Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Upper Gastrointestinal Symptoms Predictive of Candida Esophagitis and Erosive Esophagitis in HIV and Non-HIV Patients: An Endoscopy-Based Cross-Sectional Study of 6011 Patients

Upper gastrointestinal (GI) symptoms are common in both HIV and non-HIV-infected patients, but the difference of GI symptom severity between 2 groups remains unknown. Candida esophagitis and erosive esophagitis, 2 major types of esophagitis, are seen in both HIV and non-HIV-infected patients, but differences in GI symptoms that are predictive of esophagitis between 2 groups remain unknown. We aimed to determine whether GI symptoms differ between HIV-infected and non-HIV-infected patients, and identify specific symptoms of candida esophagitis and erosive esophagitis between 2 groups.We prospectively enrolled 6011 patients (HIV, 430; non-HIV, 5581) who underwent endoscopy and completed questionnaires. Nine upper GI symptoms (epigastric pain, heartburn, acid regurgitation, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia) were evaluated using a 7-point Likert scale. Associations between esophagitis and symptoms were analyzed by the multivariate logistic regression model adjusted for age, sex, and proton pump inhibitors.Endoscopy revealed GI-organic diseases in 33.4% (2010/6.011) of patients. The prevalence of candida esophagitis and erosive esophagitis was 11.2% and 12.1% in HIV-infected patients, respectively, whereas it was 2.9% and 10.7 % in non-HIV-infected patients, respectively. After excluding GI-organic diseases, HIV-infected patients had significantly (P < 0.05) higher symptom scores for heartburn, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia than non-HIV-infected patients. In HIV-infected patients, any symptom was not significantly associated with CD4 cell count. In multivariate analysis, none of the 9 GI symptoms were associated with candida esophagitis in HIV-infected patients, whereas dysphagia and odynophagia were independently (P < 0.05) associated with candida esophagitis in non-HIV-infected patients. However, heartburn and acid regurgitation were independently (P < 0.05) associated with erosive esophagitis in both patient groups. The internal consistency test using Cronbach's α revealed that the 9 symptom scores were reliable in both HIV (α, 0.86) and non-HIV-infected patients (α, 0.85).This large-scale endoscopy-based study showed that HIV-infected patients have greater GI symptom scores compared with non-HIV-infected patients even after excluding GI-organic diseases. None of the upper GI symptoms predict candida esophagitis in HIV-infected patients, but dysphagia and odynophagia predict candida esophagitis in non-HIV-infected patients. Heartburn and acid regurgitation predict erosive esophagitis in both patient groups.

Randomised clinical trial: the clinical efficacy and safety of an alginate-antacid (Gaviscon Double Action) versus placebo, for decreasing upper gastrointestinal symptoms in symptomatic gastroesophageal reflux disease (GERD) in China

BACKGROUND

There is a paucity of large-scale studies evaluating the clinical benefit of the Gaviscon Double Action (DA) alginate-antacid formulation for treating gastroesophageal reflux disease (GERD) symptoms.

AIM

Randomised double-blind placebo-controlled parallel-group study to evaluate efficacy and safety of Gaviscon DA in reducing heartburn, regurgitation and dyspepsia symptoms in individuals with mild-to-moderate GERD in China.

METHODS

Participants with symptomatic GERD (n = 1107) were randomised to receive Gaviscon DA or placebo (two tablets four times daily) for seven consecutive days. The primary endpoint compared the change in Reflux Disease Questionnaire (RDQ) score for the GERD (heartburn + regurgitation) dimension between Gaviscon DA and placebo. Secondary endpoints compared the change in RDQ scores for individual heartburn, regurgitation and dyspepsia dimensions, overall treatment evaluation (OTE) scores and incidence of adverse events (AEs).

RESULTS

Mean RDQ GERD scores: 2.51 for Gaviscon DA and 2.50 for placebo at baseline; 1.25 for Gaviscon DA and 1.46 for placebo post treatment. Gaviscon DA was statistically superior to placebo in reducing GERD and dyspepsia RDQ scores [least-squares mean (LSM) difference: GERD -0.21, P < 0.0001; dyspepsia -0.18, P = 0.0004], despite a substantial placebo response. The Gaviscon DA group reported more favourable overall treatment responses than the placebo group across all OTE categories (P < 0.0001). Superior relief of GERD symptoms was observed both in those with non-erosive and those with erosive reflux disease (LSM difference -0.14 [P = 0.038] and -0.29 [P < 0.0001] respectively). Incidence of AEs was similar in both groups.

CONCLUSION

Gaviscon DA tablets provide effective and safe reduction in acid reflux and dyspepsia symptoms in Chinese individuals with mild-to-moderate GERD. ClinicalTrials.gov: NCT01869491.

Under-recognised co-morbidities in idiopathic pulmonary fibrosis: A review

Co-morbidities in idiopathic pulmonary fibrosis are common. These co-morbidities include obstructive sleep apnoea, gastro-oesophageal reflux disease, pulmonary hypertension and depression. The presence of co-morbidities among patients with idiopathic pulmonary fibrosis contributes to worse quality of life, morbidity and mortality. Despite the high prevalence of certain co-morbidities in idiopathic pulmonary fibrosis, the optimal screening and management of many of these conditions remains unclear. The impact of co-morbidities on this patient population is becoming more apparent. Their relevance will only increase as significant effort is being made to develop novel therapeutics that will alter the disease trajectory of patients with idiopathic pulmonary fibrosis. The purpose of this review is to focus on the epidemiology, pathophysiology, diagnosis and management of select co-morbidities, including obstructive sleep apnoea, gastro-oesophageal reflux disease, pulmonary hypertension and depression, in idiopathic pulmonary fibrosis.

Systematic review: the effects of long-term proton pump inhibitor use on serum gastrin levels and gastric histology

BACKGROUND

Proton pump inhibitors (PPIs) have a well-established safety profile. However, concerns have been raised about a potential relationship between PPI-induced hypergastrinaemia and the development of enterochromaffin-like (ECL) cell hyperplasia, neuroendocrine tumours and gastric cancer during long-term therapy.

AIM

To review the effects of long-term PPI use on serum gastrin levels and gastric histopathology.

METHODS

A systematic literature search was conducted in PubMed on 21 April 2015 to identify studies reporting the effects of long-term (defined as >3 years) PPI use on gastrin levels and gastric histopathology.

RESULTS

A total of 16 studies (1920 patients) met the inclusion criteria. During long-term PPI therapy, mean gastrin levels rose to one to three times the upper limit of the normal range (~100 pg/mL), and an increased prevalence of ECL cell hyperplasia was observed (+7.8-52.0%). Helicobacter pylori-positive patients had a significantly increased risk of developing ECL linear/micronodular hyperplasia compared with H. pylori-negative patients [OR: 2.45 (95% CI: 1.47-4.10), P = 0.0006]; however, no evidence of neoplastic changes was found. The risk of corpus atrophy was markedly higher in H. pylori-positive patients than in H. pylori-negative patients [OR: 11.45 (95% CI: 6.25-20.99), P < 0.00001]. Not a single case of gastric adenocarcinoma was found.

CONCLUSIONS

Long-term PPI therapy induced moderate hypergastrinaemia in most patients and an increased prevalence of ECL cell hyperplasia. H. pylori-positive patients receiving long-term PPI therapy were exposed to a higher risk of corpus atrophy than H. pylori-negative patients. No neuroendocrine tumours or gastric cancers were found.

Gastroesophageal Reflux Disease Diagnosis Using Hierarchical Heterogeneous Descriptor Fusion Support Vector Machine

A new computer-aided diagnosis method is proposed to diagnose the gastroesophageal reflux disease (GERD) from endoscopic images of the esophageal-gastric junction. To avoid the interferences of different endoscope devices and automatic camera white balance adjustment, heterogeneous descriptors computed from heterogeneous color models are used to represent endoscopic images. Instead of concatenating these descriptors to a super vector, a hierarchical heterogeneous descriptor fusion support vector machine (HHDF-SVM) framework is proposed to simultaneously apply heterogeneous descriptors for GERD diagnosis and overcome the curse of dimensionality problem. During validation, heterogeneous descriptors are extracted from test endoscopic images at first. The classification result is obtained by using HHDF-SVM with heterogeneous descriptors. As shown in the experiments, our method can automatically diagnose GERD without any manual selection of region of interest and achieve better accuracy compared to states-of-the-art methods.

Esomeprazole for the Treatment of Erosive Esophagitis in Children: An International, Multicenter, Randomized, Parallel-Group, Double-Blind (for Dose) Study

BACKGROUND

Acid suppression with a proton pump inhibitor is standard treatment for gastroesophageal reflux disease and erosive esophagitis in adults and increasingly is becoming first-line therapy for children aged 1-17 years. We evaluated endoscopic healing of erosive esophagitis with esomeprazole in young children with gastroesophageal reflux disease and described esophageal histology.

METHODS

Children aged 1-11 years with endoscopically or histologically confirmed gastroesophageal reflux disease were randomized to esomeprazole 5 or 10 mg daily (< 20 kg) or 10 or 20 mg daily (≥ 20 kg) for 8 weeks. Patients with erosive esophagitis underwent an endoscopy after 8 weeks to assess healing of erosions.

RESULTS

Of 109 patients, 49% had erosive esophagitis and 51% had histologic evidence of reflux esophagitis without erosive esophagitis. Of the 45 patients who had erosive esophagitis and underwent follow-up endoscopy, 89% experienced erosion resolution. Dilation of intercellular space was reported in 24% of patients with histologic examination.

CONCLUSIONS

Esomeprazole (0.2-1.0 mg/kg) effectively heals macroscopic and microscopic erosive esophagitis in this pediatric population with gastroesophageal reflux disease. Dilation of intercellular space may be an important histologic marker of erosive esophagitis in children.

Pharmacokinetics and Acid-suppressive Effects of Esomeprazole in Infants 1-24 Months Old With Symptoms of Gastroesophageal Reflux Disease

OBJECTIVES

To evaluate the pharmacokinetics and acid-suppressive effects of esomeprazole in infants with gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

In this single-blind, randomized, parallel-group study, 50 infants 1 to 24 months old with symptoms of GERD, and ≥ 5% of time with intraesophageal pH <4 during 24-hour dual pH monitoring, received oral esomeprazole 0.25 mg/kg (n = 26) or 1 mg/kg (n = 24) once daily for 1 week. Intraesophageal and intragastric pH were recorded at 1 week, and blood samples were taken for pharmacokinetic analysis.

RESULTS

At baseline, mean percentages of time with intragastric pH > 4 and intraesophageal pH < 4 were 30.5% and 11.6%, respectively, in the esomeprazole 0.25 mg/kg group and 28.6% and 12.5% in the esomeprazole 1 mg/kg group. After 1 week of treatment, times with intragastric pH >4 were 47.9% and 69.3% in the esomeprazole 0.25 mg/kg and 1 mg/kg groups, respectively (P < 0.001 vs baseline), and times with intraesophageal pH < 4 were 8.4% (P < 0.05 vs baseline) and 5.5% (P < 0.001 vs. baseline), respectively. The mean number of acid reflux episodes of > 5 minutes duration decreased from 6 at baseline to 3 and 2 with esomeprazole 0.25 mg/kg and 1 mg/kg, respectively. The geometric mean AUC0-t of esomeprazole were 0.24 and 1.79 μmol · h/L for the 0.25 mg/kg and 1 mg/kg dosages of esomeprazole, respectively. Both esomeprazole dosages were well tolerated.

CONCLUSIONS

Oral treatment with esomeprazole 0.25 mg/kg and 1 mg/kg was well tolerated and provided dose-related acid suppression, dose-related exposure to esomeprazole, and decreased esophageal acid exposure in infants 1-24 months old with GERD.

Safety and Tolerability of Esomeprazole in Children With Gastroesophageal Reflux Disease

OBJECTIVES

To evaluate safety, tolerability, and symptom improvement with once-daily esomeprazole in children with endoscopically proven gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

In this 8-week, multicenter, randomized, uncontrolled, double-blind study, children ages 1 to 11 years were stratified by weight to receive esomeprazole 5 or 10 mg (children < 20 kg) or 10 or 20 mg (children ≥ 20 kg) once daily. Safety and tolerability was assessed by evaluating adverse events (AEs; both treatment- and non-treatment-related AEs) and changes from baseline in medical history, physical examinations, and clinical laboratory tests. Investigators scored symptom severity every 2 weeks using the Physician's Global Assessment (PGA). Patients' parents rated GERD symptoms of heartburn, acid regurgitation, and epigastric pain (none to severe, 0-3) at baseline (based on past 72 hours) and daily (from past 24 hours).

RESULTS

Of 109 patients randomized, 108 had safety data. AEs were experienced by 68.0% and 65.2% of children < 20 kg receiving esomeprazole 5 and 10 mg, respectively, and 83.9% and 82.8% of children ≥ 20 kg receiving esomeprazole 10 and 20 mg, respectively, regardless of causality. Overall, only 9.3% of patients reported 13 treatment-related AEs; the most common were diarrhea (2.8% [3/108]), headache (1.9% [2/108]), and somnolence (1.9% [2/108]). Vomiting, a serious AE in 2 patients, was not judged by the investigator to be related to treatment. At the final visit, PGA scores improved significantly from baseline (P < 0.001). Of 58 patients with moderate to severe baseline PGA symptom scores, 91.4% had lower scores by the final visit. GERD symptom scores were significantly improved from baseline to the final week of the study in all of the treatment groups (P < 0.01) CONCLUSIONS: In children ages 1 to 11 years with endoscopically proven GERD, esomeprazole (at daily doses of 5, 10, or 20 mg) was generally well tolerated. The frequency and severity of GERD-related symptoms were significantly reduced during the active treatment period.

Management of reflux esophagitis: does the choice of proton pump inhibitor matter?

BACKGROUND

Proton pump inhibitors (PPIs) are the treatment of choice for reflux esophagitis (RE). The effectiveness of PPIs throughout RE management, from healing to maintenance, has not been fully studied.

AIM

To compare esomeprazole with lansoprazole or pantoprazole for RE management using a management model.

METHODS

Data from six studies comparing esomeprazole with lansoprazole or pantoprazole for healing (4-8 weeks) or maintenance of healing (6 months) of RE were incorporated into hypothetical management models to determine the proportion of patients in endoscopic remission after sequential healing and maintenance therapy, assuming that patients received the same PPI throughout. The number needed to treat (NNT) to achieve one more patient in remission with esomeprazole vs. other PPIs was estimated. The hypothetical model was validated using results from the EXPO study, which compared esomeprazole with pantoprazole for RE healing and maintenance.

RESULTS

Overall, esomeprazole 40 mg produced higher rates of healing (life-table estimates) than lansoprazole 30 mg (82.4-92.6% vs. 77.5-88.8%; p < 0.01) or pantoprazole 40 mg (95.5% vs. 92.0%; p < 0.001) and higher rates of endoscopic and symptomatic remission at 6 months than lansoprazole (83.0-84.8% vs. 74.0-75.9%; p < 0.001; life-table estimates) or pantoprazole (70.9% vs. 59.6%; p < 0.0001; observed rates). In the hypothetical management model, the NNT for esomeprazole was 9 vs. lansoprazole and 8 vs. pantoprazole. The actual NNT for esomeprazole vs. pantoprazole in the EXPO study was 9 (95% confidence interval: 6; 16).

CONCLUSIONS

In this management model, esomeprazole was more effective than either lansoprazole or pantoprazole for maintaining remission after sequential healing and 6 months' maintenance therapy for RE.

Efficacy of Lafutidine Versus Famotidine in Patients with Reflux Esophagitis: A Multi-Center, Randomized, Double-Blind, Non-inferiority Phase III Trial

BACKGROUND

There has been no study on the efficacy of lafutidine for patients with reflux esophagitis in Korea.

AIM

To evaluate the efficacy of a new-generation histamine-2 receptor antagonist, lafutidine, in comparison with famotidine in patients with reflux esophagitis.

METHODS

This was a randomized, double-blind, non-inferiority trial enrolling patients with erosive esophagitis. The efficacy and safety of 20 mg lafutidine (treatment group) were compared with those of 40 mg famotidine (control group) and 20 mg omeprazole (reference group). The primary endpoint was the complete healing rates of reflux esophagitis on endoscopy after 8 weeks of treatment. The non-inferiority margin was assumed to be -15 %.

RESULTS

The healing rates of reflux esophagitis on endoscopy after 8 weeks of treatment were 70.14 % (101/144) in the lafutidine, 63.45 % (92/145) in the famotidine, and 85.71 % (126/147) in the omeprazole group. The difference in healing rates between the lafutidine and famotidine groups was 6.69 % (95 % confidence interval = [-4.14 to 17.52]). In addition, lafutidine was superior to famotidine in clinical improvement (53.73 % vs. 39.55 %, P = 0.0200).

CONCLUSIONS

Lafutidine was non-inferior to famotidine in healing of reflux esophagitis. Lafutidine, however, was superior to famotidine in terms of symptom relief of reflux esophagitis.

More art than science: impedance analysis prone to interpretation error

BACKGROUND

Impedance monitoring for reflux evaluation does not have standardized scoring, which can confound interpretation between observers. We investigated the variability of impedance testing interpretation between physicians and computer software.

METHODS

Raw impedance data from 38 patients that underwent impedance monitoring at a tertiary referral center between 2008 and 2013 were collected. Two physicians and computer software each analyzed the same impedance dataset for reflux activity and symptom-reflux correlation.

RESULTS

Normalized reflux activity interpretations did not differ between physicians and the computer for acid or non-acid reflux. However, for weakly acidic reflux, there was significant difference between physicians (p < 0.01) and between physician and computer (p < 0.01). In analyzing all reflux, significant variability existed between physicians (p < 0.01) but not between physician and computer. Variability in interpretation altered diagnosis in 24 % of patients when comparing between physicians, 18 % of patients when comparing both physicians to the computer, and an additional 24 % of cases when comparing a single physician to the computer. Symptom-reflux correlation differed in 7 % of physician-physician comparisons versus 8 % of computer-physician comparisons.

CONCLUSION

Impedance testing analysis is subject to marked variability between physicians and computer software, making impedance prone to interpretation error that can lead to differences in diagnosis and management.

Prevalence of gastroesophageal reflux disease symptoms and effects of esomeprazole on the quality of life related to reflux and dyspepsia in patients on maintenance hemodialysis

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) symptoms has not been investigated in patients on maintenance hemodialysis in Japan, and few studies have reported the effect of proton pump inhibitors (PPIs) in hemodialysis patients with GERD symptoms. Here, we investigated the prevalence of GERD symptoms and the effects of the PPI esomeprazole on the quality of life related to reflux and dyspepsia in patients on maintenance hemodialysis.

METHODS

This was a cross-sectional/cohort study of hemodialysis outpatients implemented in 10 Japanese medical facilities from October 2012 to March 2014. The trial was registered in the UMIN Clinical Trial Registry (UMIN000009124).

RESULTS

Forty-one of 385 patients (11%) reported GERD symptoms on the Global Overall Symptom (GOS) questionnaire. Multivariate logistic regression analysis identified the independent prognostic factors for GERD symptoms as a history of gastric ulcer and use of sevelamer hydrochloride or calcium polystyrene sulfonate. Participants with GERD symptoms completed the Quality of Life in Reflux and Dyspepsia, Japanese version (QOLRAD-J) questionnaire and were assigned to receive 4-week esomeprazole treatment (20 mg/day). This PPI therapy significantly improved all QOLRAD-J domains in the full analysis set (n = 28) and improved the GERD symptoms listed in the GOS questionnaire. Significantly impaired disease-specific quality of life (QOL) in the QOLRAD-J domains was observed in 44.4-74.1% of patients who had symptoms before treatment. The mean GOS and QOLRAD-J scores correlated significantly.

CONCLUSION

Therapy with 20 mg/day esomeprazole appears to be efficacious for improving disease-specific QOL and GERD symptoms in Japanese patients on maintenance hemodialysis.

Lifestyle measures in the management of gastro-oesophageal reflux disease: clinical and pathophysiological considerations

Several lifestyle and dietary factors are commonly cited as risk factors for gastro-oesophageal reflux disease (GORD) and modification of these factors has been advocated as first-line measures for the management of GORD. We performed a systematic review of the literature from 2005 to the present relating to the effect of these factors and their modification on GORD symptoms, physiological parameters of reflux as well as endoscopic appearances. Conflicting results existed for the association between smoking, alcohol and various dietary factors in the development of GORD. These equivocal findings are partly due to methodology problems. There is recent good evidence that weight reduction and smoking cessation are beneficial in reducing GORD symptoms. Clinical and physiological studies also suggest that some physical measures as well as modification of meal size and timing can also be beneficial. However, there is limited evidence for the role of avoiding alcohol and certain dietary ingredients including carbonated drinks, caffeine, fat, spicy foods, chocolate and mint.

Partnership in optimizing management of reflux symptoms: a treatment algorithm for over-the-counter proton-pump inhibitors

BACKGROUND

Uncomplicated heartburn and acid regurgitation are increasingly treated and managed using over-the-counter medications. However, with over-the-counter availability of antacids, alginates, histamine 2 receptor antagonists (H2RAs), and proton-pump inhibitors (PPIs), consumers need guidance as to appropriate options and how to use them.

METHODS

Relevant guidelines, studies, and reviews were identified via literature searches of PubMed/Medline and Google Scholar, as well as cross-referencing from the identified papers.

RESULTS

Antacids, alginates, and H2RAs are best suited to management of occasional heartburn, taken either before provocative meals or other triggers or on demand when symptoms arise. Over-the-counter PPIs are appropriate options across the range of symptom severity/frequency typically encountered in the pharmacy, but may be particularly appropriate for treatment of those with frequent and/or very bothersome heartburn. A 2-4 week course of daily PPIs can lead to complete resolution of frequent heartburn. Counseling is important to ensure that patients understand that failure of symptoms to resolve or a rapid return of symptoms while taking a PPI is an indication to consult a doctor, whereas a return of symptoms after a period of months may be an indication for just another course of treatment. The need for effective communication and for ensuring use of the correct medication in the over-the-counter setting puts much of the responsibility for management of heartburn and acid regurgitation on the pharmacist. A proposed algorithm that details when and how to use available over-the-counter medications is presented. This algorithm also highlights alarm features and atypical symptoms indicative of other underlying conditions that should be referred directly to a physician.

CONCLUSION

Implementation of a simple algorithm will empower pharmacists and consumers alike and ensure consistent and appropriate care.

Italian survey on general pediatricians' approach to children with gastroesophageal reflux symptoms

The aim of the present study was to investigate the current approach of Italian general pediatricians to children with gastroesophageal reflux (GER) symptoms, evaluating the implementation of the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines. One hundred randomly identified Italian general pediatricians were asked to complete a case report-structured questionnaire investigating their approach to infants, children, and adolescents with symptoms suggestive of GER. Only 2 % of them showed complete adherence to the guidelines. Thirty-nine percent of them diagnosed GER disease based on clinical symptoms, irrespective of the age of the child; 56 % prescribed proton pump inhibitors (PPIs) in infants with unexplained crying and/or distressed behavior and 38 % in infants with uncomplicated recurrent regurgitation and vomiting; 57 % prescribed PPIs in children younger than 8-12 years of age with vomiting and heartburn, without specific testing; and 54 % discontinued PPI therapy abruptly. The overall rate of pediatricians over-prescribing PPIs was 79 %.

CONCLUSION

According to our findings, most Italian general pediatricians do not seem to follow the recommendations of the 2009 NASPGHAN-ESPGHAN reflux guidelines and often prescribe PPIs despite a lack of efficacy for the symptoms being treated. We are well aware that the guidelines address the average situation and that the evaluation of individual patients may frequently reveal reasons for opening criteria for exceptions. Nevertheless, the over-diagnosis of gastroesophageal reflux disease (GERD) places undue burden on both families and national health system which has not been impacted by the publication of international guidelines.

The effects of transoral incisionless fundoplication on chronic GERD patients: 12-month prospective multicenter experience

PURPOSE

This study aimed to assess the impact of transoral incisionless fundoplication (TIF) on patients with chronic gastroesophageal reflux disease (GERD) at 12-month follow-up.

METHODS

Clinical outcomes of 100 consecutive patients with chronic GERD who underwent TIF between January 2010 and February 2011 were analyzed.

RESULTS

There were no major complications reported. Esophageal acid exposure was normalized in 14/27 (52%) of patients who underwent 12-month pH testing. Seventy-four percent of all patients were off proton pump inhibitors versus 92% on daily proton pump inhibitors before TIF, P<0.001. Daily bothersome heartburn and regurgitation symptoms were eliminated in 66/85 (78%) and 48/58 (83%) of patients. Median reflux symptom index score was reduced from 20 (0 to 41) to 5 (0 to 44), P<0.001. Two patients reported de novo dysphagia and 1 patient reported bloating (scores 0 to 3). Six patients underwent revision; 5 laparoscopic Nissen fundoplication and 1 TIF.

CONCLUSIONS

TIF provided a safe and effective therapeutic option for carefully selected patients with chronic GERD.

Non-nutritive sucking for gastro-oesophageal reflux disease in preterm and low birth weight infants

BACKGROUND

Gastro-oesophageal reflux (GOR) is commonly diagnosed in the neonatal population (DiPietro 1994), and generally causes few or no symptoms (Vandenplas 2009). Conversely, gastro-oesophageal reflux disease (GORD) refers to GOR that causes troublesome symptoms with or without complications such as damage to the oesophagus (Vandenplas 2009). Currently there is no evidence to support the range of measures recommended to help alleviate acid reflux experienced by infants. Non-nutritive sucking (NNS) has been used as an intervention to modulate neonatal state behaviours through its pacifying effects such as decrease infant fussiness and crying during feeds (Boiron 2007; Pickler 2004).

OBJECTIVES

To determine if NNS reduces GORD in preterm infants (less than 37 weeks' gestation) and low birth weight (less than 2500 g) infants, three months of age and less, with signs or symptoms suggestive of GORD, or infants with a diagnosis of GORD.

SEARCH METHODS

We performed computerised searches of the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2013), MEDLINE (1966 to September 2013), CINAHL (1982 to September 2013), and EMBASE (1988 to September 2013). We applied no language restrictions.

SELECTION CRITERIA

Controlled trials using random or quasi-random allocation of preterm infants (less than 37 weeks' gestation) and low birth weight (less than 2500 g) infants three months of age and less with signs or symptoms suggestive of GORD, or infants with a diagnosis of GORD. We included studies reported only by abstracts, and cluster and cross-over randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed and selected trials from searches, assessed and rated study quality and extracted relevant data. We identified two studies from the initial search. After further review, we excluded both studies.

MAIN RESULTS

We identified no studies examining the effects of NNS for GORD in preterm and low birth weight infants

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine the effectiveness of NNS for GORD. Adequately powered RCTs on the effect of NNS in preterm and low birth weight infants diagnosed with GORD are required.

Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common digestive disease, affecting one third of the world's population. The minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage refractory GERD. However, long-term benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study was therefore conducted to evaluate the outcome of patients with refractory GERD 5 years after the Stretta procedure.

METHODS

A total of 152 patients with refractory GERD underwent the Stretta procedure in our department between April 2007 and September 2008. They were followed up for 5 years, during which the primary outcome measures including symptom scores of heartburn, regurgitation, chest pain, cough and asthma and the secondary outcome measures including proton pump inhibitor (PPI) use and patients' satisfaction were analysed at 6, 12, 24, 36, 48 and 60 months respectively.

RESULTS

Of the 152 patients, 138 completed the designated 5-year follow-up and were included in the final analysis. At the end of the 5-year follow-up, the symptom scores of heartburn (2.47 ± 1.22 vs. 5.86 ± 1.52), regurgitation (2.23 ± 1.30 vs. 5.56 ± 1.65), chest pain (2.31 ± 0.76 vs. 4.79 ± 1.59), cough (3.14 ± 1.43 vs. 6.62 ± 1.73) and asthma (3.26 ± 1.53 vs. 6.83 ± 1.46) were all significantly decreased as compared with the corresponding values before the procedure (P < 0.001). After the Stretta procedure, 59 (42.8%) patients achieved complete PPI therapy independence and 104 (75.4%) patients were completely or partially satisfied with the GERD symptom control. Moreover, no severe complications were observed except for complaint of abdominal distention in 12 (8.7%) patients after the Stretta procedure.

CONCLUSION

The Stretta procedure may achieve an effective and satisfactory long-term symptom control and considerably reduce the reliance on medication without significant adverse effects in adult patients with refractory GERD, thereby having profound clinical implications.

Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common digestive disease, affecting one third of the world's population. The minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage refractory GERD. However, long-term benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study was therefore conducted to evaluate the outcome of patients with refractory GERD 5 years after the Stretta procedure.

METHODS

A total of 152 patients with refractory GERD underwent the Stretta procedure in our department between April 2007 and September 2008. They were followed up for 5 years, during which the primary outcome measures including symptom scores of heartburn, regurgitation, chest pain, cough and asthma and the secondary outcome measures including proton pump inhibitor (PPI) use and patients' satisfaction were analysed at 6, 12, 24, 36, 48 and 60 months respectively.

RESULTS

Of the 152 patients, 138 completed the designated 5-year follow-up and were included in the final analysis. At the end of the 5-year follow-up, the symptom scores of heartburn (2.47 ± 1.22 vs. 5.86 ± 1.52), regurgitation (2.23 ± 1.30 vs. 5.56 ± 1.65), chest pain (2.31 ± 0.76 vs. 4.79 ± 1.59), cough (3.14 ± 1.43 vs. 6.62 ± 1.73) and asthma (3.26 ± 1.53 vs. 6.83 ± 1.46) were all significantly decreased as compared with the corresponding values before the procedure (P < 0.001). After the Stretta procedure, 59 (42.8%) patients achieved complete PPI therapy independence and 104 (75.4%) patients were completely or partially satisfied with the GERD symptom control. Moreover, no severe complications were observed except for complaint of abdominal distention in 12 (8.7%) patients after the Stretta procedure.

CONCLUSION

The Stretta procedure may achieve an effective and satisfactory long-term symptom control and considerably reduce the reliance on medication without significant adverse effects in adult patients with refractory GERD, thereby having profound clinical implications.

Gastroesophageal Reflux Symptoms in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND: It is known that there is some relation between airways obstruction and gastroesophageal reflux symptoms (GER) symptoms in patients with chronic obstructive pulmonary disease (COPD).AIM: The aim was to determine frequency of GER symptoms and correlation with pulmonary function tests in patients with COPD.MATERIAL AND METHODS: The study included 58 patients. First group had 20 patients with mild COPD, second group had 18 patients with moderate COPD and third group had 20 patients with severe COPD. We had also a control group with 12 healthy subjects. All subjects completed their self-reported questionnaire about symptoms like: acid-regurgitation, heartburn, dysphagia, dyspnea and chronic cough.RESULTS: COPD patients with airways obstruction and significant GER symptoms had their respiratory symptoms associated with reflux events. More of COPD patients had significant GER symptoms defined as regurgitation and dysphagia once or more per week. Patients with FEV1 less than 50% showed more prevalent GER symptoms compared to those with values of FEV1 grater then 50%.CONCLUSION: GER symptoms are more prevalent in patients with severe airways obstruction when compared to less airways obstructed group and controls. We could suggest an association between the degree of airways obstruction in patients with COPD and the increased rate of GER symptoms.

Randomized controlled trial comparing the efficacy of mosapride plus omeprazole combination therapy to omeprazole monotherapy in gastroesophageal reflux disease

OBJECTIVE

We investigated whether the prokinetic activity of mosapride, a 5-hydroxytryptamine 4 receptor agonist, in combination with proton pump inhibitor (PPI) would ameliorate symptoms of gastroesophageal reflux disease (GERD) in Japanese patients.

METHODS

Patients who experienced reflux symptoms more than twice weekly were eligible for this study. In all, 60 patients were randomized to receive mosapride 5 mg thrice daily combined with omeprazole 10 mg once daily (GO group), or omeprazole alone (O group) for 4 weeks. The patients completed the frequency scale for the symptoms of GERD (FSSG) at the beginning and the end of the study. The primary outcome compared changes in the FSSG reflux-related symptom (RS) score between treatment groups during the study period.

RESULTS

The FSSG RS scores significantly decreased both in the GO group and the O group, with no differences in improvement between the groups (-5.86 for the GO group vs -4.89 for the O group, P = 0.49). In non-erosive reflux disease (NERD) patients the improvement was significantly lower than that in erosive GERD patients (-4.00 vs -7.67, P = 0.02). However, the addition of mosapride was effective in subgroup analyses of specific symptoms, such as burping.

CONCLUSIONS

Combining mosapride with PPI provided no additional amelioration of reflux symptoms compared to PPI alone. Both regimens provided less relief from reflux symptoms in NERD than in erosive GERD patients. The addition of mosapride ameliorated reflux in patients with symptoms like burping.

Dietary guideline adherence for gastroesophageal reflux disease

Background

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disease, and the cost of health care and lost productivity due to GERD is extremely high. Recently described side effects of long-term acid suppression have increased the interest in nonpharmacologic methods for alleviating GERD symptoms. We aimed to examine whether GERD patients follow recommended dietary guidelines, and if adherence is associated with the severity and frequency of reflux symptoms.

Methods

We conducted a population-based cross-sectional study within the Kaiser Permanente Northern California population, comparing 317 GERD patients to 182 asymptomatic population controls. All analyses adjusted for smoking and education.

Results

GERD patients, even those with moderate to severe symptoms or frequent symptoms, were as likely to consume tomato products and large portion meals as GERD-free controls and were even more likely to consume soft drinks and tea [odds ratio (OR) = 2.01 95% confidence interval (CI) 1.12-3.61; OR = 2.63 95% CI 1.24-5.59, respectively] and eat fried foods and high fat diet. The only reflux-triggering foods GERD patients were less likely to consume were citrus and alcohol [OR = 0.59; 95% CI: 0.35-0.97 for citrus; OR = 0.41 95% CI 0.19-0.87 for 1 + drink/day of alcohol]. The associations were similar when we excluded users of proton pump inhibitors.

Conclusions

GERD patients consume many putative GERD causing foods as frequently or even more frequently than asymptomatic patients despite reporting symptoms. These findings suggest that, if dietary modification is effective in reducing GERD, substantial opportunities for nonpharmacologic interventions exist for many GERD patients.

Diagnosis and treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common disease with a prevalence as high as 10%-20% in the western world. The disease can manifest in various symptoms which can be grouped into typical, atypical and extra-esophageal symptoms. Those with the highest specificity for GERD are acid regurgitation and heartburn. In the absence of alarm symptoms, these symptoms can allow one to make a presumptive diagnosis and initiate empiric therapy. In certain situations, further diagnostic testing is needed to confirm the diagnosis as well as to assess for complications or alternate causes for the symptoms. GERD complications include erosive esophagitis, peptic stricture, Barrett’s esophagus, esophageal adenocarcinoma and pulmonary disease. Management of GERD may involve lifestyle modification, medical therapy and surgical therapy. Lifestyle modifications including weight loss and/or head of bed elevation have been shown to improve esophageal pH and/or GERD symptoms. Medical therapy involves acid suppression which can be achieved with antacids, histamine-receptor antagonists or proton-pump inhibitors. Whereas most patients can be effectively managed with medical therapy, others may go on to require anti-reflux surgery after undergoing a proper pre-operative evaluation. The purpose of this review is to discuss the current approach to the diagnosis and treatment of gastroesophageal reflux disease.

Efficacy of turmeric in the treatment of digestive disorders: a systematic review and meta-analysis protocol

BACKGROUND

Digestive disorders pose significant burdens to millions of people worldwide in terms of morbidity, mortality and healthcare costs. Turmeric has been traditionally used for conditions associated with the digestive system, and its therapeutic benefits were also confirmed in clinical studies. However, rigorous systematic review on this topic is severely limited. Our study aims to systematically review the therapeutic and adverse effects of turmeric and its compounds on digestive disorders, including dyspepsia, peptic ulcer, irritable bowel disease, Crohn's disease, ulcerative colitis, and gastroesophageal reflux disease.

METHODS/DESIGN

This study will include both randomized controlled trials and non-randomized controlled trials assessing the efficacy and safety of turmeric or its compounds in comparison to a placebo or any other active interventions for digestive disorders without any restrictions on participant age or language of publication. The primary outcome is the proportion of patients that have experienced treatment success. Secondary outcomes are the prevalence of an individual symptom of digestive disorders, the proportion of patients who experienced relapse, the number of physician visits/hospitalization due to digestive disorders, health-related quality of life and the proportion of patients who experienced adverse events. Relevant studies will be identified through MEDLINE, EMBASE, AMED, Dissertations & Theses Database and the Cochrane Central Register of Control Trials from their inception to August 31, 2013. In addition, grey literature such as information published on drug regulatory agencies websites and abstracts/proceedings from conferences will also be reviewed. A calibration exercise will be conducted in a process of study screening, whereby two reviewers will independently screen titles and abstracts from the literature search. Any conflicts will be resolved through a subsequent team discussion. The same process will be adopted in data abstraction and methodological quality appraisal by the Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale. We will describe study and patient characteristics, risk of bias/methodological quality results, and outcomes of the included studies. If we have sufficient data and homogeneity, a random effects meta-analysis will be performed.

DISCUSSION

Our results will help patients and healthcare practitioners to make informed decisions when considering turmeric as an alternative therapy for digestive disorders.

TRIAL REGISTRATION

PROSPERO registry number: CRD42013005739.

Efficacy and safety of esomeprazole with flupentixol/melitracen in treating gastroesophageal reflux disease patients with emotional disorders

BACKGROUND AND AIM

This study was designed to demonstrate the safety and efficacy of esomeprazole combined with flupentixol/melitracen for the treatment of gastroesophageal reflux disease (GERD) patients with emotional disorders. METHODS Two hundred eighty-nine GERD patients with emotional disorders were divided randomly into two groups: group 1 received esomeprazole only (monotherapy) and group 2 received esomeprazole and flupentixol/melitracen (combination therapy). The patients' GERD questionnaire (GerdQ) and hospital anxiety and depression (HAD) scores were obtained before and after treatment. Changes in the scores, rates of symptom remission, and adverse effects were compared between the two groups.

RESULTS

After 2 weeks of treatment, the average decrease in GerdQ score in the combination group (4.04 ± 2.34) was significantly greater than that in the monotherapy group (3.34 ± 2.74; P < 0.05). Significant differences between the two groups were also found for changes in HAD anxiety scores (5.45 ± 2.41 vs 3.34 ± 2.43, P < 0.05), depression scores (5.47 ± 2.47 vs 3.00 ± 3.28, P < 0.05), and anxiety-depression scores (5.20 ± 2.71 vs 3.60 ± 2.56, P < 0.05). The remission of symptoms (eructation, abdominal pain, anorexia, and other accompanying symptoms) in the combination group was significantly better than that in the monotherapy group, and no significant difference in the incidence of adverse events was observed between the two groups.

CONCLUSIONS

The combination therapy has better efficacy than the monotherapy in improving the symptoms of gastroesophageal reflux in patients with emotional disorders. In addition, this combination treatment is safe, with a low incidence of adverse events.

Changes in forced expiratory volume in 1 second over time in patients with controlled asthma at baseline

BACKGROUND

A predominant feature of asthma is an accelerated rate of decline in forced expiratory volume in 1 s (FEV1), but data on the variability and factors associated with this change in patients with controlled asthma are largely unknown.

METHODS

140 patients with controlled asthma were enrolled based on the Global Initiative for Asthma guidelines. We examined the data of a prospective analysis of the association between asthma control and change in FEV1 over time.

RESULTS

A 3-year follow-up assessment was completed in 128 patients. The mean rate of change in FEV1 was a decline of 22.2 mL yr(-1), with significant variation in the levels of change. The between patient standard deviation for the rate of decline was 34.1 mL yr(-1). We next classified the subjects of less than the 25th percentile as rapid decliners, and greater than the 25th percentile as non-rapid decliners. The decrease in the Asthma Control Test score over a 3-year period was higher for rapid decliners than that for non-rapid decliners (p < 0.001). The rapid decliner was more likely to be older, to have higher levels of FeNO, and to have had severe exacerbations during the study. Patients with severe exacerbations had a greater annual decline in FEV1 compared to patients with no exacerbations (-13.6 vs. -53.2 mL yr(-1), p < 0.0001).

CONCLUSIONS

Among patients with controlled asthma at baseline, the rate of change in FEV1 is highly variable. Severe exacerbations are strongly associated with a rapid loss of lung function.

EAES recommendations for the management of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux.

METHODS

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

RESULTS

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

CONCLUSIONS

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

The use of proton pump inhibitors and the spectrum and number of biliary pathogens in patients with acute cholangitis

BACKGROUND

Knowledge of the bacterial spectrum for acute cholangitis is essential for adequate empiric antibiotic treatment.

AIM

To analyse the relation of proton pump inhibitors (PPI) with biliary pathogens in patients with acute cholangitis.

METHODS

This retrospective study identified 278 patients with 318 acute cholangitis episodes using an endoscopic database. The relationship between PPI and microbiological outcomes was assessed by logistic and poisson regression analysis for binary and count data.

RESULTS

In total, 882 pathogens were isolated, of which, 120 cholangitis episodes occurred with PPI; 198 cholangitis episodes without PPI. Multivariate poisson regression analysis showed that PPI use resulted in a 23% increase in the number of biliary pathogens [3.14 vs. 2.55 (Δ = 0.59), P < 0.01], whereas stent therapy, previous interventional procedures (endoscopic retrograde cholangiography/percutaneous transhepatic cholangiography), genesis, age and sex showed no significant association with the number of biliary pathogens. Significantly, more cholangitis episodes with more than one pathogen isolated occurred during PPI treatment [103/120 (86%) vs. 151/198 (76%), P = 0.04]. Analysis of intrinsic anti-microbial resistance patterns was performed: Anti-microbial combination therapies were significantly more required to cover all isolated pathogens in cholangitis episodes with PPI than in cholangitis episodes without PPI (44/120 vs. 46/198, P = 0.01). Additionally, PPI use was associated with a significantly higher incidence of oropharyngeal flora in the biliary tract (53/120 vs. 61/198, P = 0.02).

CONCLUSIONS

Proton pump inhibitors seem to influence biliary pathogens by increasing the number and broadening the spectrum of biliary pathogens. However, the findings of this hypothesis-generating study need to be tested by confirmatory studies.

Dyspepsia

Dyspepsia is a complex disorder with several distinct pathophysiologic mechanisms that are still poorly understood. Patients who experience dyspepsia have a high burden of disease, with significant personal and economic costs. Although serious pathology presenting as dyspepsia is rare, clinicians need to be aware of alarm features that should trigger prompt referral for subspecialty care. Those without alarm features can be managed in a rational way with either empiric antisecretory therapy, test-and-treat for H pylori eradication, antidepressants, and psychotherapy, or a combination of these. Given the heterogeneity of symptoms and large variability in response to different treatments, more research into specific pathophysiologic mechanisms will likely help guide diagnosis and treatment choices in the future.

Frequency of abnormal esophageal acid exposure in patients eligible for bariatric surgery

BACKGROUND

Obesity and gastroesophageal reflux disease (GERD) are both high-prevalence diseases in developed nations. Obesity has been identified as an important risk factor in the development of GERD. The objective of this study was to determine the frequency of abnormal esophageal acid exposure in patients candidate for bariatric surgery and its relationship with any clinical and endoscopic findings before surgery.

METHODS

Data collected from a group of 88 patients awaiting bariatric surgery included a series of demographic variables and symptoms typical of GERD. The tests patients underwent included manometry, pH monitoring, and upper gastrointestinal endoscopy. Univariate and multivariate analyses were conducted on the variables related to the onset of reflux.

RESULTS

Esophageal pH monitoring tests were positive in 65% of the patients. Manometries showed lower esophageal sphincter hypotonia in 46%, while 20% returned abnormal upper endoscopy results. Out of the 45% of patients who were asymptomatic or returned normal endoscopies, half returned positive esophageal pH tests. In turn, among the 55% of patients who had symptoms or an abnormal upper endoscopy, three quarters had pH tests that diagnosed reflux. pH tests were also positive in 80% of symptomatic patients and 100% of patients with esophagitis (P<.042). No statistically significant relationship was found between body mass index, sex, age, manometry, or hiatus hernia and the positive pH monitoring.

CONCLUSION

Frequency of abnormal esophageal acid exposure among obese patients is high. There is a relationship between the presence of symptoms and reflux. But the absence of symptoms does not rule out the presence of abnormal esophageal function tests.

European pediatricians' approach to children with GER symptoms: survey of the implementation of 2009 NASPGHAN-ESPGHAN guidelines

OBJECTIVE

The aim of this study was to evaluate the current implementation of the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines, and to assess proton pump inhibitors' (PPIs) prescribing patterns among pediatricians from different European countries.

METHODS

A randomly identified sample of general pediatricians distributed across 11 European countries. They were asked to complete a case report-structured questionnaire investigating their approaches to infants, children, and adolescents with symptoms suggestive of gastroesophageal reflux.

RESULTS

A total of 567 European general pediatricians completed the study questionnaire. Only 1.8% of them showed complete adherence to the guidelines. Forty-six percent of them reported that they diagnose gastroesophageal reflux disease based on clinical symptoms irrespective of the age of the child; 39% prescribe PPIs in infants with unexplained crying and/or distressed behavior and 36% prescribe PPIs in infants with uncomplicated recurrent regurgitation and vomiting; 48% prescribed PPIs in children younger than 8 to 12 years with vomiting and heartburn, without specific testing; 45% discontinue PPI therapy abruptly rather than tapering the dose. The overall rate of pediatricians overprescribing PPIs was 82%.

CONCLUSIONS

The overall results of our survey show that the majority of pediatricians are unaware of 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition reflux guidelines and often prescribe PPIs despite a lack of efficacy for the symptoms being treated. The overdiagnosis of gastroesophageal reflux disease places undue burden on both families and national health systems, which has not been affected by the publication of international guidelines.

Potential therapeutic competition in community-living older adults in the U.S.: use of medications that may adversely affect a coexisting condition

OBJECTIVE

The 75% of older adults with multiple chronic conditions are at risk of therapeutic competition (i.e. treatment for one condition may adversely affect a coexisting condition). The objective was to determine the prevalence of potential therapeutic competition in community-living older adults.

METHODS

Cross-sectional descriptive study of a representative sample of 5,815 community-living adults 65 and older in the U.S, enrolled 2007-2009. The 14 most common chronic conditions treated with at least one medication were ascertained from Medicare claims. Medication classes recommended in national disease guidelines for these conditions and used by ≥ 2% of participants were identified from in-person interviews conducted 2008-2010. Criteria for potential therapeutic competition included: 1), well-acknowledged adverse medication effect; 2) mention in disease guidelines; or 3) report in a systematic review or two studies published since 2000. Outcomes included prevalence of situations of potential therapeutic competition and frequency of use of the medication in individuals with and without the competing condition.

RESULTS

Of 27 medication classes, 15 (55.5%) recommended for one study condition may adversely affect other study conditions. Among 91 possible pairs of study chronic conditions, 25 (27.5%) have at least one potential therapeutic competition. Among participants, 1,313 (22.6%) received at least one medication that may worsen a coexisting condition; 753 (13%) had multiple pairs of such competing conditions. For example, among 846 participants with hypertension and COPD, 16.2% used a nonselective beta-blocker. In only 6 of 37 cases (16.2%) of potential therapeutic competition were those with the competing condition less likely to receive the medication than those without the competing condition.

CONCLUSIONS

One fifth of older Americans receive medications that may adversely affect coexisting conditions. Determining clinical outcomes in these situations is a research and clinical priority. Effects on coexisting conditions should be considered when prescribing medications.

Two-year subjective, objective, quality of life, and endoscopic follow-up after laparoscopic Nissen-Rossetti in patients with columnar-lined esophagus

INTRODUCTION

Barrett esophagus (BE) is a complication of gastroesophageal reflux disease. We wish to determine the effects of surgery on the histology of the esophageal mucosa and evaluate Quality of Life.

MATERIALS AND METHODS

Twenty-seven patients with columnar-lined esophagus (CLE) metaplasia underwent laparoscopic Nissen-Rossetti fundoplication. Patients were submitted to close follow-up.

RESULTS

One patient voluntarily left follow-up after surgery. CLE was still present in 18 patients (66.6%); no patient developed dysplasia or esophageal adenocarcinoma. Two patients with gastric metaplasia and 1 patient with intestinal metaplasia had regression at 12 and 24 months after surgery (11.1%). DeMeester and Johnson score decreased from 38.69 (SD ± 51.44) to 11.99 (SD ± 18.08) at 6 months, 12.69 (SD ± 12.91) at 12 months, and it was 11.38 (SD ± 6.43) at 24 months. Preoperative gastroesophageal reflux disease-health related quality of life was 19.90 (SD ± 18.54), 9.80 (SD ± 8.77) at 6 months, 9.57 (SD ± 9.14) at 12 months, and 11.53 (SD ± 6.48) at 24 months. Short form-36 measurement showed significant improvement.

CONCLUSIONS

Management of CLE requires multidisciplinary approach. Medical therapy does not prevent biliary reflux into the esophagus. Surgical therapy is effective and long lasting. It should be performed by experienced surgical teams.

Progress in treatment of gastroesophageal reflux disease by traditional Chinese medicine and Western medicine

Gastroesophageal reflux disease (GERD) is one of the most common digestive system diseases. Although the disease is benign, its symptoms can seriously affect the patient's daily life. The etiology and pathogenesis of GERD are complex. Currently, great progress has been made in the diagnosis of GERD; however, its treatment is still confined to the inhibition of gastric acid secretion, with the use of proton pump inhibitors (PPIs) being the main means of treatment. However, long-term use or discontinued use of PPIs has many disadvantages and limitations. Traditional Chinese medicine based on disease differentiation treatment combined with syndrome differentiation treatment is a comprehensive treatment and has certain advantages in the treatment of GERD.

Identifying asthma triggers

Asthma has many triggers including rhinosinusitis; allergy; irritants; medications (aspirin in aspirin-exacerbated respiratory disease); and obesity. Paradoxic vocal fold dysfunction mimics asthma and may be present along with asthma. This article reviews each of these triggers, outlining methods of recognizing the trigger and then its management. In many patients more than one trigger may be present. Full appreciation of the complexity of these relationships and targeted therapy to the trigger is needed to best care for the patient with asthma.

Efficacy, safety, and tolerability of pantoprazole magnesium in the treatment of reflux symptoms in patients with gastroesophageal reflux disease (GERD): a prospective, multicenter, post-marketing observational study

BACKGROUND

To improve proton pump inhibitor effects, pharmacological modifications have been developed such as the use of enantiomer molecules (e.g., S-omeprazole, S-pantoprazole, or dexlansoprazole), or addition of NaHCO3 (for an immediate release) or magnesium (with a lower absorption for a more sustained effect).

OBJECTIVE

The objective of this study was to assess the efficacy, safety, and tolerability of pantoprazole magnesium 40 mg once daily for 4 weeks, on the relief of reflux symptoms in gastroesophageal reflux disease (GERD) patients.

METHODS

A phase IV, open-label, prospective, multicenter study was designed. Patients included were prescribed pantoprazole magnesium 40 mg orally once daily for 28±2 days. All patients had a history of persistent or recurrent heartburn and/or acid regurgitation for at least 3 months. Effectiveness and tolerability data obtained from patients who completed a minimum of 4 weeks of pantoprazole magnesium treatment were considered for analysis.

RESULTS

The account of baseline characteristics and demographics of GERD symptom intensity was made by analyzing the group of 4,343 patients that fulfilled all inclusion criteria; 54% were females (n=2,345) and 46% (n=1,998) males, with a mean age of 36.2±7.5 years. Severity of symptoms, assessed by the physician using the 4-point Likert scale, reduced by at least 80% from baseline intensity after treatment in the per protocol population. In the case of the intention-to-treat population, the improvement in symptom intensity was 73%. The number of patients that experienced any adverse events was 175/5,027 (3.48%).

CONCLUSIONS

Pantoprazole magnesium is a safe, effective, and well-tolerated drug that significantly improves GERD symptoms.

Acid peptic diseases: pharmacological approach to treatment

Acid peptic disorders are the result of distinctive, but overlapping pathogenic mechanisms leading to either excessive acid secretion or diminished mucosal defense. They are common entities present in daily clinical practice that, owing to their chronicity, represent a significant cost to healthcare. Key elements in the success of controlling these entities have been the development of potent and safe drugs based on physiological targets. The histamine-2 receptor antagonists revolutionized the treatment of acid peptic disorders owing to their safety and efficacy profile. The proton-pump inhibitors (PPIs) represent a further therapeutic advance due to more potent inhibition of acid secretion. Ample data from clinical trials and observational experience have confirmed the utility of these agents in the treatment of acid peptic diseases, with differential efficacy and safety characteristics between and within drug classes. Paradigms in their speed and duration of action have underscored the need for new chemical entities that, from a single dose, would provide reliable duration of acid control, particularly at night. Moreover, PPIs reduce, but do not eliminate, the risk of ulcers in patients taking NSAIDs, reflecting untargeted physiopathologic pathways and a breach in the ability to sustain an intragastric pH of more than 4. This review provides an assessment of the current understanding of the physiology of acid production, a discussion of medications targeting gastric acid production and a review of efficacy in specific acid peptic diseases, as well as current challenges and future directions in the treatment of acid-mediated diseases.

Novel partial 5HT3 agonist pumosetrag reduces acid reflux events in uninvestigated GERD patients after a standard refluxogenic meal: a randomized, double-blind, placebo-controlled pharmacodynamic study

BACKGROUND

Low basal lower esophageal sphincter (LES) pressure and transient LES relaxations are major causes of gastroesophageal reflux disease (GERD). Pumosetrag, a novel selective partial 5HT3 receptor agonist, showed a promising effect on reducing reflux events in health. We aimed to evaluate the effect of pumosetrag on changes in reflux episodes, lower esophageal sphincter pressure (LESP), and specific symptoms in patients with GERD receiving a refluxogenic meal.

METHODS

Patients with GERD, who developed heartburn and/or regurgitation after ingestion of a refluxogenic meal, were randomized to 1 of 3 dose levels of pumosetrag (0.2, 0.5, or 0.8 mg) or placebo. Before and after 7 days of treatment, patients underwent manometry, intraesophageal multichannel, intraluminal impedance and pH after a standard refluxogenic meal.

KEY RESULTS

A total of 223 patients with GERD [125 (56%) women, mean (SD) age = 36 (12) years] were enrolled. No overall treatment effects were detected for the total number of reflux episodes (acidic and weakly acidic) (p > 0.5); however, significant treatment effects (p < 0.05) on the number of acid reflux episodes were observed with lower values on pumosetrag 0.2 mg (10.8 ± 1.1), 0.5 mg (9.5 ± 1.1), and 0.8 mg (9.9 ± 1.1) compared with placebo (13.3 ± 1.1). Significant treatment effects (p < 0.05) were also observed for the percentage of time pH was <4, with less time for pumosetrag at 0.5 mg (10%) and 0.8 mg (10%) compared with placebo (16%).

CONCLUSIONS & INFERENCES

In GERD, the partial 5HT3 agonist pumosetrag significantly reduced the rate of acid reflux events but did not result in a significant change in LESP or symptomatic improvement over a 1-week treatment period.

Dietary intervention in the treatment of patients with cough and symptoms suggestive of airways reflux as determined by Hull airways Reflux Questionnaire

BACKGROUND

Chronic cough is a common and distressing symptom. Gastro-oesophageal reflux is a common cause of chronic cough however the symptom complex in cough is not confined to classic peptic symptoms. Dyspeptic symptoms have previously been shown to respond to dietary modifications and weight loss. We hypothesised that weight reduction maybe a useful non-pharmacological strategy in reducing reflux cough in the obese.

METHODS

Subjects with cough were recruited from Hull Cough Clinic. They were randomised to one of two open parallel groups; one receiving the traditional dietary modifications and the other weight reduction advice in the form of an Energy Prescription (EP). Cough symptoms, using the Leicester cough questionnaire (LCQ) and dietary intake were measured at the start and end of the study.

RESULTS

Thirty-three patients were recruited and 20 patients completed the study. Mean weight loss was 3.1 kg (p < 0.001) and reported an improvement in the LCQ (mean improvement 3.1); which is greater than the clinically significant score of 1.3. . Moreover, secondary outcomes showed a significant association between baseline high calorie (r = -0.24; p < 0.001) and fat intake (r = -0.36; p = 0.001), and LCQ scores.

CONCLUSION

A high calorie and fat intake is strongly correlated with cough score. Irrespective of diet, weight loss is associated with a reduction in cough symptoms. Asking patients to lose weight by reducing fat and calorie intake may be a simple strategy to ameliorate this intractable condition.

TRIAL REGISTRATION

The study was approved by the local research ethics committee (South Humber Local Research Ethics Committee; REC04/Q1105/62). The study was registered with the Research and Development Department, Clinical Governance Directorate, Hull and East Yorkshire Hospitals NHS Trust (reference number R0086).

Sleep, immunity and inflammation in gastrointestinal disorders

Sleep disorders have become a global issue, and discovering their causes and consequences are the focus of many research endeavors. An estimated 70 million Americans suffer from some form of sleep disorder. Certain sleep disorders have been shown to cause neurocognitive impairment such as decreased cognitive ability, slower response times and performance detriments. Recent research suggests that individuals with sleep abnormalities are also at greater risk of serious adverse health, economic consequences, and most importantly increased all-cause mortality. Several research studies support the associations among sleep, immune function and inflammation. Here, we review the current research linking sleep, immune function, and gastrointestinal diseases and discuss the interdependent relationship between sleep and these gastrointestinal disorders. Different physiologic processes including immune system and inflammatory cytokines help regulate the sleep. The inflammatory cytokines such as tumor necrosis factor, interleukin-1 (IL-1), and IL-6 have been shown to be a significant contributor of sleep disturbances. On the other hand, sleep disturbances such as sleep deprivation have been shown to up regulate these inflammatory cytokines. Alterations in these cytokine levels have been demonstrated in certain gastrointestinal diseases such as inflammatory bowel disease, gastro-esophageal reflux, liver disorders and colorectal cancer. In turn, abnormal sleep brought on by these diseases is shown to contribute to the severity of these same gastrointestinal diseases. Knowledge of these relationships will allow gastroenterologists a great opportunity to enhance the care of their patients.