Gastroesophageal reflux disease (GERD): is there more to the story?

Salivary microbiota composition before and after use of proton pump inhibitors in patients with laryngopharyngeal reflux: a self-control study

BACKGROUND

Issues associated with proton pump inhibitor (PPI) usage have been documented. PPIs affect the gastrointestinal microbiome, as well as the saliva microbiota of healthy individuals. However, the alterations in the saliva microbiota of laryngopharyngeal reflux (LPR) patients remain unclear. This study aims to examine the composition of saliva microbiota in LPR patients before and after PPI usage through a self-controlled study.

METHODS

Thirty-two adult LPR patients participated in the study. Saliva samples were collected before and after an 8-week regimen of twice-daily administration of 20-mg esomeprazole. The impact of PPI administration on bacterial communities was assessed using 16 S rRNA gene sequencing. The functional and metabolic changes in saliva microbial communities after PPI usage were analyzed using PICRUSt2 based on our 16 S rRNA gene sequencing results.

RESULTS

The alpha diversity within the salivary microbiota, as measured by the PD-whole-tree index, exhibited a significant difference between samples collected before and after PPI application (P = 0.038). Additionally, PCoA analysis of unweighted UniFrac distances (beta diversity) revealed distinct separation of saliva sample microbiota structures before and after PPI application in LPR patients, with statistical significance (Adonis test, R2 = 0.063, P< 0.010). Taxon-based analysis indicated that PPI administration increased the abundance of Epsilonproteobacteria, Campylobacterales, Campylobacteraceae, Campylobacter, and Campylobacter_gracilis, while reducing the abundance of Lactobacillaceae and Lactobacillus in salivary samples ( P< 0.050). Using LEfSe to compare bacterial abundances, Bacillaceae and Anoxybacillus were found to be enriched before PPI usage in LPR patients. Furthermore, the proportion of genes responsible for indole alkaloid biosynthesis in the salivary microbiota of LPR patients significantly increased after PPI therapy (P< 0.050).

CONCLUSIONS

These findings indicate that PPIs induce alterations in the salivary microbiota of LPR patients.

CHINESE CLINICAL TRIAL REGISTRY

No. ChiCTR2300067507. Registered on January 10,2023 retrospectively.

LEVEL OF EVIDENCE: 4

Risk factors of erosive esophagitis and barrett's esophagus in patients with reflux symptoms

Background: Gastroesophageal reflux disease (GERD) is a prevalent condition. Erosive esophagitis (EE) and Barrett’s esophagus (BE) are the two important complications of GERD. We aimed to study the prevalence of EE and BE in a group of Patients with reflux symptoms who were referred for endoscopy. The relationship between reflux symptoms and endoscopic findings was also examined.

Methods: We enrolled 139 consecutive patients with characteristic symptoms of GERD. Demographic and clinical characteristics of the patients including duration and severity of reflux symptoms, were recorded. Endoscopic findings of EE were identified and classified according to the Los Angeles classification, while BE was confirmed by histopathology examination. The Fisher’s exact test and the two-sample 𝑡-test were used to test the association of esophageal lesions (BE and/or EE) with the patients' clinical and endoscopic data.

Results: Forty seven and 13 patients were found to have EE and BE, respectively. Multivariate analysis showed that older age (p=0.001) and hiatal hernia (p=0.004) was significantly related risk factors for erosive esophagitis and BE. While an increase in BMI (p=0.004) was related to EE, patients with BE were more likely to have severe reflux symptoms than others (p=0.002).

Conclusion: In patients with GERD, the presence of hiatal hernia may be strong risk factor for erosive esophagitis and BE, as does older age. For Barrett’s esophagus, severe reflux symptoms are more likely.

Transoral Incisionless Fundoplication: Is it as Safe and Efficacious as a Nissen or Toupet Fundoplication?

Transoral incisionless fundoplication (TIF) was U.S. Food and Drug Administration-approved in 2007 to treat gastroesophageal reflux disease (GERD), but comparative data are lacking. This study was undertaken to compare outcomes for patients with GERD undergoing TIF versus laparoscopic Nissen or Toupet fundoplications. We undertook a case-controlled study of three cohorts of 20 patients undergoing TIF or laparoscopic Nissen or Toupet fundoplications from 2010 to 2013 controlling for age, body mass index, and preoperative DeMeester scores. All patients were pro-spectively followed. Median data are reported. Patients undergoing TIF had significantly shorter operative times (in minutes: 71 vs 119 and 85, respectively, P < 0.001) and length of stay (in days: 1, 2, and 1, respectively, P < 0.001). No matter the approach, patients reported dramatic and similar reduction in symptom frequency and severity (e.g., heartburn 8 to 0, P < 0.05). At follow-up, 83 per cent of patients after TIF, 80 per cent after Nissen, or 92 per cent after Toupet fundoplications had symptoms less than once per month ( P = 0.12). TIF leads to dramatic symptom resolution, similar when compared with Nissen or Toupet fundoplications. TIF promotes shorter operative times and lengths of stay. Patient satisfaction and effective palliation of symptoms show that TIF is safe and efficacious in comparison to Nissen and Toupet fundoplications and support its continued application and evaluation.

Advances in understanding pathogenesis of gastroesophageal reflux-related cough

Gastroesophageal reflux-related cough (GERC) refers to chronic cough caused by gastroesophageal reflux disease (GERD) and is one of the common causes of chronic cough in adults. Compared with typical GERD, GERC has its own characteristics in the pathogenesis of cough. The main mechanisms involve direct refluxate stimulation and indirect esophageal-bronchial reflection. In addition, the high sensitivity of cough receptors, acid-producing bacteria, nongastric H⁺/K⁺-ATPases and psychological factors are also important in the pathogenesis of GERC. GERC may be the result of the combined effects of multiple factors.

The learning curve of laparoendoscopic single-Site (LESS) fundoplication: definable, short, and safe

The learning curve for laparoendoscopic single-site (LESS) surgery was found to be definable, short, and safe.

Background and Objectives:

This study of laparoendoscopic single-site (LESS) fundoplication for gastroesophageal reflux disease was undertaken to determine the “learning curve” for implementing LESS fundoplication.

Methods:

One hundred patients, 38% men, with a median age of 61 years and median body mass index of 26 kg/m², underwent LESS fundoplications. The operative times, placement of additional trocars, conversions to “open” operations, and complications were compared among patient quartiles to establish a learning curve. Median data are reported.

Results:

The median operative times and complications did not differ among 25-patient cohorts. Additional trocars were placed in 27% of patients, 67% of whom were in the first 25-patient cohort. Patients undergoing LESS fundoplication had a dramatic relief in the frequency and severity of all symptoms of reflux across all cohorts equally (P < .05), particularly for heartburn and regurgitation, without causing dysphagia.

Conclusion:

LESS fundoplication ameliorates symptoms of gastroesophageal reflux disease without apparent scarring. Notably, few operations required additional trocars after the first 25-patient cohort. Patient selection became more inclusive (eg, more “redo” fundoplications) with increasing experience, whereas operative times and complications remained relatively unchanged. The learning curve of LESS fundoplication is definable, short, and safe. We believe that patients will seek LESS fundoplication because of the efficacy and superior cosmetic outcomes; surgeons will need to meet this demand.

Identification of organic acids in wine that stimulate mechanisms of gastric acid secretion

Wine may cause stomach irritation due to its stimulatory effect on gastric acid secretion, although the mechanisms by which wine or components thereof activate pathways of gastric acid secretion are poorly understood. Gastric pH was measured with a noninvasive intragastric probe, demonstrating that administration of 125 mL of white or red wine to healthy volunteers stimulated gastric acid secretion more potently than the administration of equivalent amounts of ethanol. Between both beverages, red wine showed a clear trend for being more active in stimulating gastric acid secretion than white wine (p = 0.054). Quantification of the intracellular proton concentration in human gastric tumor cells (HGT-1), a well-established indicator of proton secretion and, in turn, stomach acid formation in vivo, confirmed the stronger effect of red wine as compared to white wine. RT-qPCR experiments on cells exposed to red wine also revealed a more pronounced effect than white wine on the fold change expression of genes associated with gastric acid secretion. Of the quantitatively abundant organic acids in wine, malic acid and succinic acid most actively stimulated proton secretion in vitro. However, addition of ethanol to individual organic acids attenuated the secretory effect of tartaric acid, but not that of the other organic acids. It was concluded that malic acid for white wine and succinic acid for red wine are key organic acids that contribute to gastric acid stimulation.

Laparoscopic Nissen Fundoplication Ameliorates Symptoms of Reflux, Especially for Patients with Very Abnormal DeMeester Scores

Intuitively, more severe acid reflux causes more severe symptoms. This study was undertaken to correlate preoperative DeMeester scores with symptoms before and after laparoscopic Nissen fundoplication. Before fundoplication, all patients with gastroesophageal reflux disease underwent 24 to 48 hour pH testing. Before and after fundoplication, the frequency and severity of reflux symptoms were scored using a Likert scale. Four hundred and eighty-one patients underwent fundoplication and were followed for a mean of 32 months. The preoperative median DeMeester score was 41 (range 14.8 to 361.5). Before fundoplication, DeMeester scores correlated with severity of gastroesophageal reflux disease symptoms (Spearman regression analysis, P < 0.05 for all). Postoperatively, all symptom scores improved (Wilcoxon matched pairs test, P < 0.05 for all). After fundoplication, preoperative DeMeester scores did not correlate with the frequency or severity of symptoms. For patients with excessive acid reflux, reflux severity impacts the frequency and severity of symptoms before fundoplication. Laparoscopic Nissen fundoplication improves the frequency and severity of all reflux symptoms. The severity of preoperative reflux does not impact the frequency or severity of symptoms after fundoplication. Relief of excessive acid reflux, regardless of severity or degree ( i.e., DeMeester scores), ameliorates symptoms of acid reflux thereby encouraging fundoplication, especially for patients with very abnormal DeMeester scores.