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Leech T, Peiris M. Mucosal neuroimmune mechanisms in gastro-oesophageal reflux disease (GORD) pathogenesis. J Gastroenterol 2024; 59:165-178. [PMID: 38221552 PMCID: PMC10904498 DOI: 10.1007/s00535-023-02065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/30/2023] [Indexed: 01/16/2024]
Abstract
Gastro-oesophageal reflux disease (GORD) is a chronic condition characterised by visceral pain in the distal oesophagus. The current first-line treatment for GORD is proton pump inhibitors (PPIs), however, PPIs are ineffective in a large cohort of patients and long-term use may have adverse effects. Emerging evidence suggests that nerve fibre number and location are likely to play interrelated roles in nociception in the oesophagus of GORD patients. Simultaneously, alterations in cells of the oesophageal mucosa, namely epithelial cells, mast cells, dendritic cells, and T lymphocytes, have been a focus of GORD research for several years. The oesophagus of GORD patients exhibits both macro- and micro-inflammation as a response to chronic acidic reflux at the epithelium. In other conditions of the GI tract, such as IBS and IBD, well-characterised bidirectional processes between immune cells and mucosal nerve fibres contribute to pathogenesis and symptom generation. Sensory alterations in these conditions such as nerve fibre outgrowth and hypersensitivity can be driven by inflammatory processes, which promote visceral pain signalling. This review will examine what is currently known of the molecular pathways linking inflammation and sensory perception leading to the development of GORD symptoms and explore potentially relevant mechanisms in other GI regions which may indicate new areas in GORD research.
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Affiliation(s)
- Tom Leech
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Madusha Peiris
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
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Yeh CC, Shun CT, Tseng LW, Chiang TH, Wu JF, Lee HC, Chen CC, Wang HP, Wu MS, Tseng PH. Combination of Symptom Profile, Endoscopic Findings, and Esophageal Mucosal Histopathology Helps to Differentiate Achalasia from Refractory Gastroesophageal Reflux Disease. Diagnostics (Basel) 2021; 11:2347. [PMID: 34943584 PMCID: PMC8700273 DOI: 10.3390/diagnostics11122347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 11/17/2022] Open
Abstract
Achalasia, a rare primary esophageal motility disorder, is often misdiagnosed as refractory gastroesophageal reflux disease (GERD). This study is aimed to identify the clinical and histopathologic features that may help to differentiate these two entities. Patients with untreated achalasia and those with refractory reflux symptoms despite ≥8 weeks of proton-pump inhibitor treatment were enrolled prospectively. All patients underwent validated symptom questionnaires, esophagogastroduodenoscopy with biopsy, and high-resolution impedance manometry (HRIM). Histopathology of esophageal mucosa was compared based on four pre-determined histological criteria: basal cell hyperplasia or papillae elongation, eosinophilic infiltration, petechiae formation, and hypertrophy of the muscularis mucosae (MM). Compared with the GERD patients, patients with achalasia had similar reflux symptoms, but higher Eckardt scores, fewer erosive esophagitis and hiatal hernia, more esophageal food retention on endoscopy, and higher prevalence of hypertrophy of the MM and petechiae formation on histopathology. Multivariate logistic regression based on Eckardt score ≥4, normal esophagogastric junction morphology or esophageal food retention, and coexistence of petechiae formation and hypertrophy of the MM, established the best prediction model for achalasia. Therefore, combination of routinely accessible variables, including Eckardt score, endoscopic features, and histopathology obtained via esophageal mucosal biopsy, may provide an earlier identification of achalasia.
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Affiliation(s)
- Chia-Chu Yeh
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (C.-C.Y.); (L.-W.T.); (C.-C.C.); (H.-P.W.); (M.-S.W.)
- Good Liver Clinic, Taipei 100, Taiwan;
- Department of Pathology, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Chia-Tung Shun
- Good Liver Clinic, Taipei 100, Taiwan;
- Department of Pathology, National Taiwan University Hospital, Taipei 100, Taiwan
- Department and Graduate Institute of Forensic Medicine, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Liang-Wei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (C.-C.Y.); (L.-W.T.); (C.-C.C.); (H.-P.W.); (M.-S.W.)
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City 24352, Taiwan
| | - Tsung-Hsien Chiang
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Children’s Hospital, Taipei 100, Taiwan; (J.-F.W.); (H.-C.L.)
| | - Hui-Chuan Lee
- Department of Pediatrics, National Taiwan University Children’s Hospital, Taipei 100, Taiwan; (J.-F.W.); (H.-C.L.)
| | - Chien-Chuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (C.-C.Y.); (L.-W.T.); (C.-C.C.); (H.-P.W.); (M.-S.W.)
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (C.-C.Y.); (L.-W.T.); (C.-C.C.); (H.-P.W.); (M.-S.W.)
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (C.-C.Y.); (L.-W.T.); (C.-C.C.); (H.-P.W.); (M.-S.W.)
| | - Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (C.-C.Y.); (L.-W.T.); (C.-C.C.); (H.-P.W.); (M.-S.W.)
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