Hospital discharges resulting from esophagitis among Medicare beneficiaries

Association of Cannabis Use with Complications Among Patients with Gastroesophageal Reflux Disease: Insights from National Inpatient Sample

Background/Objective: Cannabis, one of the most widely used recreational drug in the United States, has had a significant surge in usage following its legalization in 1996. In recent years, there has been research into the physiological effects of cannabis on the gastrointestinal (GI) system. Our study aims to systematically examine the association between cannabis use and complications of gastroesophageal reflux disease (GERD). Materials and Methods: We queried the 2016-2020 National Inpatient Sample database to identify patient encounters with GERD. Patients with eosinophilic esophagitis or missing demographics were excluded. We compared patient demographics, comorbidities, and complications among cannabis users and nonusers. Multivariate logistic regression analysis was used to investigate the relationship between cannabis use and complications of GERD. Results: A total of 27.2 million patient encounters were included in the analysis, out of which 507,190 were cannabis users. Majority of the cannabis users were aged between 45-64 years (46.6%), males (57.4%), White (63.84%), and belonged to the lowest income quartile (40.6%). Cannabis users demonstrated a higher prevalence of esophagitis compared to nonusers (6.11% vs. 3.23%, p<0.001). However, they exhibited a lower rates of esophageal stricture (0.6% vs. 0.8%, p<0.001) and esophageal cancer (0.2% vs. 0.24%, p<0.001). After adjusting for confounding factors, cannabis users were noted to have higher odds of esophagitis (adjusted odds ratio [aOR]: 1.34, 95% confidence interval [CI]: 1.30-1.39, p<0.001). A lower odds of esophageal stricture (aOR: 0.88, 95% CI: 0.81-0.96, p=0.02) and esophageal cancer (aOR: 0.48,95% CI: 0.42-0.57, p<0.001) were noted. Conclusion: Our cross-sectional study using the nationally available database indicates an association between cannabis use and higher odds of esophagitis, along with lower odds of esophageal stricture and cancer. While these findings suggest a potential relationship between cannabis use and esophageal complications, it is limited in establishing causality. Therefore, further long-term studies are warranted to understand the mechanism behind this association and to determine if cannabis use has an impact on esophagus.

Evaluation of Esophageal Dysphagia in Elderly Patients

PURPOSE OF REVIEW

While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence.

RECENT FINDINGS

In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.

The Changing Epidemiology of Gastroesophageal Reflux Disease: Are Patients Getting Younger?

Background/Aims

Gastroesophageal reflux disease (GERD) is a common disease globally with increasing prevalence and consequently greater burden on the Healthcare system. Traditionally, GERD has been considered a disease of middle-aged and older people. Since risk factors for GERD affect a growing number of the adult population, concerns have been raised that increasingly younger people may develop GERD. We aim to determine if the proportion of younger patients has increased among the GERD population.

Methods

The incidence of GERD as well as several variables were evaluated during an 11-year period. Explorys was used to evaluate datasets at a “Universal” and Healthcare system in northern Ohio to determine if trends at a local level reflected those at a universal level. GERD patients were classified into 7 age groups (15–19, 20–29, 30–39, 40–49, 50–59, 60–69, and ≥70 years).

Results

The proportion of patients with GERD increased in all age groups, except for those who were ≥70 years in the universal dataset (P < 0.001) and those who were ≥60 years in the Healthcare system (P < 0.001). The greatest rise was seen in 30–39 years in both datasets (P < 0.001). Similarly, the proportion of GERD patients who were using proton pump inhibitors increased in all age groups except for those who were ≥70 years in both datasets (P < 0.001), with the greatest increase being the group 30–39 years (P < 0.001).

Conclusion

Over the last decade, there has been a significant increase in the proportion of younger patients with GERD, especially those within the age range of 30–39 years.

Presentation and Epidemiology of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the United States, and leads to substantial morbidity, though associated mortality is rare. The prevalence of GERD symptoms appeared to increase until 1999. Risk factors for complications of GERD include advanced age, male sex, white race, abdominal obesity, and tobacco use. Most patients with GERD present with heartburn and effortless regurgitation. Coexistent dysphagia is considered an alarm symptom, prompting evaluation. There is substantial overlap between symptoms of GERD and those of eosinophilic esophagitis, functional dyspepsia, and gastroparesis, posing a challenge for patient management.

GERD Is Associated with Higher Long-Term Reoperation Rates After Bariatric Surgery

BACKGROUND

Although bariatric surgery is a safe and effective treatment for morbid obesity, long-term reoperation remains a significant source of morbidity and mortality for the patient.

METHODS

We performed a retrospective analysis of all patients undergoing laparoscopic gastric bypass (LGBP) or laparoscopic sleeve gastrectomy (LSG) surgeries at our institution between 2009 and 2013. Main outcome of interest was reoperation rate up to current date. Final logistic regression model included age, gender, BMI at time of operation, race (Caucasian vs African American), surgery time, length of stay, history of diabetes, history of gastroesophageal reflux disease (GERD), type of surgery, and readmission.

RESULTS

A total of 533 patients underwent either LGBP or LSG surgery between 2009 and 2013. Overall reoperation rate was 9.0% and mean follow-up was 43.9 months (median 45). When stratified by race, preoperative GERD in Caucasians was associated with a significant 2.2-fold increased risk of reoperation (OR 2.2, 95% CI 1.0–4.8, P = .043). GERD in African Americans had a small nonsignificant increased risk. Other significant predictors included length of stay and readmission (OR 2.1, P = 0.029; OR 5.0, P < 0.000).

CONCLUSION

Preoperative GERD in Caucasian bariatric patients is associated with a higher risk of reoperation. Lengthy hospital stay and readmission within 30 days of laparoscopic bariatric surgery are independent predictors of higher reoperation rates.

Effects of environment and lifestyle on gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is comprised of a spectrum of related disorders, including hiatal hernia, reflux disease with its associated symptoms, erosive esophagitis, peptic stricture, Barrett's esophagus, and esophageal adenocarcinoma. Besides multiple pathophysiological associations among these disorders, they are also characterized by their comorbid occurrence in identical patients and by their similar epidemiologic behavior. The occurrence of GERD is shaped by marked temporal and geographic variations, suggesting the influence of environmental risk factors in the etiology of these diseases.

VARIATIONS BY TIME, GEOGRAPHY, AND RACE

Between 1975 and 2005, the incidence of GERD and esophageal adenocarcinoma increased fivefold in most Western countries. The incidence of GERD also appears to be rising in the most developed countries of Asia. All severe forms of GERD, such as erosive esophagitis, peptic stricture, Barrett's metaplasia, and esophageal adenocarcinoma, are more common among whites than other ethnic groups.

AFFLUENCE AND OBESITY AS RISK FACTORS

Barrett's esophagus and esophageal adenocarcinoma tend to occur slightly more often in subjects with higher income. Overweight and obesity contribute to the development of hiatal hernia, increase intra-abdominal pressure, and promote gastroesophageal reflux. Weight gain increases reflux symptoms, whereas weight loss decreases such symptoms. Other risk factors, such as smoking, alcohol, dietary fat, or drugs, play only a minor role in shaping the epidemiologic patterns of GERD.

PROTECTION THROUGH HELICOBACTER PYLORI

On a population level, a high prevalence of H. pylori infection is likely to reduce levels of acid secretion and protect some carriers of the infection against reflux disease and its associated complications. Several studies have confirmed a lesser prevalence of H. pylori among subjects with than without GERD. Until recently, populations in Africa and Asia may have been protected against the development of GERD and esophageal adenocarcinoma by their higher prevalence of H. pylori infection.

CONCLUSION

The study of environmental risk factors may provide an opportunity to better understand GERD and develop a means of its prevention.

Comparison of reflux esophagitis and its complications between African Americans and non-Hispanic whites

AIM: To determine the effect of ethnicity on the severity of reflux esophagitis (RE) and its complications.

METHODS: A retrospective search of the endoscopy database at the University of Florida Health Science Center/Jacksonville for all cases of reflux esophagitis and its complications from January 1 to March 31, 2001 was performed. Inclusion criteria were endoscopic evidence of esophagitis using the LA classification, reflux related complications and self-reported ethnicity. The data obtained included esophagitis grade, presence of a hiatal hernia, esophageal ulcer, stricture and Barrett’s esophagus, and endoscopy indication.

RESULTS: The search identified 259 patients with RE or its complications, of which 171 were non-Hispanic whites and 88 were African Americans. The mean ages and male/female ratios were similar in the two groups. RE grade, esophageal ulcer, stricture and hiatal hernia frequency were likewise similar in the groups. Barrett’s esophagus was present more often in non-Hispanic whites than in African Americans (15.8% vs 4.5%; P < 0.01). Heartburn was a more frequent indication for endoscopy in non-Hispanic whites with erosive esophagitis than in African Americans (28.1% vs 7.9%; P < 0.001).

CONCLUSION: Distribution of RE grade and frequency of reflux-related esophageal ulcer, stricture and hiatal hernia are similar in non-Hispanic whites and African Americans. Heartburn was more frequently and nausea/vomiting less frequently reported as the primary endoscopic indication in non-Hispanic whites compared with African Americans with erosive esophagitis or its complications. African Americans have a decreased prevalence of Barrett’s esophagus compared with non-Hispanic whites.

Prevalence of complicated gastroesophageal reflux disease and Barrett's esophagus among racial groups in a multi-center consortium

AIMS

The Clinical Outcomes Research Initiative database was used to evaluate ethnic trends in complicated reflux disease and suspected Barrett's esophagus among various racial groups.

METHODS

Endoscopic findings for procedures performed January 2000-December 2005 for any indication and for reflux-related indications were reviewed by racial group.

RESULTS

Of 280,075 procedures examined, Hispanics were the most likely to have esophagitis (Hispanic 19.6%, white 17.3%, black 15.8%, Asian/Pacific Islander 9.5%, P-value<0.0001), and white subjects were most likely to have suspected BE (white 5.0%, Hispanic 2.9%, Asian/Pacific Islander 1.8%, black 1.5%, P-value<0.0001). Endoscopies performed for reflux-related indications had similar trends for esophagitis and esophageal stricture. Among reflux/Barrett's screening procedures adjusted for age and gender, Hispanics were most likely to have esophagitis (OR=1.28, P-value<0.0001) compared to Caucasians.

CONCLUSION

Our results demonstrate an association of suspected Barrett's esophagus and stricture with white patients and esophagitis with Hispanic patients. These findings need to be followed-up with further study.

Clinical manifestations of GERD aged patients and comparative analysis of curative effect

AIM: To analyze the symptoms of aged patients with gastroesophageal reflux disease (GERD) and to observe efficacy of comprehensive treatment for GERD.

METHODS: Two thousand out-patients who met the criteria for GERD in our hospital from January 2006 to January 2008 were randomly chosen and allocated to two groups: aged patient group (≥60, n = 1000 ) and non-aged patient group (<60, n = 1000). Incidence rate of each symptom was analyzed and compared between two groups. RDQ scores of patients before and after the treatment were estimated.

RESULTS: The rates of extra esophageal symptoms in aged group were markedly higher then those in non-aged group (P < 0.01); RDQ scores of GERD patients reduced significantly after comprehensive treatment (aged group: 8.52 ± 4.32 vs 16.67±4.56, P < 0.01; non-aged group: 7.23 ± 5.56 vs 17.56 ± 6.65, P < 0.01). Remarkable curative effect was observed in both groups.

CONCLUSION: For aged GERD patients, more importance should be attached to differential diagnosis and comprehensive treatment for a complete recovery.

The epidemiology of gastroesophageal reflux disease

Symptoms of gastroesophageal reflux disease (GERD) are among the most common encountered in primary practice. Reported symptoms certainly under-represent the true prevalence of this disease in the population, because many patients do not seek care for symptoms of GERD and many physicians do not specifically ask about such symptoms when performing the review of systems. We describe the epidemiology of GERD. We begin by considering the prevalence of GERD as a function of the disease definition used. We then discuss the epidemiology of nonerosive reflux disease. After that, we consider the population risk factors for GERD. Next, we briefly touch on the epidemiology of GERD complications, including erosive esophagitis, strictures, and Barrett esophagus. We will end with a brief discussion of population screening of those with GERD for Barrett esophagus.

Esophageal complications of gastroesophageal reflux disease: Presentation, diagnosis, management, and outcomes

The esophageal complications of gastroesophageal reflux disease include peptic esophageal erosion and ulceration, peptic esophageal strictures, and Barrett's esophagus. Endoscopy is the diagnostic procedure of choice for the initial evaluation of lesions. For most patients, symptoms can be controlled with proton pump inhibitor (PPI) therapy. PPIs are also highly effective for healing esophageal erosions and ulcerations and for preventing recurrence of peptic esophageal strictures. Because Barrett's esophagus predisposes individuals to esophageal adenocarcinoma, these patients are advised to have regular endoscopic surveillance to detect early, curable neoplasms.

Racial differences in the frequency of symptoms and complications of gastro-oesophageal reflux disease

BACKGROUND

A number of reports have suggested that there are substantial racial differences in the frequency of gastro-oesophageal reflux disease and its complications, but few studies have compared directly the frequency of this disorder amongst different racial groups.

AIM

To explore the racial differences in the frequency of gastro-oesophageal reflux disease and its complications.

METHODS

We reviewed endoscopy reports and medical records for data on race and complications of gastro-oesophageal reflux disease in 2,477 consecutive patients who had endoscopic examinations at the general endoscopy unit of an academic hospital. In addition, we prospectively interviewed 129 out-patients attending general medical clinics in the hospital and in an Asian community health centre in Boston to obtain data on race and gastro-oesophageal reflux disease symptoms.

RESULTS

One or more gastro-oesophageal reflux disease complications (peptic oesophageal ulcer, stricture or Barrett's oesophagus) were observed in 267 of 2,174 white patients (12.3%), seven of 249 black patients (2.8%), one of 21 West Asian patients (4.8%) and none of 33 East Asian patients seen at the general endoscopy unit (P < 0.001); 34.6% of whites, 46.1% of blacks and 2.6% of East Asian patients interviewed claimed that they had heartburn (P < 0.01), but the term 'heartburn' was understood by only 34.6%, 53.8% and 13.2% of whites, blacks and East Asians, respectively (P < 0.01).

CONCLUSIONS

Asian patients in Boston infrequently complain of heartburn, whereas heartburn is commonly reported by both white and black patients. Many patients do not understand the meaning of the term heartburn, however, and so physicians should be cautious when using the term during patient interviews. Complicated gastro-oesophageal reflux disease appears to be predominantly a disorder of whites.

Assessing NSAID prescription use as a predisposing factor for gastroesophageal reflux disease in a Medicaid population

PURPOSE

The purpose of the study was to determine the incidence of GERD associated with prescription NSAID consumption.

METHODS

All Georgia Medicaid patients > 25 years of age and continuously eligible for 1996, 1997, and 1998 were included in the study. Patients were excluded if they received a GERD diagnoses during 1996 and 1997. Patients were observed in 1998 and classified into GERD and control cohorts. Comorbidities, demographics, and NSAID prescription consumption were retained and modeled with logistic regression.

RESULTS

The absolute risk of developing GERD without previous NSAID consumption was 0.38. The absolute risk of developing GERD for those patients who consumed one or more NSAID prescriptions during 1996 and 1997 was 0.80. Thus, the relative risk of GERD for NSAID patients was 2.11. GERD was significantly associated with one or more NSAID prescriptions (OR = 1.82), age (OR = 1.05 for 5 year range), gender (OR = 1.31 for females), asthma (OR = 3.24), obesity (OR = 2.77), hiatal hernia (OR = 4.17), tobacco use (OR = 2.56), and alcohol (OR = 1.83). The initial NSAID prescription was responsible for the greatest marginal increase in GERD.

CONCLUSIONS

Our study suggests that NSAIDs are associated with GERD especially for females, alcohol and tobacco users, and patients with asthma, hiatal hernia, or obesity.

Epidemiology of esophageal and supraesophageal reflux injuries

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder. Despite its frequent occurrence, only a minority of patients seek medical attention, making it difficult to ascertain the true epidemiologic distribution of the disorder. A causal association between GERD and esophageal complications such as esophagitis, esophageal ulcer, and esophageal stricture is well accepted. Recent epidemiologic evidence suggests that GERD may likewise represent a risk factor for the development of supraesophageal conditions, such as asthma, chronic bronchitis, laryngitis, and even laryngeal cancer. Although epidemiologic associations do not establish a cause-and-effect relationship, they may indicate potential etiologic risk factors. Nevertheless, confirmation of the causal role of GERD in supraesophageal disorders awaits further investigation.