Refractory GERD: what is it?

Chinese expert consensus on diagnosis and management of gastroesophageal reflux disease in the elderly (2023)

Gastroesophageal reflux disease (GERD) in the elderly is characterized by atypical symptoms, relatively severe esophageal injury, and more complications, and when GERD is treated, it is also necessary to fully consider the general health condition of the elderly patients. This consensus summarized the epidemiology, pathogenesis, clinical manifestations, and diagnosis and treatment characteristics of GERD in the elderly, and provided relevant recommendations, providing guidance for medical personnel to correctly understand and standardize the diagnosis and treatment of GERD in the elderly.

Patient journey in gastroesophageal reflux disease: real-world perspectives from Italian gastroenterologists, primary care physicians, and ENT specialists

Background

Gastroesophageal reflux disease (GERD) is a challenging condition that involves different physicians, such as general practitioners (GPs), gastroenterologists, and ears, nose and throat (ENT) specialists. A common approach consists of proton-pump inhibitors (PPIs) administration. Adjunctive pharmacological treatment may have a role in the management of non-responders to PPIs.

Objectives

We aimed to survey GPs and different medical specialists to investigate the medical approaches to patients reporting GERD symptoms. In addition, we examined the use of adjunctive pharmacological treatments in patients with GERD symptoms who do not respond to PPIs.

Design

Retrospective observational study.

Methods

A survey was conducted among a large sample of gastroenterologists, GPs, and ENT specialists. Symptoms were divided into typical and extraesophageal, and their severity and impact on quality of life were explored with the GERD Impact Scale and with Reflux Symptom Index (RSI). All therapies administered usually for GERD were investigated.

Results

A total of 6211 patients were analyzed in this survey. Patients with typical symptoms were 53.5%, while those with extraesophageal symptoms were 46.5%. The latter were more frequently reported by ENT patients (53.6%, p < 0.0001). The GSI was higher in patients followed by gastroenterologists (9 points) and GPs (9 points) than ENT specialists (8 points), but the RSI was higher in the ENT group (14.3 ± 6.93) than in GPs and gastroenterologist groups (10.36 ± 6.36 and 10.81 ± 7.30, p < 0.0001). Chest pain had the highest negative impact on quality of life (p < 0.0001). Of the 3025 patients who used PPIs, non-responders showed a lower GSI when treated with a combination of adjunctive pharmacological treatments and bioadhesive compounds, than with single-component drugs.

Conclusion

Patients with GERD referred to a gastroenterologist had more severe disease and poorer quality of life. The combination of adjunctive pharmacological treatments and bioadhesive compounds seems to be effective in the management of PPI refractory patients.

A novel modified endoscopic method for treating patients with refractory gastro-esophageal disease and moderate hiatus hernia

BACKGROUND AND AIM

endoscopic anti-reflux mucosectomy (ARMS) is effective for patients with refractory gastroesophageal reflux disease (rGERD) with small hiatus hernia. However, evidence of its applicability in patients with larger hernia sac is lacking. This study aimed to evaluate the efficiency and safety of ARMS for patients with rGERD with moderate hiatus hernia (3-5 cm) and determine the appropriate resection range.

METHODS

thirty-six patients with rGERD with moderate hiatus hernia were enrolled. They were divided into 2/3 and 3/4 circumferential mucosal resection groups. The patients received modified ARMS. The gastroesophageal reflux disease questionnaire (GERD-Q) and DeMeester scores, endoscopy, 24-h pH monitoring results and lower esophageal sphincter (LES) resting pressure were compared pre- and post-procedure. Therapeutic effects and complications of the two mucosal resection ranges were analyzed.

RESULTS

thirty-six patients were enrolled in this study, all of whom had undergone ARMS surgery with at least six-month follow-up. In the 2/3 circumferential mucosal resection group, the GERD-Q score, acid exposure time (AET) and DeMeester score improved significantly compared with those before surgery (p < 0.001). In the 3/4 circumferential mucosal resection group, the GERD-Q score, AET and DeMeeter score worsened after six months (p < 0.001), but there was no difference between the two groups (p > 0.05). In both groups, there was no significant improvement in the ratio of esophagitis grade C/D and LES resting pressure after treatment compared with the baseline values (p > 0.05), and no postoperative bleeding or perforation was observed. The incidence of postoperative esophageal stenosis in the 2/3 circumferential mucosal resection group was lower than that in the 3/4 circumferential mucosal resection group (p = 0.041).

CONCLUSION

modified ARMS is effective for patients with rGERD with moderate hiatus hernia, but it cannot significantly increase the postoperative resting pressure of the LES. The 2/3 circumferential mucosal resection can reduce the incidence of postoperative esophageal stenosis.

Gastroesophageal Reflux Disease (GERD): Highlighting Diagnosis, Treatment, and Lifestyle Changes

Millions of people worldwide are affected by the prevalent clinical issue, gastroesophageal reflux disease (GERD). Both conventional and unusual symptoms can identify patients. Many people with GERD benefit from symptomatic relief and are shielded from consequences by acid suppression medication. Our capacity to recognise and manage disease consequences has improved thanks to developments in diagnostic and therapeutic technologies. One of the biggest typical gastrointestinal problems treated by physicians and primary care doctors is GERD, which is characterised by heartburn and regurgitation symptoms. GERD prevalence has increased, especially in North America and East Asia. Proton pump inhibitors (PPIs) have been the cornerstone of medical treatment for GERD for the past thirty years. However, clinicians and patients are becoming more aware of the adverse effects of the PPI class of medications recently.

Additionally, surgical fundoplication has significantly decreased, while the evolution of non-medical therapeutic methodologies for GERD has increased. In the treatment of GERD, lifestyle changes are crucial. Individual variances can be seen in how GERD symptoms change in response to different diets. The study implies that there may be a connection between reflux occurrence and salty foods, chocolates, fat-rich foods, and aerated beverages, even if there is insufficient data to support this theory. In lifestyle modifications, other factors involved are the head of the bed, patients' lying down position, smoking, fat or obesity, and physical exercise. The number of reviews focusing on various diagnostic techniques and treatment modalities is very less, so this review puts emphasis on these areas. This review also covers GERD and its symptoms, epidemiology, and pathophysiology, but significantly focuses on diagnosis, treatment, and lifestyle modification effects. 

Endoscopic management of gastroesophageal reflux disease: Panacea for proton pump inhibitors dependent/refractory patients

Endoscopic therapies in proton pump inhibitors (PPI) dependent/refractory gastroesophageal reflux disease (GERD) are increasingly indicated in patients who are not suitable or willing for chronic medical therapy and surgical fundoplication. Currently available endoluminal anti-reflux procedures include radiofrequency therapy (Stretta), suturing/plication and mucosal ablation/resection techniques at the gastroesophageal junction. Meticulous work up and patient selection results in a favorable outcome with these endoscopic therapies, especially the quality of life and partially the PPI independence. Stretta can be considered in patients with PPI refractory GERD and might have a role in patients with reflux hypersensitivity and functional heartburn. Endoscopic fundoplication using the Esophyx device and the GERD-X device have strong evidence (multiple randomized controlled trials) in patients with small hiatus hernia and high volume reflux episodes. Mucosal resection/ablation techniques like anti-reflux mucosectomy and anti-reflux mucosal ablation have shown promising results but need long term follow-up studies to prove their efficacy. The subset of PPI dependent GERD population will benefit from endoscopic therapies and the future of endoscopic management of GERD looks promising.

Beyond the Eckardt Score: Patient-Reported Outcomes Measures in Esophageal Disorders

PURPOSE OF REVIEW

To provide an overview of patient reported outcome measures (PROMs) and summarize their role in assessing undifferentiated dysphagia and common esophageal disorders, including achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD).

RECENT FINDINGS

Given the subjective nature of swallowing disorders, accurate diagnoses often rely on capturing the patient experience. As a result, the number of PROMs used to characterize esophageal symptoms is increasing with a recent particular emphasis on EoE. Overall, esophageal-focused PROMs are used to interpret patient symptoms and quality of life, diagnosis, and symptom changes over time. There are limitations with each instrument, including factors affecting validity, reliability, accessibility, patient participation, and logistical implementation. PROM instruments can be helpful tools in the diagnosis and treatment of esophageal disorders. Instruments should be chosen based on factors such as target population and setting, including research, clinical, and quality improvement efforts. Future research should address how best to implement PROMs and integrate the obtained data with patient care.

Degree of concordance on the management of patients with gastroesophageal reflux disease. A study among specialists that are members of the Sociedad Latinoamericana de Neurogastroenterología (SLNG)

INTRODUCTION AND AIMS

Due to its different clinical manifestations, gastroesophageal reflux disease (GERD) requires diverse diagnostic and therapeutic interventions. The aim of the study was to evaluate the degree of agreement among Latin American specialists, with respect to the management of GERD.

MATERIALS AND METHODS

A cross-sectional study was conducted through a survey with 42 statements (22 related to diagnosis and 20 to treatment) applied to 56 specialists from Latin America. There were 4 possible statement responses: in complete agreement, in partial agreement, in partial disagreement, and in complete disagreement. Reproducibility, level of agreement, and concordance were measured through the Kappa statistic.

RESULTS

The response rate was 81% (47/56). General concordance was low, given that there was complete concordance in only 12 statements (28.6%). There was partial concordance in 22 statements (52.4%) and no concordance in 8 (19%). The following themes had the most disagreement: the performance of endoscopy before beginning treatment, the use of proton pump inhibitors (PPIs) in patients with extraesophageal symptoms and with no typical symptoms, and the combined use of PPIs and prokinetics.

CONCLUSIONS

In the present study, we found that there was agreement among the Latin American specialists for the diagnosis and management of GERD in less than one-third of the recommendations considered standard. The low concordance could be related to the fact that the availability of diagnostic tools and medications, as well as the prevalence of GERD phenotypes, are different in each country.

Degree of concordance on the management of patients with gastroesophageal reflux disease. A study among specialists that are members of the Sociedad Latinoamericana de Neurogastroenterología (SLNG)

INTRODUCTION AND AIMS

Due to its different clinical manifestations, gastroesophageal reflux disease (GERD) requires diverse diagnostic and therapeutic interventions. The aim of the study was to evaluate the degree of concordance among Latin American specialists, with respect to the management of GERD.

MATERIALS AND METHODS

A cross-sectional study was conducted through a survey with 42 statements (22 related to diagnosis and 20 to treatment) applied to 56 specialists from Latin America. There were 4 possible statement responses: in complete agreement, in partial agreement, in partial disagreement, and in complete disagreement. Reproducibility, level of agreement, and concordance were measured through the Kappa statistic.

RESULTS

The response rate was 81% (47/56). General concordance was low, given that there was complete concordance in only 12 statements (28.6%). There was partial concordance in 22 statements (52.4%) and no concordance in 8 (19%). The following themes had the most disagreement: the performance of endoscopy before beginning treatment, the use of proton pump inhibitors (PPIs) in patients with extraesophageal symptoms and with no typical symptoms, and the combined use of PPIs and prokinetics.

CONCLUSIONS

In the present study, we found that there was agreement among the Latin American specialists for the diagnosis and management of GERD in less than one-third of the recommendations considered standard. The low concordance could be related to the fact that the availability of diagnostic tools and medications, as well as the prevalence of GERD phenotypes, are different in each country.

Measurement of low-grade inflammation of the esophageal mucosa with electrical conductivity shows promise in assessing PPI responsiveness in patients with GERD

A device that can easily measure electrical impedance might be a helpful tool for investigating the pathophysiology of gastroesophageal reflux disease. The first aim of this study was to validate our newly developed bioelectrical admittance measurement (BAM) through in vitro experimentation. The second aim was to investigate whether evaluation of BAM by this measurement differed between patients with heartburn according to their response to proton pump inhibitor (PPI) therapy. Caco-2 cell monolayers and three-dimensional tissues were examined by BAM using a frequency response analyzer. BAM was also used to measure the impedance through cell layers. Subsequently, BAM was performed during endoscopy in 41 patients experiencing heartburn without esophageal mucosal breaks. After 2-wk administration of 20-mg rabeprazole twice daily, patient responses to PPI were classified as "good" or "poor" according to their clinical course. In each patient, histological alterations and gene expression levels of inflammation mediators and tight junction proteins were evaluated. Impedance profiles indicated that monolayer Caco-2 cells on top of eight-layered normal human dermal fibroblasts had the highest magnitude of impedance over the range of frequencies. In vivo results revealed that patients with good responses to PPI displayed significantly higher admittance. Severity of low-grade inflammation was significantly associated with esophageal wall admittance. Moreover, esophageal wall admittance may be more closely related to basal zone hyperplasia than dilatation of intercellular spaces. Thus, BAM may be able to detect abnormalities in the subepithelial layer of the esophagus.NEW & NOTEWORTHY Bioelectrical admittance measurement is a new method to evaluate esophageal mucosal permeability vertically during upper gastrointestinal endoscopy. Measurement of low-grade inflammation of the esophageal mucosa with electrical conductivity shows promise in assessing proton pump inhibitor responsiveness in patients with gastroesophageal reflux disease. As various gastrointestinal diseases are associated with changes in mucosal permeability, bioelectrical admittance measurement is expected to be clinically applied to therapeutic decision-making for these diseases in the future.

Assessment of the Multiple Rapid Swallows Test for Gauging Esophageal Reflux Burden in Patients with Refractory Gastroesophageal Reflux Disease

BACKGROUND The multiple rapid swallows (MRS) test is used to assess esophageal contraction reserve. In this study, we characterized the expression of the MRS test in patients with reflux burden and other symptomatic phenotypes with refractory gastroesophageal reflux disease (rGERD). MATERIAL AND METHODS Patients with rGERD who underwent high-resolution manometry (HRM) and esophageal pH-impedance monitoring (EIM) between September 2018 and January 2020 were retrospectively studied. RESULTS We enrolled 151 patients and divided them into 4 phenotypes according to the results of EIM. In phenotype 1, the MRS distal contractile integral (DCI) was significantly positively correlated with acid-liquid reflux episodes. In phenotype 2, lower esophageal sphincter pressure (LES) length was significantly positively correlated with MRS DCI, and MRS/single-swallow (SS) DCI ratio. In phenotype 3, MRS DCI was negatively correlated with the DeMeester score, acid exposure time (AET), upright AET, long-term acid reflux episodes, acid-mixed reflux episodes, recumbent acid reflux episodes, and total acid reflux episodes. There was a significant negative correlation between MRS/SS DCI and recumbent acid reflux episodes. In phenotype 4, nonacid-liquid episodes and recumbent nonacid reflux episodes were significantly higher in the abnormal MRS group. However, acid-gas episodes, weakly acid-gas episodes, and upright gas reflux episodes were higher in the normal MRS group than in the abnormal MRS group. CONCLUSIONS Esophageal contraction reserve is heterogeneous within the reflux burden and symptomatic phenotypes of patients with rGERD.

A preliminary report on the use of Midodrine in treating refractory gastroesophageal disease: Randomized Double-Blind Controlled Trial

Background:

Gastroesophageal reflux disease (GERD) is a common disease with various clinical presentations. Acid suppression with proton pump inhibitors and lifestyle modification may not lead to satisfactory response in a substantial portion of patients. We investigated the possible effect of midodrine in patients with refractory GERD.

Methods:

Patients suffering from GERD and were refractory to one-month course of pantoprazole 40mg twice daily entered the study. This was a pilot, randomized, double-blind, and placebo-controlled study. After randomization, one group received Midodrine 5mg before meals for one month, and the other group received placebo for the same period. Meanwhile, pantoprazole was continued 40mg twice daily in both arms. The severity of symptoms was evaluated by the visual scoring system. Quality of life (QoL) in both groups was measured using a standardized version of Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD).

Results:

A total of twenty patients were enrolled in this study. There was a significant interaction between the groups and time on all measured scores based on QOLRAD questionnaire. All the markers in the Midodrine group had significant improvement over time, but the placebo group did not show any significant improvement. Both visual severity score and total QoL score in Midodrine arm showed a U shape change during 6 weeks.

Conclusions:

Midodrine before a meal could be useful in alleviating symptoms and improving QoL in the patients with refractory gastroesophageal disease. (www.actabiomedica.it)

Efficacy of the four weeks treatment of omeprazole plus mosapride combination therapy compared with that of omeprazole monotherapy in patients with proton pump inhibitor-refractory gastroesophageal reflux disease: a randomized controlled trial

Purpose

The aim of this study was to compare the effect of omeprazole plus mosapride combination therapy with that of omeprazole monotherapy in proton pump inhibitor (PPI) refractory gastroesophageal reflux disease (GERD) patients.

Patients and methods

Patients were eligible to participate in this study if they had experienced symptoms of heartburn and/or regurgitation more than twice weekly and were unresponsive to at least 8 weeks of a standard dose of PPI. A total of 44 consecutive patients were randomized to receive omeprazole 20 mg once daily plus either mosapride 5 mg or placebo three times daily for 4 weeks. We evaluated their clinical symptoms by means of frequency scale for symptoms of GERD (FSSG) questionnaires completed at the beginning and the end of the study. The primary outcome was to compare changes in FSSG scores between treatment groups during the study period.

Results

Most of the study population had non-erosive reflux disease (91.0% in the combination group and 81.8% in the control group). The minority of patients had Los Angeles grade A or B erosive esophagitis (9% in the combination group and 18.2% in the control group). None of the patients had Los Angeles grade C or D erosive esophagitis. FSSG total scores significantly decreased both in the combination group and the control group, with no significant differences in improvement between the groups (−8.00±7.18 for the combination group versus −5.68±6.29 for the control group, p=0.129). As a secondary outcome, our data showed that the effect of combination therapy on a number of symptom-free days (heartburn-free days, regurgitation-free days, and night-time heartburn-free days) was not superior to PPI monotherapy.

Conclusion

Combining mosapride for four weeks with a standard dose of PPI is not more effective than PPI alone in patients with PPI-refractory GERD.

There might be a distinctive clinical phenotype of constipation with non-cardiac chest pain which responds to combination laxatives: A retrospective, longitudinal symptom analysis

Proton pump inhibitor (PPI)-refractory non-cardiac chest pain (NCCP) is often resolved when constipation was relieved. This study aimed to investigate the clinical features of patients with both NCCP and constipated functional bowel disorders (FBD).Among 692 consecutive patients diagnosed with functional constipation or irritable bowel syndrome with constipation and underwent anorectal manometry (ARM) in our hospital, PPI-refractory NCCP was present in 37. The clinical course of various torso symptoms including NCCP and ARM findings were retrospectively evaluated.The mean age was lower in the NCCP than in the non-NCCP group (57.4 vs 61.3 years, respectively, P = .042). Back pain (16.2% vs 2.0%, P < .001) and sharp abdominal pain (13.5% vs 0.9%, P < .001) were more common in the NCCP group. Increased resting pressure (16.2% vs 6.9%, P = .036) and squeezing pressure (62.2% vs 50.7%, P = .049) of the anal sphincter, increased urgency volume (40.5% vs 23.2%, P = .004), and maximal volume (25.7% vs 15.0%, P = .032) for rectal sensation were more frequently observed in the NCCP group. After taking laxatives for 1 to 3 months, 81.1% of patients with NCCP reported improvement.Subjects with NCCP showed decreased rectal sensation more frequently at anorectal manometry. Majority of patients with NCCP reported improvement of symptom upon relief of constipation. Constipation might be a therapeutic target in patients with NCCP related to constipated functional bowel disorders.

Development and Validation of a Mucosal Impedance Contour Analysis System to Distinguish Esophageal Disorders

BACKGROUND & AIMS

Diagnostic testing for chronic esophageal disorders relies on histopathology analysis of biopsies or uncomfortable transnasal catheters or wireless pH monitoring, which capture abnormal intraluminal refluxate. We therefore developed a balloon mucosal impedance (MI) catheter system that instantly detects changes in esophageal mucosal integrity during endoscopy over a long segment of the esophagus. We performed a prospective study to evaluate the ability of a balloon-incorporated MI catheter to detect and evaluate esophageal disorders, including gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE).

METHODS

We performed a prospective study of 69 patients undergoing esophagogastroduodenoscopy with or without wireless pH monitoring. Patients were classified as having GERD (erosive esophagitis or abnormal pH; n = 24), EoE (confirmed with pathology analysis of tissues from both distal and proximal esophagus; n = 21), or non-GERD (normal results from esophagogastroduodenoscopy and pH tests; n = 24). Receiver operating characteristic curves and area under the operating characteristic curve (AUC) were used to compare the accuracy of balloon MI in diagnosis. Probabilities of assignment to each group (GERD, non-GERD, or EoE) were estimated using multinomial logistic regression. Association between MI patterns and diagnoses were validated using data from patients seen at 3 separate institutions.

RESULTS

MI pattern along the esophageal axis differed significantly (P < .01) among patients with GERD, EoE, and non-GERD. Patients with non-GERD had higher MI values along all measured segments. The MI pattern for GERD was easily distinguished from that of EoE: in patients with GERD, MI values were low in the distal esophagus and normalized along the proximal esophagus, whereas in patients with EoE, measurements were low in all segments of the esophagus. Intercept and rate of rise of MI value (slope) as distance increased from the squamocolumnar junction identified patients with GERD with an AUC = 0.67, patients with EoE with an AUC = 0.84, and patients with non-GERD with an AUC = 0.83 in the development cohort. One patient had an adverse event (reported mild chest pain after the procedure) and was discharged from the hospital without further events.

CONCLUSIONS

We developed a balloon MI catheter system that instantly detects changes in esophageal mucosal integrity during endoscopy and found it to be safe and able to identify patients with GERD, EoE, or non-GERD. We validated our findings in a separate cohort for patients. ClinicalTrials.gov ID NCT03103789.

ARE THE PERSISTENT SYMPTOMS TO PROTON PUMP INHIBITOR THERAPY DUE TO REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE OR TO OTHER DISORDERS?

BACKGROUND

Gastroesophageal reflux disease (GERD) is a clinical condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Transient lower esophageal sphincter relaxation is the main pathophysiological mechanism of GERD. Symptoms and complications can be related to the reflux of gastric contents into the esophagus, oral cavity, larynx and/or the lung. Symptoms and other possible manifestations of GERD are heartburn, regurgitation, dysphagia, non-cardiac chest pain, chronic cough, chronic laryngitis, asthma and dental erosions. The proton pump inhibitor (PPI) is the first-choice drug and the most commonly medication used for the treatment of GERD. The most widespread definition of Refractory GERD is the clinical condition that presents symptoms with partial or absent response to twice-daily PPI therapy. Persistence of symptoms occurs in 25% to 42% of patients who use PPI once-daily and in 10% to 20% who use PPI twice-daily.

OBJECTIVE

The objective is to describe a review of the current literature, highlighting the causes, diagnostic aspects and therapeutic approach of the cases with suspected reflux symptoms and unresponsive to PPI.

CONCLUSION

Initially, the management of PPI refractoriness consists in correcting low adherence to PPI therapy, adjusting the PPI dosage and emphasizing the recommendations on lifestyle modification change, avoiding food and activities that trigger symptoms. PPI decreases the number of episodes of acid reflux; however, the number of "non-acid" reflux increases and the patient continues to have reflux despite PPI. In this way, it is possible to greatly reduce greatly the occurrence of symptoms, especially those dependent on the acidity of the refluxed material. Response to PPI therapy can be evaluated through clinical, endoscopic, and reflux monitoring parameters. In the persistence of the symptoms and/or complications, other causes of Refractory GERD should be suspected. Then, diagnostic investigation must be initiated, which is supported by clinical parameters and complementary exams such as upper digestive endoscopy, esophageal manometry and ambulatory reflux monitoring (esophageal pH monitoring or esophageal impedance-pH monitoring). Causes of refractoriness to PPI therapy may be due to the true Refractory GERD, or even to other non-reflux diseases, which can generate symptoms similar to GERD. There are several causes contributing to PPI refractoriness, such as inappropriate use of the drug (lack of patient adherence to PPI therapy, inadequate dosage of PPI), residual acid reflux due to inadequate acid suppression, nocturnal acid escape, "non-acid" reflux, rapid metabolism of PPI, slow gastric emptying, and misdiagnosis of GERD. This is a common cause of failure of the clinical treatment and, in this case, the problem is not the treatment but the diagnosis. Causes of misdiagnosis of GERD are functional heartburn, achalasia, megaesophagus, eosinophilic esophagitis, other types of esophagitis, and other causes. The diagnosis and treatment are specific to each of these causes of refractoriness to clinical therapy with PPI.

Diagnostic Efficacy of 24-hr Esophageal pH Monitoring in Patients with Refractory Gastroesophageal Reflux Disease

BACKGROUND:

Gastric reflux is one of the most important causes of the referral of patients to the internal clinic, which in some cases causes problems for patients due to resistance to common treatments. Therefore, timely diagnosis and treatment of this group of patients are very important.

AIM:

The purpose of the present study was to determine the off-proton pump inhibitor (off-PPI) 24 h pH-impedance analyses in patients with refractory gastroesophageal reflux disease (GERD) attending to Taleghani Hospital since 2009 to 2017.

METHODS:

In this observational descriptive-comparative off-PPI study, 572 patients with refractory GERD who were referred to Taleghani Hospital in Tehran from 2009 to 2017 were selected, and the results of 24 h pH Impedance analysis were then assessed.

RESULTS:

The results of 24h pH-impedance indicated that 7% of cases belonged to Pure Acid Reflux followed by weakly Acid (1%), non-acid (0.3%), mixed & gas (5.2%), functional (58.4%) and oesophagal hypersensitivity (28%). Furthermore, weakly acid plus acid was also found to be 8% and Weakly Acid + Acid + Non-Acid were determined as 8.3%.

CONCLUSIONS:

Our findings suggested that nearly more than half of the patients with refractory GERD would have a functional disorder in the 24h pH-impedance analysis.

Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions

A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist.

Management of Gastroesophageal Reflux Disease

Management of gastroesophageal reflux disease (GERD) commonly starts with an empiric trial of proton pump inhibitor (PPI) therapy and complementary lifestyle measures, for patients without alarm symptoms. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. Patients with continued symptoms can be evaluated with endoscopy and tests of esophageal physiology, to better determine their disease phenotype and optimize treatment. Laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic therapies can benefit patients with well-characterized GERD. Patients with functional diseases that overlap with or mimic GERD can also be treated with neuromodulators (primarily antidepressants), or psychological interventions (psychotherapy, hypnotherapy, cognitive and behavioral therapy). Future approaches to treatment of GERD include potassium-competitive acid blockers, reflux-reducing agents, bile acid binders, injection of inert substances into the esophagogastric junction, and electrical stimulation of the lower esophageal sphincter.

Recent Advances in the Pharmacological Management of Gastroesophageal Reflux Disease

The management of proton pump inhibitor-refractory GERD (rGERD) is a challenge in clinical practice. Since up to one-third of patients with typical GERD symptoms (heartburn and/or acid regurgitation) are not satisfied with proton pump inhibitor (PPI) therapy, new drug development targeting different pathophysiologies of GERD is imperative. At present, no other drugs serve as a more potent acid suppression agent than PPIs. As an add-on therapy, histamine type-2 receptor antagonists, alginates, prokinetics and transient lower esophageal sphincter relaxation inhibitors have some impact on the subgroups of rGERD, but greater effectiveness and fewer adverse effects for widespread use are required. Visceral hypersensitivity also contributes to the perception of GERD symptoms, and neuromodulators including antidepressants play a role in this category. Esophageal pH-impedance monitoring helps to distinguish functional heartburn from true GERD, and psychologic medication and cognitive behavior therapy are further therapy options instead of PPIs.

Gastroesophageal reflux disease: A clinical overview for primary care physicians

OBJECTIVE

GERD is among the most common outpatient disease processes encountered by clinicians on a daily basis. This review provides insights about how to approach GERD in terms of disease management and treatment.

METHODS

Review articles were searched using PUBMED and MEDLINE using criteria that included English language articles published in the last 5 years concerning studies carried out only in humans. The key words used in the searches were GERD, PPI, and erosive esophagitis. Recommendations from the American College of Gastroenterology are also included in this manuscript.

RESULTS

The search resulted in ∼260 articles. The manuscript brings together and presents the results of recent recommendations from professional societies and recently published review articles on GERD.

CONCLUSION

GERD is one of the most common diagnoses made by gastroenterologists and primary care physicians. It is important to recognize the typical and atypical presentations of GERD. This paper helps primary care physicians understand the disease's pathophysiology, and when, how, and with what to treat GERD before referring patients to gastroenterologists or surgeons.

Multi-morbidities of allergic rhinitis in adults: European Academy of Allergy and Clinical Immunology Task Force Report

This report has been prepared by the European Academy of Allergy and Clinical Immunology Task Force on Allergic Rhinitis (AR) comorbidities. The aim of this multidisciplinary European consensus document is to highlight the role of multimorbidities in the definition, classification, mechanisms, recommendations for diagnosis and treatment of AR, and to define the needs in this neglected area by a literature review. AR is a systemic allergic disease and is generally associated with numerous multi-morbid disorders, including asthma, eczema, food allergies, eosinophilic oesophagitis (EoE), conjunctivitis, chronic middle ear effusions, rhinosinusitis, adenoid hypertrophy, olfaction disorders, obstructive sleep apnea, disordered sleep and consequent behavioural and educational effects. This report provides up-to-date usable information to: (1) improve the knowledge and skills of allergists, so as to ultimately improve the overall quality of patient care; (2) to increase interest in this area; and (3) to present a unique contribution to the field of upper inflammatory disease.

Pharmacokinetics, absorption, and excretion of radiolabeled revexepride: a Phase I clinical trial using a microtracer and accelerator mass spectrometry-based approach

Purpose

Gastroesophageal reflux disease involves the reflux of gastric and/or duodenal content into the esophagus. Prokinetic therapies, such as the selective 5-hydroxytryptamine receptor 4 agonist revexepride, may aid gastric emptying. This Phase I study evaluated the pharmacokinetics and excretion pathways of [¹⁴C]revexepride in healthy individuals using a microtracer approach with accelerator mass spectrometry.

Participants and methods

Six healthy men received a single oral dose of 2 mg [¹⁴C]revexepride containing ~200 nCi of radioactivity; blood, urine, and fecal samples were collected over a 10-day period.

Results

Almost 100% of ¹⁴C was recovered: 38.2%±10.3% (mean ± standard deviation) was recovered in urine, and 57.3%±0.4% was recovered in feces. Blood cell uptake was low, based on the blood plasma total radioactivity ratio of 0.8. The mean revexepride renal clearance was 8.6 L/h, which was slightly higher than the typical glomerular filtration rate in healthy individuals. Time to reach maximal concentration was 1.75±1.17 hours (mean ± standard deviation). No safety signals were identified.

Conclusion

This study demonstrated that revexepride had rapid and moderate-to-good oral absorption. Excretion of radioactivity was completed with significant amounts in feces and urine. Renal clearance slightly exceeded the typical glomerular filtration rate, suggesting the involvement of active transportation in the renal tubules.

Management of refractory typical GERD symptoms

The management of patients with refractory GERD (rGERD) is a major clinical challenge for gastroenterologists. In up to 30% of patients with typical GERD symptoms (heartburn and/or regurgitation), acid-suppressive therapy does not provide clinical benefit. In this Review, we discuss the current management algorithm for GERD and the features and management of patients who do not respond to treatment (such as those individuals with an incorrect diagnosis of GERD, inadequate PPI intake, persisting acid reflux and persisting weakly acidic reflux). Symptom response to existing surgical techniques, novel antireflux procedures, and the value of add-on medical therapies (including prokinetics and reflux inhibitors) for rGERD symptoms are discussed. Pharmaceutical agents targeting oesophageal sensitivity, a condition that can contribute to symptom generation in rGERD, are also discussed. Finally, on the basis of available published data and our expert opinion, we present an outline of a current, usable algorithm for management of patients with rGERD that considers the timing and diagnostic use of pH-impedance monitoring on or off PPI, additional diagnostic tests, the clinical use of baclofen and the use of add-on neuromodulators (tricyclic agents and selective serotonin reuptake inhibitors).

Nickel sensitization in patients with gastro-esophageal reflux disease

BACKGROUND

Gastro-esophageal reflux disease (GERD) leads to frequent medical visits, and available therapies fail in up to 40% of patients. Food allergies may be involved in GERD pathogenesis; however, allergens other than food have received little attention. Nickel allergy is common in the general population and some high-nickel foods are associated with GERD. However, the potential relationship between nickel allergy and GERD remains unaddressed.

AIM

This study aimed to evaluate the prevalence of nickel sensitization in patients with and without GERD and to compare clinical and demographic features.

METHODS

This prospective, multicenter study included 210 adult GERD patients and 140 patients without GERD who presented at the general practitioner. All GERD patients had undergone treatment with proton pump inhibitors and upper digestive endoscopy within the previous five years. Demographic and clinical data were collected by questionnaire and patients underwent a nickel patch allergy test.

RESULTS

Patients with and without GERD presented similar characteristics, with the exception of nickel sensitization, which was significantly more prevalent among GERD patients than controls (39.5% vs. 16.4%; p = 0.001). Nickel-positive GERD patients were more frequently female (90.4% vs. 65.4%, p = 0.003) and asthmatic (18.1% vs. 4.7%; p = 0.038), compared to nickel-negative GERD patients. At six-month follow-up, most of the patients, with or without nickel sensitization, reported improved symptoms without differences in drug prescription.

CONCLUSION

Nickel sensitization is particularly prevalent in GERD patients seen in general practice. Whether allergies other than food allergy play a role in GERD remains to be elucidated.

Distinguishing GERD from eosinophilic oesophagitis: concepts and controversies

Over the past three decades, the detection of oesophageal mucosal eosinophils has transitioned from a biomarker of GERD to a diagnostic criterion for eosinophilic oesophagitis (EoE). In GERD, oesophageal eosinophils are considered part of the chronic inflammatory response to acid reflux, whereas the marked eosinophilia in EoE is viewed as a central feature of the immune response to ingested food and/or environmental antigen stimulation. Descriptions of a considerable subset of patients with symptomatic, endoscopic and histological findings of EoE that resolve with PPI therapy has led to confusion and controversy regarding the distinction of EoE from GERD. Study findings indicate that PPI-responsive oesophageal eosinophilia (PPI-REE) more closely resembles EoE than GERD, both from a clinical and immunological aspect. Although responsiveness to PPI therapy should not be utilized to exclude EoE, PPI therapy is effective at reducing oesophageal eosinophilia in ∼40% of patients, and PPI therapy is both a safe and practical initial step in the management of patients with oesophageal eosinophilia. Ongoing studies elucidating the mechanism behind PPI-REE will improve our understanding and management of EoE. In this Review, the mechanisms and evidence that underlie the controversy in the distinction between GERD and EoE are evaluated.

Mucosal impedance discriminates GERD from non-GERD conditions

BACKGROUND & AIMS

Current diagnostic tests for gastroesophageal reflux disease (GERD) are suboptimal and do not accurately and reliably measure chronicity of reflux. A minimally invasive device has been developed to assess esophageal mucosal impedance (MI) as a marker of chronic reflux. We performed a prospective longitudinal study to investigate MI patterns in patients with GERD and common nonreflux conditions, to assess MI patterns before and after treatment with proton pump inhibitors and to compare the performance of MI and wireless pH tests.

METHODS

We evaluated MI in 61 patients with erosive esophagitis, 81 with nonerosive but pH-abnormal GERD, 93 without GERD, 18 with achalasia, and 15 with eosinophilic esophagitis. MI was measured at the site of esophagitis and at 2, 5, and 10 cm above the squamocolumnar junction in all participants. MI was measured before and after acid suppressive therapy, and findings were compared with those from wireless pH monitoring.

RESULTS

MI values were significantly lower in patients with GERD (erosive esophagitis or nonerosive but pH-abnormal GERD) or eosinophilic esophagitis than in patients without GERD or patients with achalasia (P < .001). The pattern of MI in patients with GERD differed from that in patients without GERD or patients with eosinophilic esophagitis; patients with GERD had low MI closer to the squamocolumnar junction, and values increased axially along the esophagus. These patterns normalized with acid suppressive therapy. MI patterns identified patients with esophagitis with higher levels of specificity (95%) and positive predictive values (96%) than wireless pH monitoring (64% and 40%, respectively).

CONCLUSIONS

Based on a prospective study using a prototype device, measurements of MI detect GERD with higher levels of specificity and positive predictive values than wireless pH monitoring. Clinical Trials.gov, Number: NCT01556919.

Noncompliance is an impact factor in the treatment of gastroesophageal reflux disease

The basis of pharmacological treatment of the gastroesophageal reflux disease is the use of proton pump inhibitors (PPIs) which provide effective gastric acid secretion blockade. However, PPI therapy failure may occur in up to 42% of patients. The main causes for therapeutic failure are non-acid or weakly acid reflux, genotypic differences, presence of comorbidities, wrong diagnosis and lack of treatment compliance. Noncompliance is an important issue and should be carefully observed. Several studies addressed patient compliance and 20-50% of patients may present lack of compliance to the PPI prescribed. When symptoms persist depite adherence has been confirmed, it is recommended to substitute the prescribed PPI to another of the same class or alternatively, prescription of a double dose of the same drug. When even so the symptoms persist, other causes of failure should be assigned. In particular cases of PPI failure, fundoplication surgery may be indicated.

Refractory gastroesophageal reflux disease: advances and treatment

'Refractory gastroesophageal reflux disease' is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with 'refractory symptoms.' We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue.

Indirect evidence for proton pump inhibitor failure in patients taking them independent of meals

PURPOSE

We investigated the association between conditions of proton pump inhibitor (PPI) treatment failure and food intake in an elderly ambulatory population.

METHODS

Our data originate from a large population-based cohort study. During a home visit done by a trained study physician, patients were asked for each medication to state whether it was taken in relation to a meal (before, concurrently with, and after) or independent of a meal. This information was analyzed for all patients taking a PPI daily and correlated to markers of PPI failure.

RESULTS

Out of 2717 patients participating in a home visit and taking at least one medication, 383 took a PPI daily (14.1%). A PPI intake independent of meals was defined as incorrect and was observed in 64 patients, whereas 319 patients took their PPI in relation to a meal, which was defined as the correct intake. Treatment failure was observed in 10 out of 64 (15.6%) PPI users with incorrect intake and in 18 out of 319 (5.6%) PPI users with correct intake. The risk of treatment failure was threefold higher in patients taking their PPI independent of meals (OR 3.35; 95%CI 1.44-7.76).

CONCLUSION

The higher risk for PPI failure in patients taking PPIs independent of meals suggests that synchronized PPI administration with meals is indeed essential, and better counseling of patients is needed.

How good is the neosquamous epithelium?

BACKGROUND/AIMS

Endoscopic radiofrequency ablation of dysplastic Barrett's esophagus (BE) combined with proton pump inhibitor therapy is commonly utilized for preventing progression of dysplastic BE to esophageal adenocarcinoma. Fundamental to the success of this and all ablative approaches is the healing of the ablated areas of BE with a stratified squamous epithelium referred to as 'neosquamous epithelium' (NSE). Although NSE appears 'normal' endoscopically, the reemergence of BE over time in the previously ablated segments raises the question of the health and integrity of NSE.

METHODS

The health of NSE was recently investigated in endoscopic biopsies in vitro in a group of patients after ablation while on proton pump inhibitors. Biopsies of NSE were compared to upper squamous epithelium (USE) from the same patients morphologically (light microscopy) and with respect to barrier function by measuring electrical resistance and fluorescein flux in mini-Ussing chambers.

RESULTS

Compared to USE, NSE exhibited dilated intercellular spaces and inflammation and defective barrier function by low electrical resistance and high fluorescein flux. Moreover, NSE exhibited downregulation of claudin-4, a highly expressed protein in squamous tight junctions.

CONCLUSION

NSE has defective barrier function in part due to downregulation of claudin-4. Since downregulation of claudin-4 increases paracellular permeability to cations, e.g. hydrogen ions, NSE is more vulnerable to attack and damage by acidic and weakly acidic refluxates--a phenomenon that may contribute in part to the reemergence of BE.

New Approaches to Management of PPI-Refractory Gastroesophageal Reflux Disease

OPINION STATEMENT

"Refractory GERD" is one the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive, often twice-daily proton pump inhibitor therapy. The term should be replaced with "refractory symptoms." We must acknowledge that in many patients, symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus, and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to esophagogastroduodenoscopy followed by pH or impedance monitoring. In the majority of patients these tests are normal. The role of non-acid reflux measured by impedance pH testing in this group is uncertain at best and the results from this test alone should not be used to refer patients to surgical fundoplication. In patients unresponsive to acid suppressive therapy, reflux is most commonly not causal and a search for non-GERD causes must ensue.

ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE)

Esophageal eosinophilia and eosinophilic esophagitis (EoE) are increasingly recognized and prevalent conditions, which now represent common clinical problems encountered by gastroenterologists, pathologists, and allergists. The study of EoE has become a dynamic field with an evolving understanding of the pathogenesis, diagnosis, and treatment. Although there are limited data supporting management decisions, clinical parameters are needed to guide the care of patients with eosinophilic-esophageal disorders. In this evidence-based review, recommendations developed by adult and pediatric gastroenterologists are provided for the evaluation and management of these patients. New terminology is emphasized, particularly the concepts of esophageal eosinophilia and proton-pump inhibitor-responsive esophageal eosinophilia (PPI-REE) as entities distinct from EoE.

Predictors of clinical response of acid suppression in Chinese patients with gastroesophageal reflux disease

BACKGROUND

Up to 40% of patients with gastroesophageal reflux disease fail to respond to proton pump inhibitor therapy.

AIMS

To determine predictors of clinical response of proton pump inhibitor therapy.

METHODS

Consecutive patients with gastroesophageal reflux disease were enrolled prospectively. All patients underwent upper endoscopy and 24-h multichannel intraluminal impedance and pH monitoring before receiving esomeprazole 20 mg b.i.d. for 2 months. Multivariate logistic regression analysis was used to determine the independent predictors of clinical response to proton pump inhibitor therapy.

RESULTS

A total of 204 patients with typical reflux symptoms were recruited and screened. Among them 153 patients (mean age 46.3 ± 10.6 years, 51.0% female) completed all the examinations and were assigned to proton pump inhibitor therapy. Ninety-five patients (62.1%) responded to acid suppression after 2 months. Multivariate logistic analysis showed that the predictor for response was pathological distal esophageal acid reflux (P = 0.001). The factors associated with proton pump inhibitor therapy failure were the presence of irritable bowel syndrome alone (P = 0.006), depression (P = 0.005), and overlap of irritable bowel syndrome and functional dyspepsia (P = 0.002).

CONCLUSIONS

The clinical response of acid suppression on gastroesophageal reflux disease could be predicted by clinical and pH parameters rather than impedance data.

Histology of symptomatic gastroesophageal reflux disease: is it predictive of response to proton pump inhibitors?

BACKGROUND AND AIM

To examine the differences in esophageal histopathology between non-erosive reflux disease (NERD) and reflux esophagitis (RE), and to investigate whether baseline esophageal histopathology can predict the therapeutic response to proton pump inhibitors (PPIs).

METHOD

The subjects comprised 94 patients with NERD (n = 71) or mild RE (n = 23). Tissue was biopsied from 5 cm above the squamo-columnar junction (SCJ), and the degree or presence of nine histopathological markers was assessed. The patients were treated with rabeprazole (RPZ) 10 mg once daily for 4 weeks. If complete heartburn relief was not achieved, RPZ was increased to 10 mg twice daily for another 2 weeks, and then to 20 mg twice daily for another 2 weeks if heartburn remained.

RESULTS

Features of esophageal histopathology 5 cm above the SCJ differed between NERD and RE patients. The esophageal histopathology in patients unresponsive to RPZ was characterized by Protein Gene Product (PGP) 9.5 negativity in those with NERD, and intraepithelial bleeding in those with RE. In addition, the combination of dilated intercellular spaces (DIS) (+)/PGP 9.5 (-) was indicative of strong resistance to PPI therapy in NERD patients.

CONCLUSION

The therapeutic efficacy of PPI can be predicted from the features of biopsied esophageal tissue. Factors predictive of resistance to treatment with PPI are negativity for PGP 9.5 in NERD patients and intraepithelial bleeding in RE patients.

Step-by-step management of refractory gastresophageal reflux disease

Up to a third of the patients who receive proton pump inhibitor (PPI) once daily will demonstrate lack or partial response to treatment. There are various mechanisms that contribute to PPI failure and they include residual acid reflux, weakly acidic and weakly alkaline reflux, esophageal hypersensitivity, and psychological comorbidity, among others. Some of these underlying mechanisms may coincide in the same patient. Evaluation for proper compliance and adequate dosing time of PPIs should be the first management step before ordering invasive diagnostic tests. Doubling the PPI dose or switching to another PPI is the second step of management. Upper endoscopy and pH testing appear to have limited diagnostic value in patients who failed PPI treatment. In contrast, esophageal impedance with pH testing (multichannel intraluminal impedance MII-pH) on therapy appears to provide the most insightful information about the subsequent management of these patients (step 3). In step 4, treatment should be tailored to the specific underlying mechanism of patient's PPI failure. For those who demonstrate weakly acidic or weakly alkaline reflux as the underlying cause of their residual symptoms, transient lower esophageal sphincter relaxation reducers, endoscopic treatment, antireflux surgery and pain modulators should be considered. In those with functional heartburn, pain modulators are the cornerstone of therapy.

Trypsin impaired epithelial barrier function and induced IL-8 secretion through basolateral PAR-2: a lesson from a stratified squamous epithelial model

Immune-mediated injury by the protease-activated receptor-2-interleukin-8 (PAR-2-IL8) pathway may underlie the development of gastroesophageal reflux disease (GERD). However, the localization of PAR-2 and the mechanism of PAR-2 activation remain unclear. This study aimed to address these questions on an esophageal stratified squamous epithelial model and in the human esophageal mucosa of GERD patients. Normal human esophageal epithelial cells were cultured with the air-liquid interface system to establish the model. SLIGKV-NH2 (PAR-2 synthetic agonist), trypsin (PAR-2 natural activator), and weak acid (pH 4, 5, and 6) were added to either the apical or basolateral compartment to evaluate their effects on transepithelial electrical resistance (TEER) and IL-8 production. PAR-2 localization was examined both in the cell model and biopsies from GERD patients by immunohistochemistry. Apical trypsin stimulation induced IL-8 accompanied by decreased TEER in vitro, whereas the effective concentration from the basolateral side was 10 times lower. SLIGKV-NH2 from basolateral but not apical stimulation induced IL-8 production. Apical weak acid stimulation did not influence TEER or IL-8 production. Immunohistochemistry showed intense reactivity of PAR-2 in the basal and suprabasal layers after stimulation with trypsin. A similar PAR-2 reactivity that was mainly located at the basal and suprabasal layers was detected in GERD patients. In conclusion, the activation of the PAR-2-IL-8 pathway probably occurred at the basal and suprabasal layers, while the esophageal epithelial barrier may influence the activation of PAR-2. Under proton pump inhibitor therapy, refluxed trypsin may remain active and be a potential agent in the pathogenesis of refractory GERD.

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.

The effect of baclofen on nocturnal gastroesophageal reflux and measures of sleep quality: a randomized, cross-over trial

BACKGROUND

Baclofen, a GABA(b) agonist, has been shown to reduce episodes of gastroesophageal reflux (GER). To determine if baclofen would significantly reduce reflux during sleep, and also improve objective and subjective measures of sleep.

METHODS

Twenty-one individuals with complaints of nighttime heartburn at least twice a week and a Carlsson GERD score of at least 5 were studied. Patients underwent polysomnography (PSG) and simultaneous esophageal pH monitoring on two occasions separated by approximately 1 week in a cross-over design. The night of each polysomnographic study, patients consumed a refluxogenic meal. Baclofen (40 mg) or placebo was given in random order 90 min prior to the start of the PSG.

KEY RESULTS

Baclofen significantly reduced the number of reflux events compared with placebo. Upright and recumbent acid contact times were both reduced by baclofen vs placebo, but the differences were not significant. Regarding sleep outcomes, several variables were significantly improved by baclofen. Total sleep time and sleep efficiency increased, and wake after sleep onset decreased in the baclofen condition compared with placebo. Proportion of Stage 1 sleep was also significantly decreased on baclofen.

CONCLUSIONS & INFERENCES

In addition to reducing the number of reflux events during sleep, baclofen significantly improved several measures of sleep in patients with documented GER and sleep disturbances. Baclofen could therefore be considered as a useful adjunct therapy to proton pump inhibitors (PPIs) in patients with nighttime heartburn and sleep disturbance who continue to have heartburn and/or sleep complaints despite PPI therapy.

Therapeutic options for refractory gastroesophageal reflux disease

Refractory gastroesophageal reflux disease may affect up to one-third of the patients that consume proton pump inhibitor (PPI) once daily. Treatment in clinical practice has been primarily focused on doubling the PPI dose, despite lack of evidence of its value. In patients who failed PPI twice daily, medical treatment has been primarily focused on reducing transient lower esophageal sphincter relaxation rate or attenuating esophageal pain perception using visceral analgesics. In patients with evidence of reflux as the direct trigger of their symptoms, endoscopic treatment or antireflux surgery may be helpful in remitting symptoms. The role of psychological interventions, as well as non-traditional therapeutic strategies remains to be further elucidated.

Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease

To assess adherence to proton pump inhibitor (PPI) treatment and associated variables in patients with gastroesophageal reflux disease (GERD). Cross-sectional and prospective comprising 240 consecutive adult patients, diagnosed with GERD for whom continuous use of standard or double dose of omeprazole had been prescribed. Patients were ranked as ne-GERD (162: 67.5%) or e-GERD classified according to the Los Angeles classification as A (48:20.0%), B (21:8.6%), C (1:0.5%), D (1:0.5%), and Barrett's esophagus (7:2.9%). The Morisky questionnaire was applied to assess adherence to therapy and a GERD questionnaire to assess symptoms and their impact. Adherence was correlated with demographics, cotherapies, comorbidities, treatment duration, symptoms scores, endoscopic findings, and patient awareness of their disease. 126 patients (52.5%) exhibited high level of adherence and 114 (47.5%) low level. Youngers (P= 0.002) or married (O.R. 2.41, P= 0.03 vs. widowers) patients had lower levels of adherence; symptomatic patients exhibited lower adherence (P= 0.02). All other variables studied had no influence on adherence. Patients with GERD attending a tertiary referral hospital in São Paulo exhibited a high rate of low adherence to the prescribed PPI therapy that may play a role in the therapy failure. Age <60 years, marital status and being symptomatic were risk factors for low adherence.

Development of a refractory gastro-oesophageal reflux score using an administrative claims database

BACKGROUND

Approximately one-third of gastro-oesophageal reflux disease (GERD) patients demonstrate refractory symptoms following treatment with proton pump inhibitor (PPI) therapy.

AIM

To develop a refractory GERD score that can be applied to predict patients' healthcare utilisation.

METHODS

We enrolled adults (≥18 years) with a diagnosis of GERD. Refractory GERD was evaluated on an 8-point scale where 1 point was given for each of the following criteria: doubling, addition, or switching of GERD medication dose, receipt of a GERD-related endoscopic procedure or surgery, or ≥3 GERD-related outpatient visits. Refractory GERD was defined as the presence of two or more points.

RESULTS

A total of 135,139 GERD patients (44% male) were analysed with a mean (±s.d.) age of 52.9 ± 15 years. The mean overall refractory GERD score was 1.12 ± 1.2 (range 0-8 on an 8-point scale); 31% of patients had refractory GERD with a mean score of 2.56 ± 0.82. Among patients with refractory GERD, 31% doubled their GERD medication, 28% added a new GERD medication, 60% switched GERD medications, 54% had a GERD-related procedure and 1% had a GERD-related surgery. Patients with refractory GERD were more likely to be female (59% vs. 55%, P < 0.001) and had a higher co-morbidity score (0.78 vs. 0.56, P < 0.001). The overall mean costs for refractory patients during the study period were significantly higher compared with treatment-responsive patients ($18,088 ± $36,220 vs. $11,044 ± $22,955, P < 0.001).

CONCLUSIONS

Refractory GERD was present in approximately one-third of the GERD patients. We created a GERD refractory score that could define need for increased anti-reflux therapy and predict higher healthcare resource utilisation.

Brain processing of visceral sensation upon esophageal chemical stimulation in different types of GERD

We designed to investigate the cortical response to esophageal acid exposure in different types of gastroesophageal reflux disease (GERD) by functional magnetic resonance imaging (fMRI). Fifteen healthy volunteers, 13 with reflux esophagitis (RE), 12 with non-erosive reflux disease with abnormal acid reflux (NERD+) and nine with non-erosive reflux disease with normal acid reflux (NERD-) received intraesophageal perfusion with isotonic saline followed by 0.1 N hydrochloric acid. Modified block-design model of fMRI scanning was performed simultaneously to the intraesophageal perfusion. The sensitized regions in different types of GERD were not completely identical but were more widely distributed compared to the sensitized regions in the healthy individuals. The activated intensity of the ACC was significantly higher in the healthy volunteers compared to the GERD patients (P<0.001). Nevertheless, healthy volunteers exhibited a significantly lighter intensity in the right side of the DLPFC (P<0.001) and a lower intensity in the left side of the insula than the GERD patients (P<0.05). In conclusion, the underlying central mechanisms of esophageal visceral sensation in different types of GERD patients are quite different. The deactivation of the ACC, the activation of the right side of the DLPFC and the right side of the insula may play an important role in the occurrence of GERD.

The hypersensitive esophagus: pathophysiology, evaluation, and treatment options

Visceral hypersensitivity plays a key role in the pathogenesis of esophageal functional disorders such as functional heartburn and chest pain of presumed esophageal origin (noncardiac chest pain). About 80% of patients with unexplained noncardiac chest pain exhibit lower esophageal sensory thresholds when compared to controls during esophageal sensory testing (ie, esophageal barostat, impedance planimetry). Such information has led to prescription of peripherally and/or centrally acting therapies for the management of these patients. This review summarizes and highlights recent and significant findings regarding the pathophysiology, evaluation, and treatment of the hypersensitive esophagus, a central factor in functional esophageal disorders.