Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

A randomized trial on endoscopic full-thickness gastroplication versus laparoscopic antireflux surgery in GERD patients without hiatal hernias

BACKGROUND AND GOALS

Endoscopic full-thickness gastroplication by the Plicator instrument has proven to be a safe and effective method to improve symptoms of gastroesophageal reflux disease. This is the first comparative objective data study for endoscopic versus laparoscopic antireflux procedures.

STUDY

In this single-center controlled open trial in 70 adult patients with documented gastroesophageal reflux disease without hiatal hernias, objective and subjective outcome parameters were evaluated prospectively and compared. Patients were randomly assigned to either endoscopic full-thickness gastroplication or laparoscopic antireflux surgery. Patients in the Plicator group received between 1 and 3 transmural-pledgeted sutures to the gastric cardia. Patients in the laparoscopic anti-reflux surgery (LARS) group underwent Nissen or Toupet fundoplication. Esophageal manometry, 24-hour impedance pH monitoring, Gastrointestinal Quality-of-Life Index, and symptom questionnaires were evaluated at baseline and at the 3-month follow-up for significant (P<0.05) changes and differences.

RESULTS

Lower esophageal sphincter pressures were increased in the LARS group and unchanged in the Plicator group. Total reflux numbers, acid, nonacid, proximal, upright, and recumbent reflux events were reduced in both groups, significantly more in the LARS group. Reductions in reflux-related esophageal acid scores were significant only in the LARS group. Similar improvements of Gastrointestinal Quality-of-Life Index were found in both groups. General and gas-related symptom scores were comparably reduced. Greater Reductions in reflux-specific symptom scores were found after LARS. Bowel dysfunction symptom scores were lower after LARS.

CONCLUSIONS

Improvements in the general subjective outcome parameters were similar after endoscopic full-thickness gastroplication compared with LARS despite a stronger reflux control provided by LARS. More effective relief of reflux-related symptoms favors LARS, and differences in side effect symptoms favor endoscopic full-thickness gastroplication.

Is the advanced age a contraindication to GERD laparoscopic surgery? Results of a long term follow-up

Background

In this prospective non randomized observational cohort study we have evaluated the influence of age on outcome of laparoscopic total fundoplication for GERD.

Methods

Six hundred and twenty consecutive patients underwent total laparoscopic fundoplication for GERD. Five hundred and twenty-four patients were younger than 65 years (YG), and 96 patients were 65 years or older (EG). The following parameters were considered in the preoperative and postoperative evaluation: presence, duration, and severity of GERD symptoms, presence of a hiatal hernia, manometric and 24 hour pH-monitoring data, duration of operation, incidence of complications and length of hospital stay.

Results

Elderly patients more often had atypical symptoms of GERD and at manometric evaluation had a higher rate of impaired esophageal peristalsis in comparison with younger patients. The duration of the operation was similar between the two groups. The incidence of intraoperative and postoperative complications was low and the difference was not statistically significant between the two groups. An excellent outcome was observed in 93.0% of young patients and in 88.9% of elderly patients (p = NS).

Conclusions

Laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients, warranting low morbidity and mortality rates and a significant improvement of symptoms comparable to younger patients.

Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial

OBJECTIVE

Weight gain is an important risk factor for gastroesophageal reflux disease (GERD); however, whether weight loss can lead to resolution of GERD symptoms is not clear. Our aim was to measure the impact of weight loss on GERD symptoms.

DESIGN AND METHODS

In a prospective cohort study at a tertiary referral center, overweight/obese subjects (BMI 25-39.9 kg/m2) were enrolled in a structured weight loss program. Weight loss strategies included dietary modifications, increased physical activity and behavioral changes. At baseline and at 6 months, BMI and waist circumference were measured and all participants completed a validated reflux disease questionnaire.

RESULTS

A total of 332 adult subjects, mean age 46 years and 66% women were prospectively enrolled. At baseline, the mean body weight, BMI, and waist circumference were 101 (±18) kg, 35 (±5) kg/m2 and 103 (±13) cm. At 6 months, majority of the subjects (97%) lost weight (average weight loss: 13 ± 7.7 kg) and as compared with baseline, there was a significant decrease in the overall prevalence of GERD (15 vs. 37%; P < 0.01) and the mean GERD symptom score (1.8 vs. 5.5; P < 0.01). Overall, 81% of the subjects had reduction in GERD symptom scores; 65% had complete resolution and 15% had partial resolution of reflux symptoms. There was a significant correlation between % body weight loss and reduction in GERD symptom scores (r = 0.17, P < 0.05).

CONCLUSIONS

In conclusion, the overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects. A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of these subjects.

Quality of life of patients undergoing surgery by videolaparoscopy for GERD treatment

BACKGROUND

Gastroesophageal reflux disease is a chronic disease of high prevalence in Western countries, with negative effects on quality of life. Surgery is indicated for patients with intolerance to continuous medication, prolonged treatment or control, or in complicated forms of the disease.

AIM

To evaluate the quality of life of patients undergoing surgery by videolaparoscopy for gastroesophageal reflux disease treatment.

METHODS

Sample comprised 43 patients of both genders (mean age = 51.4 years). For quality of life evaluation was made using the questionnaire Gastroesophageal Reflux Disease Health Related Quality of Life, translated and validated into Portuguese. Data were analyzed by Epi Info version 3.5.1, using Duncan test and Pearson's correlation coefficient, with 5% for null hypothesis (p ≤ 0.05).

RESULTS

Over 50% of participants showed good quality of life (scores <5 of the questionnaire), more than 90% indicated satisfaction with their health. A significant positive correlation between most variables related to heartburn and the time after surgery was observed (p ≤ 0.05).

CONCLUSION

Patients presented good quality of life and high level of satisfaction with their postoperative condition.

The role of impedance monitoring in patients with extraesophageal symptoms

OBJECTIVES/HYPOTHESIS

Ambulatory esophageal impedance monitoring is commonly employed to assess for nonacid reflux in patients with extraesophageal reflux. We aimed to determine if on therapy impedance data can be predicted from off therapy upper endoscopy, manometry, or pH parameters.

STUDY DESIGN

Prospective Cohort Study.

METHODS

Patients with extraesophageal reflux symptoms and either partial- or nonresponders to twice-daily PPI underwent impedance monitoring on twice-daily PPI, as well as manometry, upper endoscopy, and 48-hour wireless pH monitoring off acid-suppressive medications for 1 week. Percent time pH < 4 and number of reflux episodes were obtained. Multivariable linear regression was used to determine association between the impedance data on therapy and upper endoscopy, manometry, and pH parameters measured off therapy.

RESULTS

Seventy-five patients (77% female, median BMI 29, 38% with hiatal hernia, and 19% with esophagitis) were studied both on and off therapy. Thirty-five percent had abnormal impedance monitoring on therapy and 84% had abnormal pH testing off therapy. There was no significant (P = 0.184) overall correlation between total number of impedance events and the baseline physiologic parameters of hiatal hernia, degree of acid reflux, or manometric findings, with only weak correlation (r = 0.54, P = 0.045) with % time pH < 4 among patients with esophagitis.

CONCLUSIONS

In patients with suspected extraesophageal reflux refractory to PPI therapy, impedance measures on therapy cannot be predicted from traditional baseline esophageal physiologic parameters. We recommend caution regarding over-interpretation of impedance data.

LEVEL OF EVIDENCE

2b.

Celiac disease, eosinophilic esophagitis and gastroesophageal reflux disease, an adult population-based study

OBJECTIVE

Celiac disease (CD) has been linked to gastroesophageal reflux disease (GORD) and eosinophilic esophagitis (EoE), but population-based studies of the prevalence of CD in these conditions are lacking, that is, the aim of this study.

MATERIALS AND METHODS

An endoscopic study was carried out in 1000 randomly selected adults from the general population. CD was defined on the basis of positive serology in parallel with mucosal abnormalities of the small intestine. Any eosinophil infiltration of the esophageal epithelium was defined as esophageal eosinophilia and EoE was defined as having at least 15 eosinophils/high-power field in biopsies from the distal esophagus. We used Fisher's exact test to compare the prevalence of GORD, esophageal eosinophilia, and EoE in subjects with CD versus controls.

RESULTS

Four hundred subjects (40%) had gastroesophageal reflux symptoms (GORS), 155 (15.5%) had erosive esophagitis, 16 (1.6%) had Barrett's esophagus, 48 (4.8%) had esophageal eosinophilia, and 11 (1.1%) had EoE. CD was diagnosed in 8/400 (2.0%) individuals with GORS (vs. controls: 10/600 (1.7%), p = 0.81), in 3/155 (1.9%) with erosive esophagitis (vs. 15/845 controls (1.8%), p = 0.75), and in 2/48 (4.2%) individuals with esophageal eosinophilia (controls: 16/952 (1.7%), p = 0.21), but in none of those 16 with Barrett's esophagus (vs. 18/984 controls (1.8%), p = 1.0) or of the 11 individuals with EoE (controls: 18/989 (1.8%), p = 1.0).

CONCLUSIONS

This population-based study found no increased risk of CD among individuals with GORD, esophageal eosinophilia, or EoE. CD screening of individuals with GORD or EoE of individuals with CD cannot be recommended.

Is proton pump inhibitor therapy for reflux esophagitis sufficient?: a large real-world survey of Japanese patients

OBJECTIVE

Proton pump inhibitors (PPIs) are widely used as the mainstay of treatment for erosive reflux esophagitis, based on the excellent results obtained in clinical trials. However, the endoscopic remission rates in patients treated with PPIs in actual clinical settings have not been fully assessed. We conducted a nationwide survey to evaluate the effectiveness of PPIs based on endoscopic findings in real-world clinical settings.

METHODS

This was a multicenter retrospective study conducted among 41 Japanese institutions. Endoscopic findings before and after PPI therapy were collected from the medical records of patients diagnosed with Los Angeles grade A-D reflux esophagitis who had been treated with a PPI for at least eight weeks before undergoing a second endoscopy. The remission rates of erosive esophagitis, defined as the percentage of patients with grade N or M findings following PPI therapy, were calculated.

RESULTS

Data for 541 patients were analyzed. At first endoscopy, 45.5%, 30.3%, 15.9% and 8.3% of patients were diagnosed with grade A, B, C and D esophagitis, respectively. The mean duration of PPI therapy was 410 days, and the mean remission rate was 61.6%. The remission rate was significantly lower in the patients with more severe erosive esophagitis based on the LA grade before PPI therapy.

CONCLUSION

This study revealed that approximately 40% of the patients did not achieve remission of erosive esophagitis following PPI therapy for a mean of 1.1 years. This suggests the necessity of providing careful follow-up using periodic endoscopy and appropriately selecting PPI therapy.

Multimodality evaluation of patients with gastroesophageal reflux disease symptoms who have failed empiric proton pump inhibitor therapy

Patients with symptoms suggestive of gastroesophageal reflux disease (GERD), such as chest pain, heartburn, regurgitation, and dysphagia, are typically treated initially with a course of proton pump inhibitors (PPIs). The evaluation of patients who have either not responded at all or partially and inadequately responded to such therapy requires a more detailed history and may involve an endoscopy and esophageal biopsies, followed by esophageal manometry, ambulatory esophageal pH monitoring, and gastric emptying scanning. To assess the merits of a multimodality 'structural' and 'functional' assessment of the esophagus in patients who have inadequately controlled GERD symptoms despite using empiric PPI, a retrospective cohort study of patients without any response or with poor symptomatic control to empiric PPI (>2 months duration) who were referred to an Esophageal Studies Unit was conducted. Patients were studied using symptom questionnaires, endoscopy (+ or - for erosive disease, or Barrett's metaplasia) and multilevel esophageal biopsies (eosinophilia, metaplasia), esophageal motility (aperistalsis, dysmotility), 24-hour ambulatory esophageal pH monitoring (+ if % total time pH < 4 > 5%), and gastric emptying scanning (+ if >10% retention at 4 hours and >70% at 2 hours). Over 3 years, 275 patients (147 men and 128 women) aged 16-89 years underwent complete multimodality testing. Forty percent (n= 109) had nonerosive reflux disease (esophagogastroduodenoscopy [EGD]-, biopsy-, pH+); 19.3% (n= 53) had erosive esophagitis (EGD+); 5.5% (n= 15) Barrett's esophagus (EGD+, metaplasia+); 5.5% (n= 15) eosinophilic esophagitis (biopsy+); 2.5% (n= 7) had achalasia and 5.8% (n= 16) other dysmotility (motility+, pH-); 16% (n= 44) had functional heartburn (EGD-, pH-), and 5.8% (n= 16) had gastroparesis (gastric scan+). Cumulative symptom scores for chest pain, heartburn, regurgitation, and dysphagia were similar among the groups (mean range 1.1-1.35 on a 0-3 scale). Multimodality evaluation changed the diagnosis of GERD in 34.5% of cases and led to or guided alternative therapies in 42%. Overlap diagnoses were frequent: 10/15 (67%) of patients with eosinophilic esophagitis, 12/16 (75%) of patients with gastroparesis, and 11/23 (48%) of patients with achalasia or dysmotility had concomitant pathologic acid reflux by pH studies. Patients with persistent GERD symptoms despite empiric PPI therapy benefit from multimodality evaluation that may change the diagnosis and guide therapy in more than one third of such cases. Because symptoms are not specific and overlap diagnoses are frequent and multifaceted, objective evidence-driven therapies should be considered in such patients.

Indirect comparison of randomised controlled trials: comparative efficacy of dexlansoprazole vs. esomeprazole in the treatment of gastro-oesophageal reflux disease

BACKGROUND

Dexlansoprazole is a new proton pump inhibitor (PPI) with a dual delayed-release system. Both dexlansoprazole and esomeprazole are an enantiomer of lansoprazole and omeprazole respectively. However, there is no head-to-head trial data or indirect comparison analyses between dexlansoprazole and esomeprazole.

AIM

To compare the efficacy of dexlansoprazole with esomeprazole in healing erosive oesophagitis (EO), the maintenance of healed EO and the treatment of non-erosive reflux disease (NERD).

METHODS

Randomised Controlled Trials (RCTs) comparing dexlansoprazole or esomeprazole with either placebo or another PPI were systematically reviewed. Random-effect meta-analyses and adjusted indirect comparisons were conducted to compare the treatment effect of dexlansoprazole and esomeprazole using a common comparator. The relative risk (RR) and 95% confidence interval (CI) were calculated.

RESULTS

The indirect comparisons revealed significant differences in symptom control of heartburn in patients with NERD at 4 weeks. Dexlansoprazole 30 mg was more effective than esomeprazole 20 mg or 40 mg (RR: 2.01, 95% CI: 1.15-3.51; RR: 2.17, 95% CI: 1.39-3.38). However, there were no statistically significant differences between the two drugs in EO healing and maintenance of healed EO. Comparison of symptom control in healed EO was not able to be made due to different definitions used in the RCTs.

CONCLUSIONS

Adjusted indirect comparisons based on currently available RCT data suggested significantly better treatment effect in symptom control of heartburn in patients with NERD for dexlansoprazole against esomeprazole. No statistically significant differences were found in other EO outcomes. However, these study findings need to be interpreted with caution due to small number of studies and other limitations.

Current pharmacological management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), a common disorder with troublesome symptoms caused by reflux of gastric contents into the esophagus, has adverse impact on quality of life. A variety of medications have been used in GERD treatment, and acid suppression therapy is the mainstay of treatment for GERD. Although proton pump inhibitor is the most potent acid suppressant and provides good efficacy in esophagitis healing and symptom relief, about one-third of patients with GERD still have persistent symptoms with poor response to standard dose PPI. Antacids, alginate, histamine type-2 receptor antagonists, and prokinetic agents are usually used as add-on therapy to PPI in clinical practice. Development of novel therapeutic agents has focused on the underlying mechanisms of GERD, such as transient lower esophageal sphincter relaxation, motility disorder, mucosal protection, and esophageal hypersensitivity. Newer formulations of PPI with faster and longer duration of action and potassium-competitive acid blocker, a newer acid suppressant, have also been investigated in clinical trials. In this review, we summarize the current and developing therapeutic agents for GERD treatment.

Association between coffee intake and gastroesophageal reflux disease: a meta-analysis

Gastroesophageal reflux disease (GERD) is one of the most common diseases affecting patients worldwide, but its risk factors and causes are not clearly known. The aim of this study was to investigate the effect of coffee intake on GERD by a meta-analysis. We searched online published research databases such as PubMed, EMBASE, and Cochrane Library for studies that were published up to December 2012. These publications were reviewed by two independent authors, and studies that fulfilled the criteria were selected. Whenever there was a disagreement between the authors, a consensus was reached by discussion. Fifteen case-control studies were included in the final analysis. A meta-analysis showed that there was no significant association between coffee intake and GERD. The odds ratio was 1.06 (95% confidence interval, 0.94-1.19). In subgroup analyses in which the groups were subdivided based on the definition of GERD (diagnosed by endoscopy or by symptoms alone), only the endoscopy group showed a significantly higher odds ratio. In subgroup analyses in which the groups were subdivided based on the amount of coffee intake, quality of study, and assessment of exposure, there was no significant association between coffee intake and GERD.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease is one of the most common disorders of the gastrointestinal tract. Over past decades, considerable shifts in thinking about the disease have taken place. At a time when radiology was the only diagnostic test available, reflux disease was regarded as synonymous with hiatus hernia. After the advent of the flexible endoscope, reflux disease was, for a period, equated to oesophagitis. The introduction of oesophageal pH monitoring made us believe that reflux disease could be defined by an abnormally high proportion of time with oesophageal pH less than 4. Moreover, the successive arrival of histamine-2-receptor antagonists and proton-pump inhibitors changed our idea of treatment for the disease, with swings from and towards surgery, endoscopic techniques, and alternative pharmaceutical options.

Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications

Proton pump inhibitors (PPIs) remain the superior choice worldwide in antisecretory therapy in the evidence-based treatment of upper gastrointestinal disorders including gastroesophageal reflux disease, erosive esophagitis, dyspepsia and peptic ulcer disease. PPI overutilization in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. Nonjudicious use of PPIs creates both preventable financial as well as medical concerns. PPIs have been associated with an increased risk of vitamin and mineral deficiencies impacting vitamin B12, vitamin C, calcium, iron and magnesium metabolism. While these risks are considered to be relatively low in the general population, they may be notable in elderly and malnourished patients, as well as those on chronic hemodialysis and concomitant PPI therapy. No current evidence recommends routine screening or supplementation for these potential vitamin and mineral deficiencies in patients on either short- or long-term PPI therapy. Reducing inappropriate prescribing of PPIs can minimize the potential risk of vitamin and mineral deficiencies.

Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease

BACKGROUND

Approximately 25% of adults regularly experience heartburn, a symptom of gastro-oesophageal reflux disease (GORD). Most patients are treated empirically (without specific diagnostic evaluation e.g. endoscopy. Among patients who have an upper endoscopy, findings range from a normal appearance, mild erythema to severe oesophagitis with stricture formation. Patients without visible damage to the oesophagus have endoscopy negative reflux disease (ENRD). The pathogenesis of ENRD, and its response to treatment may differ from GORD with oesophagitis.

OBJECTIVES

Summarise, quantify and compare the efficacy of short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in adults with GORD, treated empirically and in those with endoscopy negative reflux disease (ENRD).

SEARCH METHODS

We searched MEDLINE (January 1966 to November 2011), EMBASE (January 1988 to November 2011), and EBMR in November 2011.

SELECTION CRITERIA

Randomised controlled trials reporting symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Participants had to be either from an empirical treatment group (no endoscopy used in treatment allocation) or from an endoscopy negative reflux disease group (no signs of erosive oesophagitis).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

Thirty-four trials (1314 participants) were included: fifteen in the empirical treatment group, fifteen in the ENRD group and four in both. In empirical treatment of GORD the risk ratio (RR) for heartburn remission (the primary efficacy variable) in placebo-controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32 to 0.44), for H2RAs 0.77 (two trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73 to 1.01). In a direct comparison PPIs were more effective than H2RAs (seven trials, RR 0.66, 95% CI 0.60 to 0.73) and prokinetics (two trials, RR 0.53, 95% CI 0.32 to 0.87).In treatment of ENRD, the RR for heartburn remission for PPI versus placebo was 0.71 (ten trials, 95% CI 0.65 to 0.78) and for H2RA versus placebo was 0.84 (two trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.78 (three trials, 95% CI 0.62 to 0.97) and for PPI versus prokinetic 0.72 (one trial, 95% CI 0.56 to 0.92).

AUTHORS' CONCLUSIONS

PPIs are more effective than H2RAs in relieving heartburn in patients with GORD who are treated empirically and in those with ENRD, although the magnitude of benefit is greater for those treated empirically.

Indications and safety of proton pump inhibitor drug use in patients with cancer

INTRODUCTION

Although the exact prevalence of proton pump inhibitor (PPI) use in cancer patients is not known, it is generally perceived to be widespread. PPIs are generally well tolerated and carry an excellent safety profile. However, increasing and longer term PPI use has raised concerns about the risk of pneumonia, bone fractures and enteric infections, and a possible interaction with clopidogrel that could increase the risk of cardiovascular events.

AREAS COVERED

We conducted a PubMed search of English language articles addressing the safety and adverse events associated with PPI use with particular emphasis in cancer patients.

EXPERT OPINION

PPIs, frequently used in cancer patients, are generally well tolerated and carry an excellent safety profile. PPI-induced acid suppression may increase the risk of Clostridium difficile or other enteric infections, nutritional deficiencies and community acquired pneumonia, all particularly important in cancer patients. The indications for PPI use in cancer patients should be carefully reviewed prior to use.

Causes of Dysphagia in a Tertiary-Care Swallowing Center

Objectives:

Dysphagia can be caused by a myriad of disease processes, and it has significant impacts on patients' quality of life, life expectancy, and economic burden. To date, the most common causes of dysphagia in outpatient tertiary-care swallowing centers are unknown. We undertook this study to determine these prevalences. We also describe the diagnostic techniques utilized to establish the diagnosis.

Methods:

The electronic charts of 100 consecutive patients who presented to an outpatient tertiary-care university swallowing center between January 2010 and April 2011 were retrospectively reviewed. Information regarding patient demographics, validated symptom surveys, diagnostic workups, and ultimate diagnoses was abstracted and tabulated into a central database. Descriptive statistics were used to evaluate the association between patient symptoms and diagnoses.

Results:

The mean age of the entire cohort was 62 ± 13.5 years, and 58% of the cohort was male. The most common identified causes of dysphagia were reflux (27%), postirradiation dysphagia (14%), and cricopharyngeus muscle dysfunction (11%). In 13% of cases, the cause of dysphagia was undetermined. The diagnostic tests utilized included flexible laryngoscopy (71%; 17% with endoscopic swallow evaluation), modified barium swallow study (45%), esophagoscopy (35%), barium esophagography (21%), manometry (10%), and ambulatory pH testing (2%).

Conclusions:

The most common causes of dysphagia in a tertiary-care swallowing center are reflux, postirradiation dysphagia, and cricopharyngeus muscle dysfunction. A precise cause for the symptom could not be identified in 13% of our cohort. Endoscopic visualization (laryngoscopy, flexible endoscopic evaluation of swallowing, and transnasal esophagoscopy) and fluoroscopic swallow studies were the investigations most often utilized. These techniques can be used to arrive at a diagnosis in 80% of cases.

Dietary lipids and functional gastrointestinal disorders

There is convincing evidence that patients with functional gastrointestinal disorders (FGIDs) exhibit dysfunctions of the gut involving hypersensitivity and abnormal reflexes, so that physiological, normally unperceived, stimuli induce symptoms. The type of symptoms depends on the specific sensory-reflex pathways and region(s) affected. Fat modulates the responses of the gut to various stimuli, and some of these modulatory mechanisms are abnormal in patients with FGIDs. Indeed, laboratory-based studies have shown that the symptoms experienced by these patients can be induced, or exacerbated, by administration of lipids in amounts that are well tolerated by healthy controls, and, thus, demonstrate a hypersensitivity to lipid. Very few studies have evaluated dietary patterns and eating behavior in these patients, with often-conflicting outcomes, and no studies have been performed to evaluate the role of targeted dietary interventions for the relief of symptoms. Given the evidence from laboratory studies, as well as patient experience, such studies, in large cohorts of patients, are needed with the view to develop personalized, cost-effective treatment approaches.

Comparison of health care resource utilization and costs among patients with GERD on once-daily or twice-daily proton pump inhibitor therapy

BACKGROUND

The purpose of this study was to assess differences in health care resource utilization and costs associated with once-daily and twice-daily proton pump inhibitor (PPI) therapy. Most patients with gastroesophageal reflux disease (GERD) achieve symptom control on once-daily PPI therapy, but approximately 20%-30% require twice-daily dosing.

METHODS

Patients were ≥18 years of age with at least one medical claim for GERD and at least two PPI claims from HealthCore's Integrated Research Database (HIRD(SM)) during 2004-2009. Patients were continuously eligible for 12 months before and after the index date (date of first PPI claim). Based on PPI dosing throughout the post-index period (quantity of medication dispensed/number of days supply), patients were classified as once-daily (dose ≤ 1.5 pills per day) or twice-daily (≥1.5) PPI users.

RESULTS

The study cohort included 248,386 patients with GERD (mean age 52.8 ± 13.93 years, 56% females) of whom 90% were once-daily and 10% were twice-daily PPI users. The Deyo-Charlson Comorbidity Index for once-daily and twice-daily PPI users was 0.70 ± 1.37 and 0.89 ± 1.54, respectively (P < 0.05). More once-daily patients had claims for Barrett's esophagus (5% versus 2%, P < 0.0001) than twice-daily patients. Post-index, higher proportions of twice-daily patients had at least one GERD-related inpatient visit (7% versus 5%), outpatient visit (60% versus 49%), and office visit (48% versus 38%) versus once-daily patients (P < 0.0001). Mean total GERD-related health care costs were $2065 ± $6636 versus $3749 ± $11,081 for once-daily and twice-daily PPI users, respectively (P < 0.0001).

CONCLUSION

Patients receiving twice-daily PPI therapy were likely to have more comorbid conditions and greater health care utilization and overall costs compared with patients using once-daily PPI therapy.

Batteryless implantable dual-sensor capsule for esophageal reflux monitoring

BACKGROUND

Chronic GERD affects approximately 15% of adults in the United States and is one of the most prevalent clinical conditions involving the GI tract. The commercial tools for monitoring GERD include multichannel intraluminal impedance (MII) probes and pH-sensing capsules. However, MII probes cause discomfort, which alters patients' regular activities, whereas the pH-sensing capsule lacks the ability to detect weak or nonacid episodes, misses reflux episodes with similar pH values, and has a limited sampling rate and battery life.

OBJECTIVE

To develop and test an implantable batteryless dual-sensor capsule that can be used to diagnose and monitor GERD.

DESIGN

The implanted capsule is wirelessly powered by an external device. Simulated reflux episodes were created in 3 live porcine models. Impedance and pH data were continuously measured and recorded.

INTERVENTION

The implant capsule was placed in the esophagus along with a commercial pH-sensing capsule for comparison.

MAIN OUTCOME MEASUREMENTS

Precise impedance and pH readouts were obtained and compared with those from a commercial pH-sensing capsule.

RESULTS

The wireless energy supplied by the external unit was strong enough to power the implant. The pH sensor accurately measured pH levels and the impedance sensor precisely located the reflux episodes.

LIMITATION

Simulated reflux events in a pig model.

CONCLUSION

Our wireless sensors are reliable in operation and provide accurate assessment of simulated reflux episodes. The entire device can potentially be used to diagnose and monitor GERD.

[Updated guidelines 2012 for gastroesophageal reflux disease]

In 2010, a Korean guideline for the management of gastroesophageal reflux disease (GERD) was made by the Korean Society of Neurogastroenterology and Motility, in which the definition and diagnosis of GERD were not included. The aim of this guideline was to update the clinical approach to the diagnosis and management of GERD in adult patients. This guideline was developed by the adaptation process of the ADAPTE framework. Twelve guidelines were retrieved from initial queries through the Appraisal of Guidelines for Research & Evaluation II process. Twenty-seven statements were made as a draft and revised by modified Delphi method. Finally, 24 consensus statements for the definition (n=4), diagnosis (n=7) and management (n=13) of GERD were developed. Multidisciplinary experts participated in the development of the guideline, and the external review of the guideline was conducted at the finalization phase.

The effect of a proton pump inhibitor on bone metabolism in ovariectomized rats

Recent studies revealed that long-term intake of proton pump inhibitor (PPI) increases the risk of vertebral or hip fracture; however, the exact mechanism for this is not known. To evaluate the effect of long-term PPI therapy on bone turnover, we analyzed the signaling pathway involved in osteoclast differentiation and bone resorption/formation markers using ovariectomized rats. Six-week-old Sprague-Dawley (S-D) rats were ovariectomized, and two weeks later they were divided into four groups (group A, normal diet + placebo; group B, low calcium diet + placebo; group C, normal diet + PPI; and group D, low calcium diet + PPI). Omeprazole, at a concentration of 30 mg/kg, was administered orally for eight weeks and the rats were sacrificed when they were 16 weeks old. The relative expression levels of the receptor activator of NF-κB ligand (RANKL)/osteoprotegerin (OPG) ratio, c-Fos, nuclear factor of activated T cells c1 (NFATc1) and osteocalcin in femoral bone marrow cells were compared, and serum C-terminal cross-linking telopeptide of type I (CTX-1) levels were determined. The relative ratio of RANKL/OPG was increased in group D, and gene expression levels of c-Fos and NFATc1 were upregulated in groups B and D, which are involved in differentiation and activation of osteoclasts. Furthermore, expression levels of osteocalcin, a bone formation marker, were decreased and levels of serum CTX-1, a bone resorption marker, were increased in group D. Taken together, a low calcium diet and PPI administration are thought to collaborate in order to alter osteoclast activity and bone resorption signaling.

Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial

OBJECTIVE

Weight gain is an important risk factor for gastroesophageal reflux disease (GERD); however, whether weight loss can lead to resolution of GERD symptoms is not clear. Our aim was to measure the impact of weight loss on GERD symptoms.

DESIGN AND METHODS

In a prospective cohort study at a tertiary referral center, overweight/obese subjects (BMI 25-39.9 kg/m2) were enrolled in a structured weight loss program. Weight loss strategies included dietary modifications, increased physical activity and behavioral changes. At baseline and at 6 months, BMI and waist circumference were measured and all participants completed a validated reflux disease questionnaire.

RESULTS

A total of 332 adult subjects, mean age 46 years and 66% women were prospectively enrolled. At baseline, the mean body weight, BMI, and waist circumference were 101 (±18) kg, 35 (±5) kg/m2 and 103 (±13) cm. At 6 months, majority of the subjects (97%) lost weight (average weight loss: 13 ± 7.7 kg) and as compared with baseline, there was a significant decrease in the overall prevalence of GERD (15 vs. 37%; P < 0.01) and the mean GERD symptom score (1.8 vs. 5.5; P < 0.01). Overall, 81% of the subjects had reduction in GERD symptom scores; 65% had complete resolution and 15% had partial resolution of reflux symptoms. There was a significant correlation between % body weight loss and reduction in GERD symptom scores (r = 0.17, P < 0.05).

CONCLUSIONS

In conclusion, the overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects. A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of these subjects.

Symptoms of gastroesophageal reflux disease improve after parathyroidectomy

BACKGROUND

Primary hyperparathyroidism can be associated with symptoms related to GERD, but it is unclear which symptoms of GERD improve after parathyroidectomy. Our goal was to assess prospectively for changes in specific GERD symptoms after parathyroidectomy using a validated questionnaire.

METHODS

Using the GERD health-related quality of life (GERD-HRQL) questionnaire, symptoms of heartburn were prospectively assessed before and 6 months after treatment of hyperparathyroidism with parathyroidectomy. This validated questionnaire includes 10 items, with a Likert scale of 0-5. Scores range from 0 to 45, a lesser score indicates fewer/less severe symptoms.

RESULTS

Pre- and postoperative surveys were available for 51 patients. Parathyroidectomy improved the overall questionnaire score (12.5 ± 1.3 vs 4.5 ± 0.9, P < .0001). Overall scores for each question improved after parathyroidectomy, including symptoms of dysphagia (P = .001) and overall satisfaction with symptoms (P < .0001). However, the number of patients taking antireflux medication before and after parathyroidectomy was not substantially different (34 vs 28 patients, P = .17).

CONCLUSION

All symptoms of GERD improved after parathyroidectomy for hyperparathyroidism. Despite the decrease in symptoms, there was not a change in the number of patients who remained on anti-reflux therapy. For patients with symptoms of GERD, a trial off antireflux medications after parathyroidectomy should be considered.

Chronic proton pump inihibitor therapy and calcium metabolism

Proton pump inhibitors (PPIs) have been widely used since their introduction in the late 1980s because they are highly effective for acid-related conditions. However, some recent epidemiological studies have suggested a positive association between PPI therapy and the risk of osteoporotic fractures. The potential mechanisms underlying this association may be related to the physiologic effects of chronic acid suppression on calcium metabolism. First, chronic hypergastrinemia induced by PPI therapy may lead to parathyroid hyperplasia, resulting in increased loss of calcium from the bone. Second, profound gastric acid suppression may reduce the bioavailability of calcium for intestinal absorption. I will review the published evidence regarding these potential links and discuss their clinical implications.

Quality improvement in gastroenterology clinical practice

An emphasis on quality improvement (QI) is vital to the cost-effective provision of evidence-based health care. QI projects in gastroenterology have typically focused on endoscopy to minimize or eliminate procedure-related complications or errors. However, a significant component of gastroenterology care is based on the management of chronic disease. Patients with chronic diseases are seen in many different outpatient practices in the community and academia. In an attempt to ensure that every patient receives high-quality care, major gastrointestinal societies have published guidelines on the management of common gastrointestinal complaints. However, adherence to these guidelines varies. We discuss common outpatient gastrointestinal illnesses with established guidelines for management that could benefit from active QI projects; these would ensure a consistently high standard of care for every patient.

GERD in elderly patients: surgical treatment with Nissen-Rossetti laparoscopic technique, outcome

Background

The gastro-esophageal reflux disease (GERD) is one of the most frequent disease of the upper gastro-entheric tract. Surgical treatment is reserved to selected patients, affected by severe forms of disease and/or without compliance to medical therapy.

In 95%-60% of the patients submitted to surgical antireflux intervention, a notable improvement of the quality of life is observed.

Functional evaluations performed on pre and post – surgical pHmetric and manometric examination have provided new acquisitions about improvements in the restoration of anatomical and functional integrity of the esophagus-gastric antireflux barrier.

Methods

45 elderly patients with GERD were recruited in a 27 months period. All patients were subjected to laparoscopic Nissen-Rossetti 360° fundoplication. The subjects had a pre-surgical evaluation with:

• 24 hours pHmetry,

• esophageal manometry,

The same evaluation was repeated 1 month and 6 months after surgical intervention.

Results

In our series all patients get benefit from surgical treatment, with an improvement of pHmetric and manometric parameters and a regression of complications of GERD such as Barrett's metaplasia. In 8.33% of patients a PPI therapy was necessary, after the surgical intervention, to control symptoms.

Conclusions

The role of surgery in GERD concerns selected patients. Nissen-Rossetti mini-invasive approach is performed with an acceptable percentage of complications (3%-10%). This technique is associated with a good control of GERD symptoms in a short and middle term and with an improvement of functional parameters, such as pHmetric and manometric.

[The Mexican consensus on gastroesophageal reflux disease. Part I]

BACKGROUND

The changes, advances, and new discoveries regarding different aspects of gastroesophageal reflux disease (GERD) have made it necessary to update the Mexican Consensus published in 2002.

AIMS

To elaborate a new Mexican Consensus on GERD.

METHODS

The general project coordinators selected six GERD experts to carry out an extensive review of the literature for the purpose of elaborating statements on the principal aspects of GERD. These were then placed under the consideration of specialists in the study of this disease. Definitive approval by all participants was reached using the modified Delphi method with three rounds of anonymous and iterative voting. The following scale was employed: A- in complete agreement; B- in agreement, but with minor concerns; C- in agreement, but with major concerns; D- in disagreement, but with major concerns; E- in disagreement, but with minor concerns; or F- in complete disagreement. Consensus was declared when 67.00% or more of the participants concurred on a category of agreement (A, B, or C).

RESULTS

A consensus was reached on 160 of the statements upon completion of the voting rounds, with 90.00% concurrence for the majority of them.

CONCLUSIONS

The 2011 Mexican Consensus on Gastroesophageal Disease is a practical and up-to-date consultation tool, providing the opinion of Mexican experts on all the new information available about this disease. It allows there to be homogeneity in diagnostic and therapeutic criteria, all of which serves to benefit our patients.

Esophageal motility, vagal function and gastroesophageal reflux in a cohort of adult asthmatics

BACKGROUND

Asthmatics are known to have esophageal hypomotility. Vagal hypofunction and prolonged intra-esophageal acidification cause esophageal hypomotility. The contribution of gastroesophageal reflux (GER) and vagal function to esophageal motility in asthmatics is unclear. We studied the relationship between esophageal motility, GER and vagal function in a cohort of adult asthmatics.

METHODS

Thirty mild, stable asthmatics (ATS criteria) and 30 healthy volunteers underwent 24-hour ambulatory esophageal monitoring, manometry, autonomic function testing and GER symptom assessment. 27 asthmatics underwent gastroscopy. A vagal function score calculated from 3 tests (valsalva maneuver, heart rate response to deep breathing and to standing from supine position) was correlated with esophageal function parameters.

RESULTS

Asthmatics (mean age 34.8 (SD 8.4), 60% female) had more frequent GERD symptoms than controls (mean age 30.9 (SD 7.7), 50% female). 10/27 asthmatics had esophageal mucosal damage, 22 showed hypervagal response, none had a hyperadrenergic response. 14 asthmatics had ineffective esophageal motility. Higher GERD-score asthmatics had significantly fewer peristaltic and more simultaneous contractions than controls, and higher esophageal acid contact times than those with lower scores. All reflux parameters were significantly higher and acid clearance time prolonged in asthmatics than controls (p < 0.001, Mann-Whitney U test). There was no correlation between vagal function score and esophageal function parameters.

CONCLUSIONS

A cohort of adult asthmatics was found to have peristaltic dysfunction and pathological GER, but otherwise normal esophageal motility. The peristaltic dysfunction seems to be associated with vagal hyperreactivity rather than vagal hypofunction.

Use of direct, endoscopic-guided measurements of mucosal impedance in diagnosis of gastroesophageal reflux disease

BACKGROUND & AIMS

Diagnostic tests for gastroesophageal reflux disease (GERD) are constrained because measurements are made at a single time point, so the long-term effects on the mucosa cannot be determined. We developed a minimally invasive system to assess changes in esophageal mucosal impedance (MI), a marker of reflux. We measured the extent of changes in MI along the esophagus and show that the device to assess MI can be used to diagnose patients with GERD.

METHODS

A single-channel MI catheter composed of a unique sensor array was designed to easily traverse the working channel of an upper endoscope. We performed a prospective longitudinal study of patients with erosive esophagitis (n = 19), nonerosive but pH-positive GERD (n = 23), and those without GERD (n = 27). MI was measured at the site of esophagitis as well as 2, 5, and 10 cm above the squamocolumnar junction. The MI values were compared among groups, at different levels along the esophageal axis.

RESULTS

Median MI values were significantly lower at the site of erosive mucosa (811 Ω; range, 621-1272 Ω) than other nonerosive regions (3723 Ω; range, 2421-4671 Ω; P = .001), and were significantly lower at 2 cm above the squamocolumnar junction in patients with GERD (2096 Ω; range, 1415-2808 Ω), compared with those without GERD (3607 Ω; range, 1973-4238 Ω; P = .008). There was a significant and graded increase in MI along the axis of the distal to proximal esophagus in patients with GERD that was not observed in individuals without reflux (P = .004).

CONCLUSIONS

Measurements of MI along the esophagus can be used to identify patients with GERD. ClinicalTrials.gov, number NCT01194323.

A prospective multicenter registry of patients with chronic gastroesophageal reflux disease receiving transoral incisionless fundoplication

BACKGROUND

This study was undertaken to validate previously reported safety and symptomatic outcomes of transoral incisionless fundoplication (TIF), evaluate the relative benefit of TIF within different gastroesophageal reflux disease (GERD) subgroups, and to determine predictors of success in community settings.

STUDY DESIGN

Between January 2010 and February 2011, 100 consecutive patients who underwent TIF procedures at 10 centers were enrolled in this prospective, open-label, multicenter, single-arm study. Symptom improvement and objective outcomes of TIF were analyzed at 6-month follow-up.

RESULTS

One hundred TIF procedures were performed. No complications were reported. Median GERD symptom duration was 9 years (range 1 to 35 years) and median duration of proton pump inhibitor (PPI) use was 7 years (1 to 20 years). Maximal medical therapy resulted in incomplete symptom control for 92% of patients; GERD Health-Related Quality of Life (GERD-HRQL) total score was normalized in 73%. Median heartburn and regurgitation scores improved significantly, from 18 (range 0 to 30) and 15 (range 0 to 30) on PPIs before TIF to 3 (range 0 to 25) and 0 (range 0 to 25), respectively; p < 0.001. Median Reflux Symptom Index scores were reduced after TIF from 24 (range 14 to 41) to 7 (range 0 to 44); p < 0.001. Eighty percent of patients were completely off PPIs after TIF vs 92% of patients on PPIs before TIF. Preoperative factors associated with clinical outcomes were less severe heartburn (total GERD-HRQL ≤ 30, p = 0.02) and the presence of esophagitis (p < 0.02).

CONCLUSIONS

Transoral incisionless fundoplication is safe and effective in multiple community-based settings in the treatment of medically refractory GERD, as demonstrated by an absence of complications, excellent symptom relief, and complete cessation of PPIs at 6-month follow-up.

Temporal trends in the relative prevalence of dysphagia etiologies from 1999-2009

AIM: To examine the relative prevalence and temporal variation of dysphagia etiologies in patients undergoing upper endoscopy (EGD) over the past decade.

METHODS: EGDs with the indication of dysphagia at an urban, university medical center in 1999, 2004 and 2009 were retrospectively identified from the electronic medical record. The entire patient chart, including EGD, pathology, manometry, radiographic and clinician reports, was reviewed for demographic and clinical data and to determine the etiology of dysphagia. The number of EGDs in which an esophageal biopsy was performed was also noted. Gastroesophageal reflux disease (GERD) as a cause of dysphagia independent of peptic stricture was defined by symptoms with erosive esophagitis or symptom response to proton pump inhibition (PPI). Cases of eosinophilic esophagitis (EoE) were defined by an appropriate clinical history and histological criteria of ≥ 15 eosinophils per high powered field. PPI-responsive esophageal eosinophilia was not routinely reported prior to 2008. Statistical analysis was performed using one-way analysis of variance to analyze for trends between 1999, 2004 and 2009 and a post-hoc Tukey analysis was performed following a significant main effect.

RESULTS: A total of 1371 cases (mean age 54 years, 43% male) met pre-specified inclusion criteria with 191, 504 and 675 cases in 1999, 2004 and 2009, respectively. Patients were older in 2004 compared to 2009 (mean ± SD, 54.0 ± 15.7 years vs 52.3 ± 16.8 years, P = 0.02) and there were more males in 1999 compared to 2004 (57.5% vs 40.8%, P = 0.005). Overall, GERD (27.6%) and EoE (7.7%) were the most common identifiable causes of dysphagia. An unspecified diagnosis accounted for 21% of overall cases. There were no significant differences in the relative prevalence of achalasia or other motility disorders, peptic stricture, Schatzki’s ring, esophageal cancer or unspecified diagnoses over the 10-year time period. There was, however, a decrease in the relative prevalence of GERD (39.3% vs 24.1%, P < 0.001) and increases in the relative prevalence of EoE (1.6% vs 11.2%, P < 0.001) and oropharyngeal disorders (1.6% vs 4.2%, P = 0.02) from 1999 to 2009. Post-hoc analyses determined that the increase in relative prevalence of EoE was significant between 1999 and 2009 as well as 2004 and 2009 (5.4% vs 11.6%, P < 0.001), but not between 1999 and 2004 (1.6% P 5.4%, P = 0.21). On the other hand, the decrease in relative prevalence of GERD was significant between 1999 and 2009 and 1999 and 2004 (39.3% vs 27.7%, P = 0.006), but not between 2004 and 2009 (27.7% vs 24.1%, P = 0.36). There were also significantly more EGDs in which a biopsy was obtained in 1999 compared to 2009 (36.7% vs 68.7%, P < 0.001) as well as between 2004 and 2009 (37.5% vs 68.7%, P < 0.001). While total EGD volume did increase over the 10-year time period, the percentage of EGDs for the indication of dysphagia remained stable making increasing upper endoscopy an unlikely reason for the observed increased prevalence of EoE.

CONCLUSION: EoE has emerged as a dominant cause of dysphagia in adults. Whether this was due to a rise in disease incidence or increased recognition is unclear.

Associated demographics of persistent exhaled nitric oxide elevation in treated asthmatics

BACKGROUND

The fraction of exhaled nitric oxide (FENO) is reduced by anti-inflammatory treatment in asthma. However, the FENO level is also regulated by individual demographics and there is considerable variation among clinically stable patients.

OBJECTIVE

We hypothesized that some demographics may be responsible for persistent FENO elevation despite inhaled corticosteroids (ICS) therapy in asthma.

METHODS

This was a prospective observational study. We initially screened 250 stable asthmatics and determined the FENO cut-off point for identifying poorly controlled asthma defined by one of the following criteria: Asthma control test <20, or forced expiratory volume in one-second % of predicted <80%, or peak expiratory flow variability <80% (Study 1). After 12-weeks, 229 patients who maintained high or low FENO were selected and the independent factors which might contribute to a high FENO were examined (Study 2).

RESULTS

A FENO level >39.5 p.p.b. yielded 67% sensitivity and 76% specificity for identifying the patients with poorly controlled asthma. The persistent high FENO group (≥ 40 p.p.b.) was more likely to be ex-smokers, to show evidence of atopy (positive specific IgE, higher serum IgE and blood eosinophils), and to have allergic comorbidities. Especially, past smoking history, blood eosinophils, and chronic rhinosinusitis were identified to be independent predictors of high FENO. Neither the dose of ICS nor other medication use showed any difference between the groups.

CONCLUSIONS AND CLINICAL RELEVANCE

These results suggested that past smoking history, blood eosinophilia, and chronic rhinosinusitis are involved in the persistent airway inflammation detected by FENO. Although their relative contributions on FENO values should be further quantified, clarification of the features of the subjects with high FENO might provide clues for adjustment of the treatment approach in asthma.

Nonlinear relationship between body mass index and esophageal acid exposure in the extraesophageal manifestations of reflux

BACKGROUND & AIMS

Obesity is believed to be an important etiologic factor in gastroesophageal reflux disease. However, it is not clear how obesity might affect esophageal acid exposure in patients with extraesophageal manifestations of reflux.

METHODS

We conducted a cross-sectional study of 223 patients with extraesophageal symptoms suspected of being related to reflux. Participants underwent endoscopy and 48-hour wireless pH testing. The percentage of time at a pH of less than 4 (total, upright, and supine) was measured for each patient, and data were compared with corresponding body mass index (BMI), as continuous and categoric variables (normal, 18.5 to <25; overweight, 25 to <30; and obese, >30). Multivariable linear regression was used to identify variables associated with percentage of total time at a pH less than 4. The primary predictor of interest was BMI; age, sex, esophagitis, and hiatal hernia status were considered potential confounders or precision variables.

RESULTS

Esophageal acid exposure was associated significantly (P < .001) with BMI. The percentage of time at a pH less than 4 and total symptomatic reflux events increased significantly (P = .005) with increasing BMI. The relationship between percentage of time at a pH less than 4 and BMI was nonlinear and S-shaped. With BMI ranges, the percentage of time at a pH less than 4 increased by 0.23% (normal BMI), 0.75% (overweight), and 0.07% (obese) for every 1-kg/m(2) increase in BMI (P < .001).

CONCLUSIONS

Increases in esophageal acid exposure are greatest among overweight patients and plateau in obese patients. The findings have implications for benefit of weight loss in patients with suspected extraesophageal manifestations of gastroesophageal reflux disease.

Use of the Montreal global definition as an assessment of quality of life in reflux disease

According to the Montreal Consensus Group's classification, gastroesophageal reflux disease develops when the reflux of stomach contents causes troublesome symptoms and/or complications such as esophagitis. The characteristic gastroesophageal reflux disease symptoms included in this statement are retrosternal burning and regurgitation. Troublesome is meant to imply that these symptoms impact on the well-being of affected individuals; in essence, quality of life (QOL). Whether heartburn and regurgitation symptoms would be characterized as more troublesome in those with confirmed pathologic acid reflux was determined. A second purpose was to assess how well troublesome scores correlated with the results of a validated, disease-specific QOL instrument. Subjects who underwent esophagogastroduodenoscopy (EGD) with 48-hour wireless esophageal pH testing off proton pump inhibitor therapy were interviewed. Esophagitis on EGD or pH < 4.0 for ≥4.5% of time over the 2-day period was considered positive for acid reflux. Assessment of how troublesome their symptoms of heartburn and regurgitation were made using separate 0-100 visual analog scales (VAS). Subjects were then asked to complete the Quality of Life in Reflux and Dyspepsia (QOLRAD) 25-item questionnaire. Sixty-seven patients (21 males, 46 females) with mean age 47.8 ± 15.6 years were identified. Forty (59.7%) had an EGD or pH study positive for acid reflux. Overall 35/40 (87.5%) complained of either heartburn or regurgitation. There was no difference (P= 0.80) in heartburn VAS troublesome ratings for those with (54.0 ± 43.9) and without (56.7 ± 37.6) confirmed acid reflux. The same was true for regurgitation VAS troublesome ratings (P= 0.62). Likewise, mean QOLRAD scores did not differ between those with and without confirmed acid reflux by pH or EGD (4.5 ± 1.7 vs. 4.3 ± 1.7; P= 0.61). There was a moderately strong inverse correlation between patient self-rated VAS troublesome scores for both heartburn and regurgitation with each dimension (emotional distress, sleep disturbance, eating problems, physical/social functioning, and vitality) of the QOLRAD (P < 0.05 for all comparisons). In regression analysis, both heartburn and regurgitation troublesome ratings were associated with the overall QOLRAD score independent of pH data, frequency of reflux episodes, age, and gender. Use of the term troublesome in the Montreal Consensus Group classification is supported by our findings. It correlates well with the results of a validated disease-specific QOL instrument. Use of heartburn and regurgitation VAS may serve as accurate measures of the burden of reflux disease on patients. It is likely that these scales will not have sufficient discriminate value to identify individuals with pathologic acid reflux from those with negative studies.

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.

Phase I, multicenter, randomized, open-label study evaluating the pharmacokinetics and safety profile of repeated once-daily doses of intravenous esomeprazole in children 0 to 17 years of age

BACKGROUND

Several oral proton pump inhibitors (PPIs) are currently approved for use in pediatric patients in North America and Europe. However, when use of oral therapy is not possible or appropriate, intravenous formulations of PPIs may be helpful. Intravenous esomeprazole is approved in the United States for the short-term treatment of gastroesophageal reflux disease (GERD) with erosive esophagitis in adults and in pediatric patients 1 month to 17 years of age (inclusive) as an alternative to oral therapy. Four open-label, randomized, 2-way crossover studies in adults with GERD found no clinically relevant differences in acid suppression between repeated doses of oral and intravenous esomeprazole. However, the pharmacokinetics of intravenous esomeprazole has not been studied extensively in children.

OBJECTIVE

The aim of this study was to evaluate steady-state pharmacokinetics and tolerability of repeated doses of intravenous esomeprazole in children.

METHODS

In this multicenter, open-label study, hospitalized patients (0-17 years of age) considered for acid suppression therapy received once-daily intravenous esomeprazole sodium for injection at 0.5 mg/kg (0-1 month of age), 1.0 mg/kg (1-11 months of age), 10 mg (1-5 years of age), 10 or 20 mg (6-11 years of age), or 20 or 40 mg (12-17 years of age) for 4 days. Children 6 to 11 years of age (inclusive) were randomized in a 1:1 ratio to receive esomeprazole 10 or 20 mg, and adolescents 12 to 17 years of age (inclusive) were randomized in a 1:1 ratio to receive esomeprazole 20 or 40 mg. Blood samples were drawn pre- and post-dose. Plasma esomeprazole was measured using reversed-phase liquid chromatography and mass spectrometry. Pharmacokinetic variables were derived using mixed-effects modeling. Adverse events (AEs) were assessed.

RESULTS

Fifty-nine patients were randomized and 57 received the study drug. A majority of patients were white (44 white, 5 black/African American, 3 Asian, 5 other) and male (35/57). Fifty patients were eligible for pharmacokinetic analysis, including 6 to 8 patients in each age group. Esomeprazole pharmacokinetics was dose proportional and related to weight and age. Clearance increased with increasing weight and age. The mean AUC(τ) ranged from 6.9 μmol · h/L (10 mg, 6-11 years) to 17.6 μmol · h/L (40 mg, 12-17 years). The mean C(ss,max) ranged from 3.7 μmol/L (0.5 mg/kg, 0-1 month) to 10.5 μmol/L (40 mg, 12-17 years). Thirty-one patients experienced 1 or more AEs; 6 patients experienced 1 or more treatment-unrelated serious AEs.

CONCLUSIONS

Intravenous esomeprazole at doses resulting in targeted AUC(τ) and C(ss,max) similar to therapeutic exposure in adults appeared to be reasonably well tolerated in this small, select pediatric population. ClinicalTrials.gov identifier: NCT00474019.

Current trends in the management of gastroesophageal reflux disease: a review

Gastroesophageal reflux disease (GERD) is a chronic disorder of the upper gastrointestinal tract with global distribution. The incidence is on the increase in different parts of the world. In the last 30 to 40 years, research findings have given rise to a more robust understanding of its pathophysiology, clinical presentation, and management. The current definition of GERD (The Montreal definition, 2006) is not only symptom-based and patient-driven, but also encompasses esophageal and extraesophageal manifestations of the disease. The implication is that the disease can be confidently diagnosed based on symptoms alone. Nonerosive reflux disease (NERD) remains the predominant form of GERD. Current thinking is that NERD and erosive reflux disease (ERD) are distinct phenotypes of GERD rather than the old concept which regarded them as components of a disease spectrum. Non erosive reflux disease is a very heterogeneous group with significant overlap with other functional gastrointestinal disorders. There is no gold standard for the diagnosis of GERD. Esophageal pH monitoring and intraluminal impedance monitoring have thrown some light on the heterogeneity of NERD. A substantial proportion of GERD patients continue to have symptoms despite optimal PPI therapy, and this has necessitated research into the development of new drugs. Several safety concerns have been raised about chronic use of proton pump inhibitors but these are yet to be substantiated in controlled studies. The debate about efficacy of long-term medical treatment compared to surgery continues, however, recent data indicate that modern surgical techniques and long-term PPI therapy have comparable efficacy. These and other issues are subjects of further research.

Overutilization of proton-pump inhibitors: what the clinician needs to know

Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders, including gastroesophageal reflux disease, dyspepsia, and peptic ulcer disease. The effectiveness of PPIs has led to overutilization in multiple treatment arenas, exposing patients to an increasing number of potential risks. The overutilization of PPIs in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. PPI overutilization in the inpatient setting is often a result of inappropriate stress ulcer prophylaxis (SUP) in nonintensive care unit patients, and failure to discontinue SUP prior to hospital discharge. Potential consequences of prolonged PPI therapy include hypergastrinemia, enterochromaffin-like cell hyperplasia, and parietal cell hypertrophy, leading to rebound acid hypersecretion. PPIs have been linked via retrospective studies to increased risk of enteric infections including Clostridium difficile-associated diarrhea, community-acquired pneumonia, bone fracture, nutritional deficiencies, and interference with metabolism of antiplatelet agents. Reducing inappropriate prescribing of PPIs in the inpatient and outpatient settings can minimize potential for adverse events, and foster controllable cost expenditure.

Proton pump inhibitors: are they overutilised in clinical practice and do they pose significant risk?

Proton pump inhibitors are highly effective acid suppressants with decades of use highlighting positive outcomes in millions of patients worldwide, and they offer minimal risk of adverse events. PPIs are considered overutilised when prescribed without an appropriate indication, when patients are left on them 'indefinitely' without appropriate indications and when they are continued after being utilised for most cases of hospital SUP. While several adverse outcomes have been linked to PPI therapy, most data are from retrospective observational studies that may be subject to confounding and bias.

A cross-sectional study on the risk factors for erosive esophagitis in young adults

OBJECTIVE

To investigate the impact of metabolic and lifestyle factors on erosive esophagitis in young adults.

METHODS

A total of 5,069 people under the age of 40 years old were enrolled in a medical survey at our institute. People with a previous history of upper gastrointestinal tract surgery were excluded, as were individuals taking medication for reflux symptoms, peptic ulcers, or malignancies. Independent and significant predictors affecting the presence of erosive esophagitis were determined by multivariate analysis.

RESULTS

A total of 4,990 participants (male/female; 3,871/1,119, age; 33.9±3.9 years) were eligible. A total of 728 participants (14.6%) had erosive esophagitis. Male gender and increasing age were independent predictors for increased prevalence of erosive esophagitis (odds ratio=2.242 and 1.045. 95% confidence interval=1.613-3.117 and 1.019-1.072; p<0.001 and 0.001, respectively). Moderate-to-heavy alcohol consumption, light-to-moderate-to-heavy smoking, hypertension, hyperglycemia, and hiatal hernia each significantly and independently increased the risk for erosive esophagitis (odds ratio=1.499, 1.398, 1.353, 1.570, 1.884, 1.297, 1.562, and 3.213. 95% confidence interval=1.181-1.903, 1.040-1.880, 1.094-1.675, 1.250-1.971, 1.307-2.716, 1.074-1.566, 1.063-2.295, and 2.712-3.807; p=0.001, 0.027, 0.005, <0.001, 0.001, <0.001, 0.007, 0.023, and <0.001 respectively). Helicobacter pylori infection decreased the risk for erosive esophagitis (odds ratio=0.575, 95% confidence interval =0.436-0.759 p<0.001). Neither body mass index nor waist girth conferred increased risk of erosive esophagitis after adjusting for potential confounding factors.

CONCLUSION

Risk of erosive esophagitis in Japanese young adults was not increased by obesity, but it was increased by hiatal hernia and metabolic and lifestyle profiles including hypertension, hyperglycemia, alcohol consumption and smoking.

Evaluation of dilation of intercellular spaces of squamous epithelium in the lower esophagus in the diagnosis of non-erosive reflux disease

AIM: To evaluate the diagnostic value of dilation of intercellular spaces (DIS) of squamous epithelium in the lower esophagus for non-erosive reflux disease (NERD).

METHODS: Sixty-six NERD patients and thirty-eight healthy volunteers were enrolled. All participants underwent evaluation using the gastroesophageal reflux disease questionnaire (GerdQ), 24 h esophageal pH monitoring, gastroscopy, and biopsy of mucosa in the lower esophagus at the Z-line and 2 cm above the Z-line for measurement of diameter of intercellular spaces by transmission electron microscopy (TEM). NERD patients with negative pH monitoring results underwent proton pump inhibitor test to confirm the diagnosis.

RESULTS: The mean diameter of intercellular spaces of squamous epithelium at the Z-line and 2 cm above the Z-line were (0.90 ± 0.11) μm and (0.92 ± 0.16) μm in the NERD group, and were (0.65 ± 0.08) μm and (0.67 ± 0.08) μm in the control group, without significant differences within the groups (both P > 0.05), but with significant differences between the two groups (both P < 0.05). No significant differences in the mean diameter of intercellular spaces of squamous epithelium at the Z-line and 2 cm above the Z-line in NERD patients were observed between pH(+) and pH(-) groups and between GerdQ(+) and GerdQ(-) groups. Positive correlations were found between the DeMeester scores and mean intercellular space diameters either at the Z-line (r = 0.33, P = 0.001) or 2 cm above the Z-line (r = 0.35, P = 0.001), and between the GerdQ scores and mean intercellular space diameters either at the Z-line (r = 0.32, P = 0.006) or 2 cm above the Z-line (r = 0.45, P < 0.001). The best cut-off values for mean intercellular space diameter were both 0.81 μm at the Z-line and 2 cm above the Z-line, with a highest Youden index of 0.808 at the Z-line (sensitivity 80.8%, specificity 100%) and 0.731 2 cm above the Z-line (sensitivity 78.8%, specificity 97.4%).

CONCLUSION: The diameter of intercellular spaces of squamous epithelium in the lower esophagus of patients with NERD is significantly increased and correlates with acid reflux and reflux symptoms. Dilated intercellular space can serve as a sensitive and objective histopathological indicator for the diagnosis of NERD.

Lifestyle factors affecting gastroesophageal reflux disease symptoms: a cross-sectional study of healthy 19864 adults using FSSG scores

BACKGROUND

Gastroesophageal reflux disease (GERD) is a very common disorder worldwide, comprised of reflux esophagitis (RE) and non-erosive reflux disease (NERD). As more than half of GERD patients are classified into the NERD group, precise evaluation of bothersome epigastric symptoms is essential. Nevertheless, compared with many reports targeting endoscopic reflux esophagitis, large-scale studies focusing on GERD symptoms have been very scarce.

METHODS

To elucidate lifestyle factors affecting GERD symptoms, 19,864 healthy adults in Japan were analyzed. Sub-analyses of 371 proton pump inhibitor (PPI) users and 539 histamine H₂-receptor antagonist (H₂RA) users were also performed. Using the FSSG (Frequency Scale for the Symptoms of GERD) score as a response variable, 25 lifestyle-related factors were univariately evaluated by Student's t-test or Pearson's correlation coefficient, and were further analyzed with multiple linear regression modelling.

RESULTS

Average FSSG scores were 4.8 ± 5.2 for total subjects, 9.0 ± 7.3 for PPI users, and 8.2 ± 6.6 for H₂RA users. Among the total population, positively correlated factors and standardized coefficients (β) for FSSG scores are inadequate sleep (β = 0.158), digestive drug users (β = 0.0972 for PPI, β = 0.0903 for H₂RA, and β = 0.104 for others), increased body weight in adulthood (β = 0.081), dinner just before bedtime (β = 0.061), the habit of midnight snack (β = 0.055), lower body mass index (β = 0.054), NSAID users (β = 0.051), female gender (β = 0.048), lack of breakfast (β = 0.045), lack of physical exercise (β = 0.035), younger age (β = 0.033), antihyperglycemic agents non-users (β = 0.026), the habit of quick eating (β = 0.025), alcohol drinking (β = 0.025), history of gastrectomy (β = 0.024), history of cardiovascular disease (β = 0.020), and smoking (β = 0.018). Positively correlated factors for PPI users are female gender (β = 0.198), inadequate sleep (β = 0.150), lack of breakfast (β = 0.146), antihypertensive agent non-users (β = 0.134), and dinner just before bedtime (β = 0.129), whereas those for H₂RA users are inadequate sleep (β = 0.248), habit of midnight snack (β = 0.160), anticoagulants non-users (β = 0.106), and antihypertensive agents non-users (β = 0.095).

CONCLUSIONS

Among many lifestyle-related factors correlated with GERD symptoms, poor quality of sleep and irregular dietary habits are strong risk factors for high FSSG scores. At present, usual dose of PPI or H₂RA in Japan cannot fully relieve GERD symptoms.