnant females (n = 400) at various stages of pregnancy attending the antenatal clinic or admitted in the antenatal wards were enrolled. Patients with heartburn or regurgitation or both (n = 182) for at least a week were defined as cases, and controls were those without these symptoms (n = 218). Data on demographic variables and symptoms were analyzed using Pearson chi-square, Yates corrected chi-square and Fischer exact test and student independent t-test as appropriate; p < 0.05 was considered significant.

RESULTS

Demographic characteristics between cases and controls were similar. The mean age of cases (23.68±3.37 years) was similar to that of controls (23.25±3.31 years). The overall prevalence of GER was 45.5% (182/400), 77 (19.3%) had heartburn (GER-HB), 54 (13.5%) had regurgitation (GER-R) and 51 (12.8%) had both (GER-HB + R). Age and gravida did not influence the frequency of symptoms. Symptoms were more frequent in the second (43.1%) and third trimester (54.1%) as compared to the first trimester (9.5%) in pregnant women with GER (p < 0.001). Atypical symptoms were uncommon. GER was common among non-vegetarians (p = 0.02) and frequent aerated beverage users (p = 0.001).

CONCLUSIONS

GER prevalence was high in pregnancy, often in second and third trimester. Non-vegetarianism and aerated beverages increased the risk of reflux in pregnancy.

From GERD to Barrett's esophagus: is the pattern in Asia mirroring that in the West?

Gastroesophageal reflux disease (GERD) is a known predisposing factor for Barrett's esophagus. Amongst individuals with symptomatic GERD, the prevalence of Barrett esophagus is estimated to be more than 10%, and an individual with Barrett's esophagus is more likely than the general population to develop esophageal adenocarcinoma. In Western Europe and North America, incidence of esophageal adenocarcinoma had been on the upward trend for many decades. In comparison, although the prevalence of GERD and reflux esophagitis has increased several fold in some parts of Asia, the prevalence of esophageal adenocarcinoma and Barrett's esophagus remains generally low in the region. Rising incidence of esophageal adenocarcinoma has been observed in regions witnessing increasing prevalence of GERD. If the recent increase in prevalence of GERD in parts of urbanized Asia is any indication of the beginning of an upsurge in the incidence of Barrett's esophagus and associated adenocarcinoma, would we be witnessing a pattern of epidemiological shift mirroring that in the West? Given that more than 90% of Barrett's esophagus in Asian patients is of the short-segment type, which is reported to have lesser propensity to develop to adenocarcinoma, could the ongoing epidemiologic transition take Asia on the same trail as that which the West has taken? This article will draw on relevant findings from various parts of Asia and take an in-depth look at prevailing disease trends to see where Asia stands now in the changing epidemiology of GERD, Barrett's esophagus and associated adenocarcinoma.

Prevalence and risk factor of erosive esophagitis observed in Korean National Cancer Screening Program

Prevalence of erosive esophagitis (EE) has been increasing in Korea. The purpose of this study was to estimate prevalence of EE among low socioeconomic population in Korea and to investigate risk factors for EE. We reviewed the medical records of 7,278 subjects who were examined by upper endoscopy in the Korean National Cancer Screening Program at Chung-Ang University Yong-san Hospital from March 2003 to March 2008. The study population included subjects ≥ 40 yr of age who were Medicaid recipients and beneficiaries in the National Health Insurance Corporation. Multivariate analysis was used to determine risk factors for EE. Prevalence of EE was 6.7% (486/7,278). According to the LA classification system, LA-A in 344 subjects, LA-B in 135 subjects, and LA-C and D in 7 subjects. In multivariate analysis, age ≥ 60 yr, male sex, BMI ≥ 25, current smoking, alcohol consumption, fasting glucose level ≥ 126 mg/dL, and endoscopic hiatal hernia were significant risk factors for EE. The prevalence of EE in low socioeconomic Korean population is similar to that in personal annual medical check-ups. Risk factors for EE among them include old age, male sex, BMI ≥ 25, current smoking, alcohol consumption, fasting glucose level ≥ 126 mg/dL, and hiatal hernia.

The value of Carlsson-dent questionnaire in diagnosis of gastroesophageal reflux disease in area with low prevalence of gastroesophageal reflux disease

Background/Aims

Symptom-based diagnosis for gastroesophageal reflux disease (GERD) has been accepted in the population with high prevalence. Carlsson-Dent questionnaire (CDQ) is a standardized symptom-based diagnosis tool for GERD. The value of this tool in the population with low prevalence is unknown. The aim of this study was to determine CDQ performance for diagnosis of GERD in Thai population with low prevalence versus endoscopy or 24 hour pH monitoring.

Methods

Patients with dyspepsia by Rome II criteria were recruited. All patients completed a Thai version of CDQ and underwent endoscopic examination. Those without esophagitis or peptic ulcer and positive CDQ score took pH monitoring.

Results

One hundred patients (68 female) with mean age ± SD of 45.6 ± 12.4 years were recruited. Six with Los Angeles grade A esophagitis had negative CDQ score. In 44 with positive CDQ score, 3 had Los Angeles grade B esophagitis and 41 had pH monitoring done with 8 having positive test. The GERD diagnosis by CDQ was confirmed in 11 of 44 patients (25%). CDQ detected 11 out of 17 GERD detected by endoscopy and pH monitoring and the sensitivity of CDQ was 64%.

Conclusions

CDQ diagnosed more GERD in Thai population with low prevalence compared with endoscopy and pH monitoring. This may be due to some patients with functional heartburn were picked up by CDQ and some patients with GERD were not detected by endoscopy and pH monitoring.

Risk factors for erosive esophagitis: a cross-sectional study of a large number of Japanese males

BACKGROUND

The impact of obesity on gastroesophageal reflux disease remains controversial. We undertook this study, with a large sample size, to investigate risk factors for endoscopic erosive esophagitis by multivariate analysis, including visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) as covariates.

METHODS

Japanese males who visited our institute for a comprehensive medical survey between 2007 and 2010 were enrolled. All subjects voluntarily participated in a self-paid health check-up program including blood test screening, physical examinations, and esophagogastroduodenoscopy. VAT and SAT were measured by computed tomography at the navel level. Independent and significant predictors of erosive esophagitis were determined by multivariate analysis.

RESULTS

Of 9840 eligible subjects, 1831 (18.6%) were diagnosed with erosive esophagitis. Body mass index and triglyceride were predictors of an increased prevalence of erosive esophagitis (odds ratios [ORs] = 1.063 and 1.001; 95% confidence intervals [CIs] = 1.020-1.108 and 1.001-1.002; p = 0.004 and <0.001, respectively). Heavy alcohol consumption, heavy smoking, and hiatal hernia were also associated with an increased prevalence of erosive esophagitis (ORs = 1.276, 1.399, and 2.758; 95% CIs = 1.085-1.501, 1.220-1.605, and 2.474-3.075; p < 0.001 for all). Helicobacter pylori infection significantly and independently decreased the prevalence of erosive esophagitis (OR = 0.346, 95% CI = 0.299-0.401, p < 0.001). Central obesity, as determined by VAT and waist girth, did not confer an increased risk of erosive esophagitis after adjusting for confounders.

CONCLUSIONS

Lifestyle factors including heavy alcohol consumption, heavy smoking, metabolic disorders, and hiatal hernia increased the risk of erosive esophagitis, but central obesity did not.

Current status of Barrett's esophagus research in Asia

In Western countries, the epidemiology of esophageal cancer has changed considerably over the past decades with a rise in the ratio of adenocarcinoma to squamous cell carcinoma. Although the prevalence of gastroesophageal reflux is increasing in Asia, the prevalences of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) have remained low in most Asian countries. The Asian Barrett's Consortium recently conducted a review of published studies on BE from Asia to assess the current status of BE research in Asia, and to recommend potential areas for future BE research in the region. Differences in study design, enrolled population, and endoscopic biopsy protocols used have led to substantial variability in the reported BE prevalence (0.06% to 19.9%) across Asia. In particular, some Japanese studies used diagnostic criteria that differed considerably from what was used in most Asian studies. As in Western countries, increased age, male sex, tobacco smoking, reflux symptoms, and erosive esophagitis have been found to be risk factors for BE in several case-control studies from Asia. The Prague C and M criteria, developed to provide better interobserver reliability in diagnosis and grading of BE, are currently under extensive evaluation in the Asian population. There is a need for standardized protocols for endoscopic and histopathologic diagnosis before initiating collaborative projects to identify etiologic determinants of BE and its ensuing malignant transformation. At present, data regarding the management and long-term outcome of BE are extremely limited in Asia. More studies of BE in this geographic area are warranted.

Global epidemiology of Barrett's esophagus

Barrett's esophagus (BE) is defined as a metaplastic change of the distal esophageal epithelium from squamous to columnar type epithelium with the presence of intestinal metaplasia. There is a striking geographic variation in the prevalence rates of BE. Most epidemiological data on BE are derived from patients undergoing endoscopy and do not reflect prevalence rates in the general population. BE is much more common in the West when compared with Asia and Africa. Although BE is less common in Asia, the demographics are similar to the West, being predominantly found in older men with longer duration of reflux symptoms. Some studies from the West have suggested an increase in prevalence rates of BE. An increase in prevalence rates will have significant implications for health resource utilization and costs, due to the small but significant risk of developing esophageal adenocarcinoma. Endoscopic surveillance with the aim of detecting early lesions has been advocated. Compared with conventional white-light endoscopy with blind four-quadrant biopsies, the use of image-enhanced endoscopy, including chromoendoscopy, may improve detection of subtle mucosal irregularities and facilitate targeted biopsies. However, a truly cost-effective surveillance strategy remains to be determined.

[Diagnosis of gastroesophageal reflux disease: a systematic review]

The prevalence of gastoesophageal reflux disease (GERD) has been rapidly increased in Korea during last 20 years. However, there has been no systematic review regarding this disease. The aim of this article was to provide a review of available diagnostic modalities for GERD. This review includes proton pump inhibitor (PPI) test, endoscopy, ambulatory pH monitoring, impedance pH monitoring, and esophageal manometry in order to provide a basis for the currently applicable recommendations in the diagnosis of GERD in Korea. With weekly heartburn or acid regurgitation, the prevalence of GERD has been reported as 3.4% to 7.9%, indicating an increase of GERD in Korea. As the prevalence of Barrett's esophagus has been reported to be low, the screening endoscopy for Barrett's esophagus is not recommended. Several recent meta-analyses re-evaluated the value of the PPI test in patients with typical GERD symptoms and non-cardiac chest pain. That is, the PPI test has been proven to be a sensitive tool for diagnosing GERD in patients with non-cardiac chest pain and in some preliminary trials regarding extraesophageal manifestations of GERD. Ambulatory pH monitoring of the esophagus helps to confirm gastroesophageal reflux in patients with persistent symptoms (both typical and atypical) in the absence of esophageal mucosal damage, especially when a trial of acid suppression has failed. Impedance pH test is useful in refractory reflux patients with primary complaints of typical GERD symptoms, but this value has not been proved in patients with non-cardiac chest pain or extraesophageal symptoms. This systematic review is targeted to establish the strategy of GERD diagnosis, which is essential for the current clinical practice.

Epidemiology of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), a common disorder in Western society, is less seen in Asian countries, but there is an evidence that the incidence of GERD and its complications is rising. Many factors are believed to be responsible for the pathogenesis of GERD. In addition to some recognized factors, the role of other factors, such as obesity and Helicobacter pylori infection, in the pathogenesis of GERD is still unclear. Furthermore, GERD is believed to be associated with the development of many other diseases. This review summarizes the prevalence and risk factors of GERD and its complications.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease.

METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using meta-analysis.

RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients’ satisfaction, perioperative complications, postoperative heartburn, reflux recurrence and re-operation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gas-bloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.

CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Prevalence of overlaps between GERD, FD and IBS and impact on health-related quality of life

OBJECTIVE

Gastroesophageal reflux disease (GERD), functional dyspepsia (FD), and irritable bowel syndrome (IBS) are common, and have negative impacts on health-related quality of life (HR-QOL). Several studies demonstrated a significant overlap between two of these three diseases. The purpose of this study was to examine the prevalence of GERD, FD, and IBS, their overlap rates, and HR-QOL for each disease and each overlap compared with healthy controls in the Japanese general population.

METHODS

We performed a cross-sectional study of Japanese workers who visited a clinic for a routine health check-up, and asked them to fill out a self-report questionnaire. Prevalence and overlap rate of GERD defined as heartburn and/or acid regurgitation at least weekly, FD and IBS based on Rome III criteria, and HR-QOL by SF-8 were examined.

RESULTS

Of the 2680 eligible subjects, 207 (7.7%) were diagnosed as having GERD, 269 (10.0%) as FD, and 381 (14.2%) as IBS. Overlaps were found in 46.9% in GERD, 47.6% in FD, and 34.4% in IBS. Prevalence of overlaps in subjects with IBS was significantly lower compared with those among GERD or FD. Sufferers from GERD, FD, or IBS reported significantly poorer HR-QOL across all domains compared with controls. Overlaps significantly worsened HR-QOL in most domains except in the 'role emotional' domain. HR-QOL was particularly poor in the physical component summary for overlapping GERD and in the mental component summary for overlapping IBS.

CONCLUSION

Overlaps among GERD, FD and IBS were common and worsened HR-QOL in Japanese general population.

Barrett's oesophagus and oesophageal adenocarcinoma: time for a new synthesis

The public health importance of Barrett's oesophagus lies in its association with oesophageal adenocarcinoma. The incidence of oesophageal adenocarcinoma has risen at an alarming rate over the past four decades in many regions of the Western world, and there are indications that the incidence of this disease is on the rise in Asian populations in which it has been rare. Much has been learned of host and environmental risk factors that affect the incidence of oesophageal adenocarcinoma, and data indicate that patients with Barrett's oesophagus rarely develop oesophageal adenocarcinoma. Given that 95% of oesophageal adenocarcinomas arise in individuals without a prior diagnosis of Barrett's oesophagus, what strategies can be used to reduce late diagnosis of oesophageal adenocarcinoma?

Acid-related disorders in the elderly

Diseases of the upper gastrointestinal tract such as gastroesophageal reflux disease (GERD), peptic ulcer and gastric cancer become more common and more severe with advancing age. Older individuals also tend to have a higher prevalence of co-morbid factors, such as Helicobacter pylori infection, presence of other diseases, or use of medications (e.g., nonsteroidal anti-inflammatory drugs, bisphosphonates) that increase their risk for acid-related disorders. Unfortunately, in the elderly patient with these disorders symptom presentation may be slight or atypical, resulting in a delayed diagnosis. In general, the treatment of older individuals with peptic ulcer or GERD and its complications is similar to that of younger individuals. Proton pump inhibitors are the basis of therapy for symptom relief, healing of erosive esophagitis and peptic ulceration, reduction of the risk for NSAID induced mucosal damage, and prevention of disease relapses. The strongest prevalence of H.pylori infection in the elderly, as well as the role of H.pylori in the occurrence of gastric lesions, in particular ulcer diseases, gastric precancerous lesions and gastric cancer, make the diagnosis and the eradication of H.pylori in this population of the utmost importance. Strategies to improve the management of upper gastrointestinal diseases in older people will reduce mortality and improve quality of life.

Systematic investigation of gastrointestinal diseases in China (SILC): validation of survey methodology

Background

Symptom-based surveys suggest that the prevalence of gastrointestinal diseases is lower in China than in Western countries. The aim of this study was to validate a methodology for the epidemiological investigation of gastrointestinal symptoms and endoscopic findings in China.

Methods

A randomized, stratified, multi-stage sampling methodology was used to select 18 000 adults aged 18-80 years from Shanghai, Beijing, Xi'an, Wuhan and Guangzhou. Participants from Shanghai were invited to provide blood samples and undergo upper gastrointestinal endoscopy. All participants completed Chinese versions of the Reflux Disease Questionnaire (RDQ) and the modified Rome II questionnaire; 20% were also invited to complete the 36-item Short Form Health Survey (SF-36) and Epworth Sleepiness Scale (ESS). The psychometric properties of the questionnaires were evaluated statistically.

Results

The study was completed by 16 091 individuals (response rate: 89.4%), with 3219 (89.4% of those invited) completing the SF-36 and ESS. All 3153 participants in Shanghai provided blood samples and 1030 (32.7%) underwent endoscopy. Cronbach's alpha coefficients were 0.89, 0.89, 0.80 and 0.91, respectively, for the RDQ, modified Rome II questionnaire, ESS and SF-36, supporting internal consistency. Factor analysis supported construct validity of all questionnaire dimensions except SF-36 psychosocial dimensions.

Conclusion

This population-based study has great potential to characterize the relationship between gastrointestinal symptoms and endoscopic findings in China.

Helicobacter pylori and non-malignant diseases

It is well known that Helicobacter pylori infection is associated with many nonmalignant disorders such as gastritis, peptic ulcer, gastroesophageal reflux disease (GERD), gastric polyp, nonsteroidal anti-inflammatory drug (NSAID)/aspirin-induced gastric injury, and functional dyspepsia. In 2008, interesting articles on the association of H. pylori infection with these disorders were presented, some of which intended to reveal the mechanisms of inter-individual differences in response to H. pylori infection, and have demonstrated that genetic differences in host and bacterial factors as well as environmental factors account for these differences. A decline in the occurrence of peptic ulcer related to H. pylori was confirmed. An inverse relationship between H. pylori infection and GERD was also confirmed but the impact of gastric atrophy on the prevention of GERD remained debatable. For NSAID-induced gastric injury, eradication of H. pylori infection has been recommended. During this year, eradication of H. pylori infection was recommended for patients treated with antiplatelet therapy as well as aspirin and NSAID. It was also reported that for patients with functional dyspepsia, eradication of H. pylori offers a modest but significant benefit.