Effects of age on the gastroesophageal junction, esophageal motility, and reflux disease

Characteristics of Laryngopharyngeal Reflux in Patients of Different Genders and Ages

OBJECTIVES

To investigate the differences in laryngopharyngeal reflux (LPR) characteristics between gender and age groups based on the Reflux Symptom Index (RSI), Reflux Finding Score (RFS) scale and 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (HEMII-pH) monitoring.

METHODS

The enrolled were patients with LPR symptoms completed the 24h-HEMII-pH monitoring and divided into two gender groups (male and female) and elderly group (>60 years), middle-aged group (41-60 years) and young group (18-40 years). The total RSI and RFS scores of individuals were counted. Various potential differences as well as incidence of each type of LPR events between gender and age groups were analyzed.

RESULTS

A total of 420 patients were included, with 333 (79.3%) diagnosed with LPR confirmed by 24h-HEMII-pH monitoring. Females (n=49) had a statistically higher LPR positivity (91.0% vs. 76.6%, P < 0.01) than males (n=342). Female patients with LPR had significantly higher RSI scores (14.08 ± 6.72 vs. 11.08 ± 4.82, P < 0.001) than male patients. The positive rate of LPR were 82.6%, 80.7% and 63.3% in the elderly, middle-aged and young groups. The Elderly group had significantly lower RSI scores (10.20 ± 4.06 vs. 12.80 ± 6.58, 12.24 ± 5.57, P < 0.001) but higher RFS scores (9.37 ± 3.25 vs. 8.16 ± 3.34, 8.57 ± 2.58, P < 0.05) than the other two groups. The number of acid hypopharyngeal-proximal reflux episodes (HREs) and distal esophageal acid reflux were significantly higher in elderly than in young patients. Except for non-acid gas HREs, the positive rates of other types of HREs were increasing from young to middle-aged to the elderly group (P < 0.05).

CONCLUSIONS

Female patients with suspected LPR symptoms had a higher positive rate of LPR and RSI score than males. The prevalence of LPR and the number of acid reflux were progressively increasing with age, but the perception of reflux symptoms may diminish.

Long-term efficacy of on-demand vonoprazan treatment for mild reflux esophagitis: success rates and predictors of treatment failure

BACKGROUND

Concerns surrounding long-term proton pump inhibitor use have prompted the exploration of alternative treatments for reflux esophagitis (RE). We previously demonstrated that 24 weeks of on-demand treatment with vonoprazan, a potassium-competitive acid blocker, effectively managed mild RE (Los Angeles classification grade A/B) in more than 80% of patients. However, its long-term efficacy remains unknown. Therefore, the present study investigated sustained effectiveness.

METHODS

We conducted a retrospective observational study on 30 participants with mild RE from our previous research. Participants with recurrent RE or symptom exacerbation were excluded and considered as treatment failure. Participants with the remission of RE and reflux symptoms under on-demand treatment until the clinic visit between October 2023 and February 2024 were regarded as treatment success. Predictors of treatment failure were analyzed.

RESULTS

During the observation period, 5 participants failed treatment due to symptom exacerbation and 6 due to recurrent RE. Five participants were excluded from analyses due to non-GERD causes. Fourteen participants (56.0%) successfully continued on-demand treatment for 91.5 months [89.3-92.8]. Age > 67 years significantly predicted treatment failure with a sensitivity of 72.7% and specificity of 85.7%. Although none of the patients with RE grade A had recurrent RE, it was not a significant difference.

CONCLUSIONS

Approximately 50% of patients with mild RE successfully continued on-demand treatment for more than 7 years. Age > 67 years was identified as a predictor of treatment failure. Prospective multi-center studies are warranted to validate these results.

Differences in Diagnostic Rates After Hypopharyngeal-esophageal Impedance-pH Monitoring of Laryngopharyngeal Reflux Patients by Age and Sex

PURPOSE

To evaluate the differences in diagnostic rates according to the age and sex of patients with suspected laryngopharyngeal reflux (LPR) symptoms and completed the 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24h-HEMII-pH) monitoring.

METHODS

Patients with LPR symptoms underwent the 24h-HEMII-pH monitoring. We compared the diagnostic rates of LPR in patients with LPR symptoms according to age and sex. The number of reflux episodes and type of reflux were compared among patients who were confirmed to have LPR according to age and sex.

RESULTS

A total of 249 patients with suspected LPR symptoms who completed 24h-HEMII-pH monitoring were analyzed. A total of 170 patients (68.3%) were diagnosed with LPR after 24h-HEMII-pH monitoring. There were 57 (67.1%) men and 113 (68.9%) women. The old age group (older than 55 years) showed a statistically significant higher diagnostic rate than the young age group (73.5%, 60.8%, p=0.034). Women's diagnostic rate was statistically higher in the old age group than that in the young age group (75% vs. 58.3%, p=0.026). There were no specific differences in the number of refluxes in the diagnosed patients between the age groups, and there were no differences in the initial reflux symptom index.

CONCLUSIONS

Among those who visited the clinic with suspected LPR symptoms and performed 24h-HEMII-pH monitoring, the diagnostic rate of LPR was higher in the older age group than that in the younger age group.

Medication use and risk of reflux oesophagitis

OBJECTIVE

Reflux oesophagitis (RO) is one of the most common diseases encountered by gastroenterologists and primary care physicians. However, few epidemiological studies have investigated the association of medication use and RO. This study aimed to investigate the prevalence of RO and its risk factors, particularly with respect to medication use.

METHODS

This retrospective, cross-sectional study included consecutive patients who underwent oesophagogastroduodenoscopy (OGD) and were assessed using questionnaires at the National Center for Global Health and Medicine (Shinjuku, Tokyo, Japan) between October 2015 and December 2021. The questionnaire collected data on patient characteristics, medical history, smoking and alcohol consumption, and medications that patients were taking at the time of OGD.

RESULTS

Among the 13 993 eligible patients, the prevalence of RO was 11.8%. Multivariate logistic regression analysis indicated that male sex (OR=1.52 (95% CI 1.35 to 1.72), p<0.001); obesity (OR=1.57 (95% CI 1.40 to 1.77), p<0.001); smoking (OR=1.19 (95% CI 1.02 to 1.38), p=0.026); alcohol consumption (OR=1.20 (95% CI 1.07 to 1.35), p=0.002); diabetes (OR=1.19 (95% CI 1.02 to 1.39), p=0.029); hiatal hernia (OR=3.10 (95% CI 2.78 to 3.46), p<0.001); absence of severe gastric atrophy (OR=2.14 (95% CI 0.39 to 0.56), p<0.001); and the use of calcium channel blockers (CCBs) (OR=1.22 (95% CI 1.06 to 1.40), p=0.007), theophylline (OR=2.13 (95% CI 1.27 to 3.56), p=0.004), and non-steroidal anti-inflammatory drugs (NSAIDs) (OR=1.29 (95% CI 1.03 to 1.61), p=0.026) were independent predictors of RO.

CONCLUSION

RO was present in 11.8% of patients. Use of CCBs, theophylline, and NSAIDs were independent predictors of RO.

Update Motility Disorders: Gastro-Oesophageal Reflux Disease - Diagnostic and Conservative Approach

Background

Gastro-oesophageal reflux disease (GORD) is extremely common, with at least 1 in 10 people in the general population reporting heartburn and acid regurgitation on a weekly basis. GORD can also be associated with a variety of atypical symptoms, including chest pain, chronic cough, and laryngopharyngeal symptoms. The causes of GORD are multifactorial, and the severity of symptoms is influenced by peripheral and central factors, including psychosocial stress and anxiety. Therefore, for a variety of reasons, no single investigation provides a definitive diagnosis, and standard treatment with acid suppressants is not always effective.

Summary

This review introduces the Lyon Consensus, now in its second iteration, a classification system that provides a "conclusive" positive or negative diagnosis of GORD by integrating the results of endoscopy, ambulatory reflux monitoring, and high-resolution manometry. Different algorithms are applied to patients with high and low pre-test probability of a causal relationship between reflux episodes and patient symptoms. The results of these studies identify patients with "actionable" results that require escalation, revision, or discontinuation of GORD treatment. Guidance is provided on the range of conservative treatments available for GORD, including dietary and lifestyle advice, antacids and alginates, and drugs that suppress acid secretion.

Key Messages

GORD is a common disorder; however, the causes of reflux and symptoms can be complex. As a result, the diagnosis can be missed, and management is sometimes challenging, especially for patients with atypical symptoms. The Lyon classification establishes a conclusive diagnosis of GORD, based on results of endoscopic and physiological investigation. Typical symptoms usually respond to empiric use of alginate-antacid preparations and acid suppression; however, the management of treatment refractory symptoms is tailored to the individual.

Reflux, eosinophilic esophagitis, and celiac disease - the blurred lines

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) is a commonly recognized cause of dysphagia. Conversely, eosinophilic esophagitis (EoE) and celiac disease are rarer and often overlooked as dysphagia culprits. Overlap between these conditions complicates diagnosis and delays appropriate treatment. This review aims to clarify the distinctive dysphagia characteristics in each condition, explore potential overlaps, and offer guidance on differentiation.

RECENT FINDINGS

Recent studies have advanced our understanding of dysphagia mechanisms in GERD, EoE, and celiac disease, particularly in characterizing disordered motility and dysphagia's natural history. While upper endoscopy, biopsies, and manometry remain crucial in dysphagia assessment, novel diagnostic tools are emerging. New insights highlight the significance of cytokine-induced mucosal injury in all three conditions, revealing potential connections where mucosal damage in one disorder may contribute to the development of others.

SUMMARY

GERD, EoE, and celiac disease can coexist and present with similar symptoms. Distinguishing between them often entails upper endoscopy, esophageal biopsies, pH testing, and celiac serologies. EoE should be considered when GERD patients fail proton pump inhibitor therapy or when celiac patients have persistent esophageal symptoms despite a gluten-free diet. Consider celiac disease if dysphagia accompanies iron deficiency anemia, malabsorptive diarrhea, or osteoporosis. Recognizing the potential overlap between these conditions is crucial for guiding clinical evaluation and therapy.

The relationship between gastrointestinal symptoms in FGID patients and D-type personality and emotion regulation strategies

This study examines the relationship between gastrointestinal symptoms in patients with functional gastrointestinal disorders (FGIDs) and type D personality traits, as well as emotion regulation strategies. Analyzing a diverse group of FGID patients, we uncover significant effects of gender and age on gastrointestinal symptoms. Negative Affectivity emerges as a key predictor, positively associated with symptom severity, whereas Social Inhibition correlates negatively with Abdominal Pain. Additionally, our findings suggest that the expressive suppression strategy predicts heightened gastrointestinal symptoms, whereas cognitive reappraisal predicts lower levels of certain symptoms. These findings provide valuable insights for precise diagnosis and tailored treatments of FGIDs. Further research is warranted to explore underlying mechanisms and inform evidence-based interventions.

Esophageal Motility Abnormalities in Lung Transplant Recipients With Esophageal Acid Reflux Are Different From Matched Controls

Background/Aims

There is an increased incidence of gastroesophageal reflux disease (GERD) after lung transplantation (LT) that can be associated with graft dysfunction. It is unclear if the underlying esophageal motility changes in GERD are different following LT. This study aimed to use esophageal high-resolution manometry (HRM) to explore GERD mechanisms in LT recipients compared to matched controls.

Methods

This was a retrospective study including patients with pathologic acid reflux who underwent HRM and pH testing at our healthcare facility July 2012 to October 2019. The study included 12 LT recipients and 36 controls. Controls were matched in a 1:3 ratio for age, gender, and acid exposure time (AET).

Results

LT recipients had less hypotensive esophagogastric junction (EGJ) (mean EGJ-contractile integral 89.2 mmHg/cm in LT vs 33.9 mmHg/cm in controls, P < 0.001). AET correlated with distal contractile integral and total EGJ-contractile integral only in LT group (r = -0.79, P = 0.002 and r = -0.57, P = 0.051, respectively).

Conclusions

Following LT, acid reflux is characterized by a less hypotensive EGJ compared to controls with similar AET. The strongest correlation with AET after LT was found to be esophageal peristaltic vigor. These results add to the understanding of reflux after LT and may help tailor an individualized treatment plan.

Esophageal motor abnormalities in gastroesophageal reflux disorders

Gastroesophageal reflux disease (GERD), a prevalent condition with multifactorial pathogenesis, involves esophageal motor dysmotility as a key contributing factor to its development. When suspected GERD patients have an inadequate response to proton-pump inhibitor (PPI) therapy and normal upper endoscopy results, high-resolution manometry (HRM) is utilized to rule out alternative diagnosis such as achalasia spectrum disorders, rumination, or supragastric belching. At present, HRM continues to provide supportive evidence for diagnosing GERD and determining the appropriate treatment. This review focuses on the existing understanding of the connection between esophageal motor findings and the pathogenesis of GERD, along with the significance of esophageal HRM in managing GERD patients. The International GERD Consensus Working Group introduced a three-step method, assessing the esophagogastric junction (EGJ), esophageal body motility, and contraction reserve with multiple rapid swallow (MRS) maneuvers. Crucial HRM abnormalities in GERD include frequent transient lower esophageal sphincter relaxations, disrupted EGJ, and esophageal body hypomotility. Emerging HRM metrics like EGJ-contractile integral and innovative provocative maneuver like straight leg raise have the potential to enhance our understanding of factors contributing to GERD, thereby increasing the value of HRM performed in patients who experience symptoms suspected of GERD.

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.

The Time-Point Distribution Characteristics of Laryngopharyngeal Reflux in Elderly Patients

OBJECTIVE

To identify the characteristics of the time-point distribution of the occurrence of hypopharyngeal-proximal reflux episodes (HREs) in elderly and younger patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Retrospective cohort study.

SETTING

Analysis of data from patients with LPR-related symptoms and 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24-hour HEMII-pH) monitoring from February 2017 to September 2022 at Sixth Medical Center of PLA General Hospital.

METHODS

Patients were divided into 2 age groups: the elderly group (>60 years) and the younger group (≤60 years). The time series of HREs and meals within 24 hours were analyzed based on HEMII-pH.

RESULTS

A total of 305 patients were included (126 elderly patients). In younger patients, except for nonacid-gas HREs, the incidence of the remaining types of HREs tended to increase within 2 hours after meals, especially after dinner. The incidence of all types of HREs pre- and postmeal was not significantly different in the elderly group (χ2  = 0.080, P = .777). The incidence of nighttime HREs in elderly patients was statistically higher than in younger patients (6.23% vs 3.96%, P = .030), particularly acid-/nonacid-liquid HREs.

CONCLUSION

HREs tend to increase within 2 hours after meals in younger LPR patients, except for nonacid-gas HREs. In elderly LPR patients, the incidence of all types of HREs pre- and postmeal were not significantly different, and nighttime fluid HREs was more prone to occur than in younger patients.

Endoscopic plication compared to laparoscopic fundoplication in the treatment of gastroesophageal reflux disease: a systematic review and meta-analysis

INTRODUCTION

Endoscopic plication offers an alternative to surgical fundoplication for treatment of gastroesophageal reflux disease (GERD). This systematic review and meta-analysis evaluate outcomes following endoscopic plication compared to laparoscopic fundoplication.

METHODS AND PROCEDURES

Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in September 2022. Study followed PRISMA guidelines. Studies comparing endoscopic plication to laparoscopic fundoplication with n > 5 were included. Primary outcome was PPI cessation, with secondary outcomes including complications, procedure duration, length of stay, change in lower esophageal sphincter (LES) tone, and DeMeester score.

RESULTS

We reviewed 1544 studies, with five included comparing 105 (46.1%) patients receiving endoscopic plication (ENDO) to 123 (53.9%) undergoing laparoscopic fundoplication (LAP). Average patient age was 47.6 years, with those undergoing plication being younger (46.4 ENDO vs 48.5 LAP). BMI (26.6 kg/m² ENDO vs 26.2 kg/m² LAP), and proportion of females (42.9% ENDO vs 37.4% LAP) were similar. Patients undergoing laparoscopic procedures had worse baseline LES pressure (12.8 mmHg ENDO vs 9.0 mmHg LAP) and lower preoperative DeMeester scores (34.6 ENDO vs. 34.1 LAP). The primary outcome demonstrated that 89.2% of patients undergoing laparoscopic fundoplication discontinued PPI compared to 69.4% for those receiving plication. Meta-analysis revealed that plication had significantly reduced odds of PPI discontinuation (OR 0.27, studies = 3, 95% CI 0.12 to 0.64, P = 0.003, I² = 0%). Secondary outcomes demonstrated that odds of complications (OR 1.46, studies = 4, 95% CI 0.34 to 6.32, P = 0.62, I² = 0%), length of stay (MD - 1.37, studies = 3, 95% CI - 3.48 to 0.73, P = 0.20, I² = 94%), and procedure durations were similar (MD 0.78, studies = 3, 95% CI - 39.70 to 41.26, P = 0.97, I² = 98%).

CONCLUSIONS

This is the first meta-analysis comparing endoscopic plication to laparoscopic fundoplication. Results demonstrate greater likelihood of PPI discontinuation with laparoscopic fundoplication with similar post-procedural risk.

Revisiting the Mucosa of the Gastric Cardia: A Scope to Modify an Upper Gastrointestinal Endoscopy

Introduction The mucosa in the cardiac region of the stomach has been less understood. Cardiac mucosa (CM) with less parietal and oxyntic cells has been defined as a normal mucosa. Studies have shown that CM can be the result of occult reflux. Oxyntic mucosa (OM) is normal, and it changes to CM with age. In advancing age, it is more common to find CM instead of OM and oxyntocardiac mucosa (OCM). This study is an attempt to examine the distribution of the three different types of mucosa in various age groups. Materials and methods The study was conducted in the Department of Anatomy and Department of Forensic Medicine and Toxicology of Gauhati Medical College, Guwahati, Assam, India, from 2017 to 2019. Once the stomach was opened, histological specimens were prepared, and the type of mucosa was observed and recorded. Then, the distribution of the types of mucosa in various age groups was analyzed. Results The distribution of mucosa varies significantly across different age groups, and CM increases with age. Conclusion Our present study suggests that CM frequency increases with age. This is in accordance with studies that suggest that CM is a result of occult reflux with age. This observation creates a scope to revise the approaches for upper gastrointestinal (GI) endoscopy.

Safety and Tolerability of Antimicrobial Agents in the Older Patient

Older patients are at high risk of infections, which often present atypically and are associated with high morbidity and mortality. Antimicrobial treatment in older individuals with infectious diseases represents a clinical challenge, causing an increasing burden on worldwide healthcare systems; immunosenescence and the coexistence of multiple comorbidities determine complex polypharmacy regimens with an increase in drug-drug interactions and spread of multidrug-resistance infections. Aging-induced pharmacokinetic and pharmacodynamic changes can additionally increase the risk of inappropriate drug dosing, with underexposure that is associated with antimicrobial resistance and overexposure that may lead to adverse effects and poor adherence because of low tolerability. These issues need to be considered when starting antimicrobial prescriptions. National and international efforts have been made towards the implementation of antimicrobial stewardship (AMS) interventions to help clinicians improve the appropriateness and safety of antimicrobial prescriptions in both acute and long-term care settings. AMS programs were shown to decrease consumption of antimicrobials and to improve safety in hospitalized patients and older nursing home residents. With the abundance of antimicrobial prescriptions and the recent emergence of multidrug resistant pathogens, an in-depth review of antimicrobial prescriptions in geriatric clinical practice is needed. This review will discuss the special considerations for older individuals needing antimicrobials, including risk factors that shape risk profiles in geriatric populations as well as an evidence-based description of antimicrobial-induced adverse events in this patient population. It will highlight agents of concern for this age group and discuss interventions to mitigate the effects of inappropriate antimicrobial prescribing.

Clinical efficacy and mechanism of transcutaneous neuromodulation on ineffective esophageal motility in patients with gastroesophageal reflux disease

BACKGROUND

Esophageal motility disorder is one of the pathogenesis of gastroesophageal reflux disease (GERD). The clinical and functional relationship between the ineffective esophageal motility (IEM) and GERD have been found. PPI is a widely used drug of this diaease, but some patients have poor efficacy. The purpose of this study was to investigate the efficacy and possible mechanism of Transcutaneous Neuromodulation in these patients.

METHODS

Fifty-six patients with GERD with IEM were enrolled and randomly divided into two groups, one group was TN ST-36 group, the other group was sham TN group. The GERD questionnaire (GerdQ), quality of life score, MOS item short from health survey (SF-36), Hospital Anxiety and Depression Scale (HADS) were used to assess the severity of symptoms. High-resolution esophageal manometry (HRM) test was performed to assess low esophageal sphincter (LES) pressure and distal contractile integral (DCI). The heart rate variability (HRV) test was performed to assess autonomic nervous function.

KEY RESULTS

Compared with sham TN, chronic TN treatment decreased the GERD-Q score (p < 0.001). The anxiety score (p = 0.058) and depression score (p = 0.156) were decreased, but there were no statistical differences. Chronic TN treatment also significantly improved the quality of life of patients, mainly in physical function, physical pain, overall health, vitality, social function, emotional function, and mental health. Acute TN treatment increased the DCI (p < 0.001) and LES pressure (p < 0.001) significantly and decreased the combined percentage of failed and weak peristalsis (p < 0.001). Concurrently, acute TN enhanced vagal activity (p < 0.001).

CONCLUSIONS AND INFERENCES

IEM is an important link in the pathogenesis of GERD. Chronic TN treatment can significantly improve the clinical symptoms of patients. Acute TN treatment can significantly increase LES pressure and DCI and reduce the frequency of esophageal lost peristalsis and weak peristalsis. The improvement of esophageal motility in GERD patients with IEM by TN treatment may be related to the regulation of autonomic nervous function.

The association between shift work and the incidence of reflux esophagitis in Korea: a cohort study

Shift work has adverse health effects such as diabetes, cardiovascular disease, sleep disturbance, depression, and breast cancer. Gastro-esophageal reflux disease (GERD) results in lesions such as reflux esophagitis (RE) and Barrett's esophagus. This study investigated the association between shift work and RE. A cohort study was conducted with 140,553 participants who were followed up at least once from 2012 to 2018. Type of working and shift types were collected using standardized questionnaires. Esophagogastroduodenoscopy (EGD) was performed by experienced endoscopists who were blinded to the aims of this study. According to the Los Angeles classification, RE was categorized based on the extent of esophageal mucosal breaks. During the 469,217.2 person-years of follow-up, 35,185 participants developed incident cases of RE. The multivariable adjusted hazard ratio (95% confidence intervals) for incident cases comparing shift work to fixed day work was 1.09 (1.04-1.13). This association was more strongly observed in the younger age group (18-39 years old) and the female group. In conclusion, shift work was significantly associated with the incidence of RE. Particularly, the results were more significant in the younger and female groups.

Usefulness of Endoscopy for the Detection and Diagnosis of Primary Esophageal Motility Disorders and Diseases Relating to Abnormal Esophageal Motility

Esophagogastroduodenoscopy (EGD) is performed to rule out organic diseases in the diagnosis of esophageal motility disorders (EMDs). Abnormal endoscopic findings can be observed during EGD, which indicate the presence of EMDs. Several endoscopic findings at both the esophagogastric junction and esophageal body that are related to EMDs have been reported. Gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) could be detected during EGD, and these diseases are often associated with abnormal esophageal motility. Image-enhanced endoscopy (IEE) could improve the detection of these diseases during EGD. Although no report has been published previously on the potential usefulness of IEE in the endoscopic diagnosis of EMDs, IEE can be used to detect disorders that can be associated with abnormal esophageal motility.

Dietary factors involved in GERD management

Gastroesophageal reflux disease (GERD) is extremely common, and even modest weight gain has been associated with higher symptom burden as well as objective evidence of reflux on endoscopy and physiological measurement. Certain trigger foods, especially citrus, coffee, chocolate, fried food, spicy food and red sauces are frequently reported to worsen reflux symptoms, although hard evidence linking these items to objective GERD is lacking. There is better evidence that large meal volume and high calorie content can increase esophageal reflux burden. Conversely, sleeping with the head end of the bed raised, avoiding lying down close to meals, sleeping on the left side and weight loss can improve reflux symptoms and objective reflux evidence, especially when the esophagogastric junction 'reflux barrier' is compromised (e.g., in the presence of a hiatus hernia). Consequently, attention to diet and weight loss are both important elements of management of GERD, and need to be incorporated into management plans.

Treating and Managing Laryngopharyngeal Reflux Disease in the Over 65s: Evidence to Date

PURPOSE

The clinical presentation and therapeutic outcomes of elderly patients may be different from those in younger populations, leading to additional diagnostic and therapeutic difficulties. The present study reviewed the findings on the epidemiology, and clinical, diagnostic, and therapeutic outcomes of elderly patients with laryngopharyngeal reflux (LPR).

METHODS

A PubMed, Cochrane Library, and Scopus literature search was conducted on the epidemiological, clinical, diagnostic, and therapeutic findings of elderly LPR patients.

FINDINGS

The prevalence of LPR in the elderly population remains unknown. From a clinical standpoint, older LPR patients report overall lower symptom scores and related quality-of-life outcomes at the time of the diagnosis. The required treatment time to obtain symptom relief appears to be longer in older compared with younger patients. Particular attention needs to be paid to prolonged medication use because the elderly population is characterized by polypharmacy and there is a higher risk of proton-pump inhibitor (PPI) interactions and adverse events. The plasma clearance of most PPIs is reduced with age, which must be considered by practitioners in the prescription of antireflux therapy.

CONCLUSION

The clinical presentation and treatment efficacy of elderly LPR patients differ from those in younger patients. Practitioners need to carefully consider the risk of drug interactions and adverse events in elderly patients.

Gastroesophageal Reflux Disease Symptoms after Laparoscopic Sleeve Gastrectomy: A Retrospective Study

(1) Background: Laparoscopic sleeve gastrectomy (LSG) is widely performed in bariatric surgery. However, the prevalence and risk factors of gastroesophageal reflux disease (GERD) symptoms after LSG remain unclear to date. This study aimed to identify risk factors of GERD after LSG. (2) Methods: We conducted a retrospective study at Linkou Chang Gung Memorial Hospital and reviewed 296 patients who underwent LSG from 2016 to 2019. A total of 143 patients who underwent preoperative esophagogastroduodenoscopy and completed the 12-month postoperative follow-up were enrolled. Patients’ demographic data, comorbidities, and postoperative weight loss results were recorded for analysis. The GerdQ questionnaire was used to assess GERD after LSG. (3) Results: There were eight surgical complications (5.6%) among the 143 studied patients (median age, 36 years; 56 (39.2%) men; median body weight 105.5 kg; median body mass index [BMI], 38.5 kg/m2). Twenty-three patients (16.1%) developed de novo GERD symptoms. GERD was significantly associated with older age (p = 0.022) and lower BMI (<35 kg/m2, p = 0.028). In multiple logistic regression analysis, age and BMI were significantly associated with GERD. (4) Conclusions: LSG is a safe and effective weight loss surgery. In our study, it led to 16.1% of de novo GERD symptoms, which were significantly related to older age and lower BMI (<35 kg/m2).

Clinical Implications of the Gastroesophageal Reflux Disease Questionnaire and Reflux Symptom Index in Patients With Suspected Laryngopharyngeal Reflux Symptoms

Background/Aims

To evaluate the usefulness of gastroesophageal reflux disease questionnaire (GerdQ) and reflux symptom index (RSI) for diagnosis of gastroesophageal reflux disease (GERD) in patients with suspected laryngopharyngeal reflux (LPR) symptoms (cough, hoarseness, globus, and throat pain).

Methods

A total of 98 patients with LPR symptoms were incorporated from either gastroenterology or otorhinolaryngology clinic. Patient’s laryngoscopic findings were graded by reflux finding score (RFS), and RFS ≥ 7 was considered as positive LPR. Erosive esophagitis on endoscopy or abnormal results on ambulatory impedance-pH monitoring were used as diagnostic criteria for GERD. Esophageal motor function was evaluated using high-resolution esophageal manometry.

Results

Ninety-three (94.9%) of the 98 subjects were diagnosed as LPR by RFS, but only 15 (15.3%) had GERD. For GerdQ, the cutoff value of 9 showed the highest area under curve (AUC) to diagnose GERD by receiver operating curve analysis (AUC = 0.565); the sensitivity, specificity, positive predictive value, and negative predictive value were unsatisfactory (50.0%, 70.7%, 22.6%, and 89.2%, respectively.) RSI also showed poor performance in diagnosing GERD; the cutoff value of 25 showed the highest yield (AUC = 0.581); the sensitivity, specificity, positive predictive value, and negative predictive value were 42.9%, 79.3%, 26.1%, and 89.0%, respectively. Ineffective esophageal motility was frequently observed (69 of 98, 70.4%), but there was no difference in esophageal motility parameters between GERD and non-GERD patients.

Conclusions

In patients with LPR symptoms, significant discrepancies are observed between laryngoscopic diagnosis and GERD. In this population, neither GerdQ nor RSI is useful in diagnosing GERD.

Aging Combined with High Waist-to-Hip Ratio Is Associated with a Higher Risk of Gastro-Esophageal Reflux Disease

Background and Objective: To assess whether the combination of high waist-to-hip ratio (WHR) and elderly age is associated with higher risk of GERD. Material and Methods: A total of 16,996 subjects aged ≥20 years who received esophagogastroduodenoscopy (EGD) between January 2010 and December 2019. We evaluated the risk of GERD in different age groups and WHR groups in unadjusted analysis and multivariate logistic regression models for predictors of GERD. Results: There was a trend towards more participants with both age ≥65 years and WHR ≥ 1 (n = 129) (n = 66, 51%) than participants with age < 65 and WHR < 0.9 (n = 10,422) (n = 2814, 27%) presenting with GERD. Participants who had both age ≥ 65 years and high WHR ≥ 1 had the highest risk of any type of GERD (adjusted OR, 2.07; 95% CI, 1.44−2.96, p value < 0.05) based on multivariate logistic regression analysis. Conclusions: The combination of having a high WHR and being elderly was associated with a higher risk of GERD, and preventing central obesity in the elderly population reduced the risk of GERD and the requirement for medical resources.

The role of hormones in symptoms and pathophysiology of reflux and esophageal motility disorders

PURPOSE

A few studies suggest that hormones play a role in the motility of the lower esophagus, but data is rare. In this prospective study we evaluated the correlation between hormones (TSH, fT3, fT4, calcitonin, gastrin, and VIP) and gastroesophageal reflux disease (GERD), esophageal motility disorders, and gastrointestinal symptoms.

METHODS

100 consecutive patients with reflux symptoms and dysphagia were hospitalized for diagnostic evaluation. Self-reporting questionnaires were handed out and patients routinely underwent serum analysis (TSH, fT3, fT4, calcitonin, gastrin, and VIP), 24-hour-pH-impendance monitoring, and high-resolution manometry.

RESULTS

Motility disorders were found in 38 out of 86 patients. There were no correlations between hormones, the DeMeester Score, and the lower esophageal sphincter pressure. A strong inverse relation between calcitonin and the Integrated Relaxation Pressure of the esophagogastric junction was found (r=-0.492; p<0.001). No correlations were found between hormone levels and the responses given in the questionnaires. Positive correlations, however, were found between VIP and gastrointestinal symptoms, as well as correlations between fT3 and dysphagia. Within the group with minor motility disorders, TSH and fT4 correlated with outcomes of the SCL-questionnaire. fT4 correlated with the typical symptoms, as well as the gastrointestinal symptoms (diarrhea, constipation, flatulence). TSH correlated with the typical symptoms. Moreover, a correlation between VIP and gas-bloat-symptoms was found within group II CONCLUSIONS: No correlation between TSH, fT3, fT4, gastrin, VIP, calcitonin, and GERD in the sense of acid reflux was found, although calcitonin seems to have an effect on the lower esophageal sphincter.

Validation of the Lyon classification for GORD diagnosis: acid exposure time assessed by prolonged wireless pH monitoring in healthy controls and patients with erosive oesophagitis

OBJECTIVE

Acid exposure time (AET) from ambulatory pH studies and reflux oesophagitis are independent measurements used by the Lyon classification to diagnose GORD. This study aimed to validate AET reference ranges and diagnostic thresholds by analysis of 96-hour wireless pH studies from healthy, asymptomatic controls (HCs) and patients with and without oesophagitis.

DESIGN

HC and consecutive patients referred for wireless pH studies (off acid suppressants for >7 days) underwent 96-hour pH studies at two tertiary referral centres. Erosive oesophagitis was categorised by the Los Angeles (LA) classification. Linear regression and receiver operating curve (ROC) analysis were performed to define optimal diagnostic cut-offs.

RESULTS

Prolonged, 96-hour pH studies were completed in 39 HCs (age 28 (18-53) years, 72% female) and 944 patients (age 46 (16-85) years, 65% female), of whom 136 (14.5%) had reflux oesophagitis. Median AET in HC was 1.3% (upper 95th percentile 4.6%) for any study day and 2.6% (upper 95th percentile 6.9%) for the worst day (24-hour period) during the study. ROC analysis for average AET differentiated HC from patients with moderate-to-severe oesophagitis (LA BCD; sensitivity 87%, specificity 95%, positive predictive value (PPV) 59%, negative predictive value 99% for a cut-off AET of 4.3%; area under the receiver operating curve 0.95). Specificity was higher, but PPV was substantially lower for severe oesophagitis (LA CD). 'Worst-day' analysis provided similar results; however, day-to-day variability was high.

CONCLUSION

Diagnostic thresholds for average AET were identified that accurately discriminate between HCs and patients with erosive oesophagitis. The findings provide conditional support for diagnostic criteria for GORD proposed by the Lyon Consensus.

Clinical Characteristics of Esophageal Motility Disorders in Patients With Heartburn

BACKGROUND/AIMS

Esophageal motility disorders (EMDs) contribute to the pathophysiology of gastroesophageal reflux disease. However, the causes of EMDs and their impact on gastroesophageal reflux disease-associated symptoms remain unknown. This study aims to elucidate clinical features associated with various types of EMDs in patients with heartburn symptoms.

METHODS

Of the 511 patients who underwent high-resolution manometry, 394 who were evaluated for heartburn symptoms were examined. Patients subjected to high-resolution manometry were classified into 4 groups: outflow obstruction group, hypermotility group, hypomotility group, and normal motility group. Symptoms were evaluated using 3 questionnaires. Patient characteristics and symptoms for each EMD type were compared with those of the normal motility group.

RESULTS

Of the 394 patients, 193 (48.9%) were diagnosed with EMDs, including 71 with outflow obstruction, 15 with hypermotility, and 107 with hypomotility. The mean dysphagia score was significantly higher in each of the 3 EMD groups compared with those with normal motility. The mean acid reflux and dyspepsia scores were significantly lower in the outflow obstruction group (P < 0.05). The mean body mass index and median Brinkman index were significantly higher in the hypermotility group (P = 0.001 and P = 0.018, respectively), whereas the mean diarrhea and constipation scores were significantly lower in the hypomotility group (P < 0.05).

CONCLUSIONS

The results of our study indicate that different EMDs have distinct characteristics. Cigarette smoking and high body mass index were associated with esophageal hypermotility. Assessment of the dysphagia symptom scores may help identify patients with EMDs.

Impaired Proximal Esophageal Contractility Predicts Pharyngeal Reflux in Patients With Laryngopharyngeal Reflux Symptoms

OBJECTIVES

The pathophysiology of laryngopharyngeal reflux (LPR) remains incompletely understood. Proximal esophageal motor dysfunction may impair bolus clearance, increasing the risk of pharyngeal refluxate exposure. We aimed to evaluate the association of proximal esophageal contractility with objective reflux metrics.

METHODS

We evaluated adults with LPR symptoms undergoing high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing at a tertiary center between March 2018 and August 2019. Routine parameters per Chicago classification were obtained on HRM. Proximal esophageal contractility was evaluated using proximal contractile integral (PCI), which quantifies contractile pressure >20 mm Hg for the region spanning the distal margin of the upper esophageal sphincter and transition zone. Univariate (Kendall correlation and Student t test) and multivariable (general linear regression and logistic regression) analyses were performed.

RESULTS

We enrolled 138 patients (66.7% women, mean age 57.1 years) in this study. Lower PCI was associated with an elevated risk of increased pharyngeal reflux (adjusted odds ratio 0.83 per 100 mm Hg-s-cm change in PCI, 95% confidence interval: 0.69-0.98), with a trend toward increased bolus exposure time and total reflux events, after multivariable adjustment. The relationship between PCI and pharyngeal reflux was strongest among participants without a primary motility disorder on HRM (adjusted odds ratio 0.63, 95% confidence interval: 0.42-0.85, P interaction = 0.04). Among continuously expressed reflux parameters, lower PCI was significantly associated with more distal acid reflux events (β = -0.0094, P = 0.03) and total reflux events (β = -0.0172, P = 0.05), after adjusting for confounders.

DISCUSSION

Reduced proximal esophageal contractility as assessed by decreased PCI on HRM independently predicted increased pharyngeal reflux in patients with LPR symptoms, particularly among those without a coexisting motility disorder.

Associations Between Muscular Strength and Gastroesophageal Reflux Disease in Older Adults

BACKGROUND

The association between muscular strength (MS) and prevalent gastroesophageal reflux disease (GERD) in the older adults is not well established.

METHODS

This study included 542 older adults with no history of myocardial infarction, stroke, or cancer. MS was measured by handgrip dynamometry. Participants were categorized into sex-specific quartiles of MS, while cases of GERD were identified by self-reported physician diagnosis. Logistic regression was used to calculate the odds ratios and 95% confidence intervals of GERD by quartiles of MS.

RESULTS

There were 112 GERD cases. Compared with the first quartile of MS, the odds ratios (95% confidence intervals) of GERD were 0.50 (0.27-0.95), 0.39 (0.20-0.75), and 0.55 (0.29-1.04) in the second, third, and fourth quartiles of MS, respectively, after adjusting for possible confounders including body mass index. In a joint analysis of MS and body mass index, participants were dichotomized into weak (first MS quartile) or strong (upper 3 MS quartiles) and normal weight, overweight, or obese. Compared with the weak-obese group, odds ratios (95% confidence intervals) were 0.34 (0.14-0.80), 0.43 (0.16-1.13), 0.29 (0.12-0.68), 0.18 (0.06-0.55), and 0.07 (0.03-0.21) for the strong-obese, weak-overweight, strong-overweight, weak-normal weight, and strong-normal weight.

CONCLUSIONS

MS was independently and inversely associated with GERD in older adults.

Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility

Esophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high-resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100-450 mmHg·cm·s), transition zone defects >5 cm measured using a 20 mmHg isobaric contour, or failure of peristalsis (DCI < 100 mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%-70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.

Esophageal hypervigilance is prevalent across gastroesophageal reflux disease presentations

BACKGROUND

There is a need to identify factors outside of abnormal reflux that contribute to gastroesophageal reflux disease (GERD). Esophageal hypervigilance is a psychological process impacting symptom experience in esophageal disease. However, little is known about the presence of hypervigilance in GERD phenotypes, especially in those with abnormal acid exposure or symptom index scores. The primary aim was to assess differences in self-reported esophageal hypervigilance across different GERD presentations. The secondary aim was to evaluate esophageal hypervigilance as a predictor of symptom severity.

METHODS

We conducted retrospective data analyses on a cohort of adult patients with reflux symptoms that underwent 96-hour wireless pH monitoring from 9/2015 to 9/2017. Patients were stratified into groups based on the number of days they exhibited positive acid exposure time (AET; 0 days, 1-2 days, 3+ days), and symptom index scores (SI; 0 days, 1-day, 2+ days). Esophageal hypervigilance and anxiety, and symptom frequency and severity were assessed between groups.

KEY RESULTS

A total of 123 AET cases and 116 SI cases were included for analysis. Esophageal hypervigilance and anxiety scores did not significantly differ based on the number of days of positive AET (p = 0.311) or SI (p = 0.118). Symptom severity and perceived symptom frequency differed between groups. Hypervigilance significantly predicted symptom severity, when controlling for symptom-specific anxiety.

CONCLUSIONS

Esophageal hypervigilance is persistent across patients with reflux, irrespective of acid burden and symptom index, and significantly predicts symptom severity. Hypervigilance should be considered as an independent factor contributing to esophageal symptom perception.

Impact of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease and Risk Factors Associated with Its Occurrence Based Upon Quality of Life

BACKGROUND

To assess the impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms and to determine factors associated with the occurrence of post-LSG GERD symptoms.

MATERIAL AND METHODS

This is a retrospective study that included all obese patients who underwent LSG in Aseer Central Hospital, during the period from August 2017 to August 2019. GERD-Health-Related Quality of Life questionnaire was used to assess the patients' pre- and postoperative GERD symptoms and their satisfaction toward their general health.

RESULTS

The study included 326 patients (195 males and 131 females) with a mean age of 39.43 ± 11.17 years. Postoperatively, GERD symptoms newly developed in 105 patients (32.2%), while 25 patients out of 127 with preoperative GERD symptoms (19.69%) showed resolution of symptoms. There were significant associations (p < 0.001) between the old age, smoking and existence of comorbidities, and the occurrence of postoperative heartburn and regurgitation symptoms. Postoperatively, excess weight loss (EWL) was significantly associated with postoperative regurgitation (p = 0.045) and patients showed significant improvement in their satisfaction toward their health condition even those who developed GERD symptoms.

CONCLUSIONS

After LSG, GERD symptoms developed in about one-third of the patients while symptoms improved in only one-fifth of patients. Older patients, smokers, patients with comorbidities, and patients with more EWL had significantly worse GERD symptoms postoperatively. Weight loss rather than GERD symptoms significantly influenced patients' satisfaction toward their general health. Further prospective studies are needed to determine the relationship between weight loss and other factors associated with post-LSG reflux and overall quality of life.

Relationship between gastroesophageal reflux disease (GERD) and constipation: laxative use is common in GERD patients

BACKGROUND

The relationship between gastroesophageal reflux disease (GERD) and constipation has not yet been examined in Japan. We herein analyzed the use of laxatives by GERD and non-GERD patients to clarify the relationship between GERD and constipation.

METHODS

This was a retrospective observational study designed to examine the use of laxatives by GERD and non-GERD patients. A total of 118 patients (mean age 69.7 years, 50 males) with reflux esophagitis (RE) and non-erosive reflux disease (NERD) who received maintenance acid-suppressive therapy for more than 1 year were included in the GERD group (83 RE patients, 35NERD patients). Similarly, 61 patients (mean age 69.4 years, 28 males) who received regular acid-suppressive therapy for reasons other than GERD were included in the non-GERD group. We also investigated demographic factors associated with the onset of GERD, including body mass index (BMI), age, and sex.

RESULTS

The frequency of laxative use was significantly higher in the GERD group (38.1%) than in the non-GERD group (21.3%). No significant differences were observed in dose frequencies between the groups. The type of laxative used also did not significantly differ between the groups. Furthermore, no significant differences were noted in sex, age, or BMI between the groups.

CONCLUSIONS

The use of laxatives was significantly more common in GERD patients than in non-GERD patients. The present results suggest that a relationship exists between GERD and constipation.

Clinical features and therapeutic responses to proton pump inhibitor in patients with severe reflux esophagitis: A multicenter prospective observational study

BACKGROUND AND AIM

In patients with severe erosive reflux disease (ERD; Los Angeles classification grade C/D) who do not undergo endoscopic examination, insufficient strength and duration of proton pump inhibitor (PPI) therapy may lead to complications such as esophageal bleeding and stenosis. Therefore, to provide a safe and effective treatment for gastroesophageal reflux disease (GERD), we investigated the clinical features of patients with severe ERD and their responses to PPI therapy.

METHODS

Patients with GERD symptoms received PPI therapy for 4 weeks after endoscopic examination. The patients completed the Gastroesophageal reflux and dyspepsia therapeutic efficacy and satisfaction test questionnaire before and 2 or 4 weeks after PPI treatment. Patient characteristics, presence/absence of coexisting atrophic gastritis (AG) and hiatus hernia (HH), and responses to PPI therapy were compared in patients with GERD among three groups (nonerosive reflux disease, mild ERD [grade A/B], and severe ERD).

RESULTS

The severe ERD group had a significantly higher proportion of males, higher body mass index, and longer duration of GERD morbidity. Furthermore, the severe ERD group also had a significantly lower incidence of coexisting AG and higher incidence of HH. There was no difference in the severity of GERD before PPI treatment among the three groups. Unexpectedly, the response to PPI therapy was the best in the severe ERD group.

CONCLUSION

Sufficient strength and period of PPI therapy are required, even if the symptoms show early improvement, when treating GERD patients without performing endoscopy, considering the possibility of severe ERD.

Gastroesophageal Reflux Disease and Barrett Esophagus in the Elderly

As our population continues to age, the early diagnosis and optimal management of patients with gastroesophageal reflux disease becomes paramount. Maintaining a low threshold for evaluating atypical symptoms in this population is key to improving outcomes. Should patients develop complications including severe esophagitis, peptic stricture, or Barrett esophagus, then a discussion of medical, endoscopic, and surgical treatments that accounts for patient's comorbidities and survival is important. Advances in screening, surveillance, and endoscopic treatment of Barrett esophagus have allowed us to dispel concerns of futility and treat a larger subset of the at-risk population.

Esophageal and Gastric Motility Disorders in the Elderly

The elderly are particularly prone to developing upper gastrointestinal disturbances. Changes are due to the aging process, diabetes, cardiovascular risk factors, and neurologic issues. Medications used to treat these underlying conditions can cause gastrointestinal symptoms. Dysphagia is common and can be oropharyngeal and/or esophageal. Gastroparesis is due to either medications such opiates, or due to neurologic sequala of diabetes, cerebrovascular accidents, or neurologic diseases such as Parkinson's disease. Given limitations in many commonly used prokinetics with a wide range of side effect profiles including neurologic and cardiac, the focus of treatment should be on symptom management with dietary changes.

Clinical and pathological predictors of failure of endoscopic therapy for Barrett's related high-grade dysplasia and early esophageal adenocarcinoma

BACKGROUND AND AIMS

Multimodal endoscopic treatment for Barrett's esophagus (BE) related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) is safe and effective. However, there is a paucity of data to predict the response to endoscopic treatment. This study aimed to identify predictors of failure to achieve complete eradication of neoplasia (CE-N) and complete eradication of intestinal metaplasia (CE-IM).

METHODS

We performed a retrospective analysis of prospectively collected data of all HGD/EAC cases treated endoscopically at a tertiary referral center. Only patients with confirmed HGD/EAC from initial endoscopic mucosal resection (EMR) were included. Potential predictive variables including clinical characteristics, endoscopic features, and index histologic parameters of the EMR specimens were evaluated using multivariate Cox regression.

RESULTS

A total of 457 patients were diagnosed with HGD/EAC by initial EMR from January 2008 to January 2019. Of these, 366 patients who underwent subsequent endoscopic treatment with or without RFA were included. Cumulative incidence rates at 3 years for CE-N and CE-IM were 91.4% (95% CI 87.8-94.2%) and 66.8% (95% CI 61.2-72.3%), respectively during a median follow-up period of 35 months. BE segment of 3-10 cm (HR 0.45; 95% CI 0.36-0.57) and > 10 cm (HR 0.25; 95% CI 0.15-0.40) were independent clinical predictors associated with failure to achieve CE-N. With respect to CE-IM, increasing age (HR 0.88; 95% CI 0.78-1.00) was another predictor along with BE segment of 3-10 cm (HR 0.37; 95% CI 0.28-0.49) and > 10 cm (HR 0.15; 95% CI 0.07-0.30). Lymphovascular invasion increased the risk of CE-N and CE-IM failure in EAC cases.

CONCLUSION

Failure to achieve CE-N and CE-IM is associated with long-segment BE and other clinical variables. Patients with these predictors should be considered for a more intensive endoscopic treatment approach at expert centers.

Gastroesophageal reflux disease in a typical African population: a symptom-based multicenter study

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) in Africa is not known but is believed to be increasing because of demographic and epidemiologic transition. The main objectives of this study were to determine the prevalence and risk factors of GERD, and its degree of overlap with dyspepsia and irritable bowel syndrome (IBS) in Nigeria, a typical African population.

METHODS

This was an observational, cross-sectional and descriptive study of adult Nigerians. Diagnosis of GERD was by means of the gastroesophageal reflux disease questionnaire (GERDQ) while the diagnosis of dyspepsia and IBS was based on the Rome III criteria for the diagnosis of functional gastrointestinal disorders. The GERDQ and Rome III questionnaires for dyspepsia and IBS were merged into a composite questionnaire and administered to the study participants who were recruited with a multi-stage sampling technique.

RESULTS

Out of 3520 subjects who participated in the study across the country, 269 (7.6%) satisfied the diagnostic criteria for GERD, while 107 (3.0%) had GERD associated with significant impairment of quality of life. Risk factors of GERD (represented by odds ratios) were age 1.014(95% CI: 1.006-1.022), use of analgesics 1.461 (95% CI: 1.060-2.025), and use of herbs 1.318 (95% CI: 1.020-1.704). Overlap of GERD with dyspepsia and/or IBS was observed in over 50% of cases.

CONCLUSIONS

The prevalence of GERD in this study is 7.6%. Age, use of analgesics and use of herbs increase the risk, albeit minimally. A high degree of overlap with dyspepsia and IBS exists in Nigerian patients with GERD.

Risk assessment of obstructive sleep apnea among gastroesophageal reflux disease patients in Taif, Saudi Arabia

Background:

Previous studies have reported the association between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA).

Objectives:

The aim of the present study was to assess the prevalence of GERD among Saudi population, and to determine the risk of OSA among those diagnosed with GERD in Taif city of Saudi Arabia.

Materials and Methods:

A cross-sectional online survey was done among 843 Saudi participants using a questionnaire by collecting demographic data, weight, height, blood group, and having a previous nose or throat surgery. The GERD questionnaire and the sleep apnea symptom index were used to determine GERD and OSA prevalence.

Results:

The prevalence of GERD and OSA was 17.6% and 2.4%, respectively. A significantly higher prevalence of GERD was found among males, those with age >50 years, employees and obese participants, and those having OSA. Participants with an age >50 years and males, had a significantly higher prevalence of OSA. Being a male and older age were predictors for GERD, and the presence of GERD was an independent predictors for OSA.

Conclusion:

Future population-based studies including a representative sample of the population should be done to confirm the revealed association between GERD and OSA. It is necessary to assess GERD in patients with OSA in clinical practice.

Characteristics of Patients With Esophageal Dysphagia Assessed by Chest X-Ray Imaging After Videofluoroscopic Swallowing Study

Objective

To evaluate the prevalence rate, types, characteristics, and associated factors of esophageal dysphagia detected on chest X-ray images after videofluoroscopic swallowing study (VFSS).

Methods

The medical records of 535 adults were reviewed retrospectively. Chest X-ray images taken after barium swallow study were analyzed and presence of any residual barium in the esophagus was considered as esophageal dysphagia. Esophageal dysphagia was classified based on the largest width of barium deposit (mild, <2 cm; severe ≥2 cm) and the anatomic level at which it was located (upper and lower esophagus).

Results

Esophageal residual barium on chest X-ray images was identified in 40 patients (7.5%, 40/535). Esophageal dysphagia was more frequent in individuals aged 65–79 years (odds ratio=4.78, p<0.05) than in those aged <65 years. Mild esophageal dysphagia was more frequent (n=32) than its severe form (n=8). Lower esophageal dysphagia was more frequent (n=31) than upper esophageal dysphagia (n=9). Esophageal residual barium in patients diagnosed with esophageal cancer or lung cancer was significantly associated with severe esophageal dysphagia (p<0.05) and at the upper esophagus level (p<0.01).

Conclusion

Esophageal residual barium was observed on chest X-ray imaging after VFSS. Esophageal barium in the upper esophagus with a diameter of ≥2 cm is an important indicator of malignancy, and chest X-ray image taken after VFSS is an important step to evaluate the presence of esophageal disorder.

Real-time MRI for dynamic assessment of gastroesophageal reflux disease: Comparison to pH-metry and impedance

PURPOSE

To evaluate the diagnostic potential of real-time MRI for dynamic assessment of gastroesophageal reflux in patients with GERD (gastroesophageal reflux disease)-like symptoms compared to pH-metry and impedance.

METHODS

Patients who underwent real-time MRI and pH-metry between 2015-2018 were included in this retrospective study. Real-time MRI at 3 T was achieved by undersampled radial FLASH acquisitions with iterative image reconstruction by NLINV. Real-time MRI visualized transit of pineapple juice through the gastroesophageal junction and during Valsalva maneuver. MRI results were compared to 24 h pH-metry to assess acidic reflux (following Lyon Consensus guidelines) and to impedance to assess non-acidic reflux. A standard 2 × 2 table was chosen to calculate diagnostic performance.

RESULTS

91/93 eligible patients fulfilled inclusion criteria (male n = 49; female n = 42; median age 55 y). All MRI studies were successfully completed without adverse events at a mean examination time of 15 min. On real-time MRI, reflux was evident in 60 patients (66 %). pH-metry revealed reflux in 41 patients (45 %), and impedance in 54 patients (59 %). Compared to pH-metry and impedance, real-time MRI sensitivity was 0.78 (95 % CI: 0.66-0.87), specificity 0.67 (95 % CI: 0.45-0.84) and PPV 0.87 (95 % CI: 0.75-0.94).

CONCLUSION

Real-time MRI is an imaging method for assessment of gastroesophageal reflux in patients with GERD-like symptoms. Considering its high positive predictive value, real-time MRI can accurately identify patients in which further invasive testing with pH-metry and impedance might be considered.

Risk of hemorrhage and stricture significantly increases in elderly patients with proton pump inhibitor (PPI)-resistant reflux esophagitis

BACKGROUND

To examine the clinical characteristics, including complications, of patients older than 75 years of age with proton pump inhibitor-resistant reflux esophagitis.

METHODS

Patients who were resistant to standard-dose proton pump inhibitors were enrolled in the present study. Eligible patients (n = 26) were divided into those who were older (n = 11) and younger (n = 15) than 75 years of age. Clinical characteristics including complications (hemorrhage and stricture), body mass index, the severity of reflux esophagitis, Helicobactor pylori infection, gastric mucosal atrophy, hiatal hernia, kyphosis, and the use of antithrombotic agents were examined. The efficacy of 20 mg vonoprazan for proton pump inhibitor-resistant reflux esophagitis was also investigated.

RESULTS

The severity of reflux esophagitis was significantly higher in the elderly group than in the non-elderly group. No other significant differences were observed between the groups. The proportion of patients with hemorrhage was significantly larger in the elderly group than in the non-elderly group. Similarly, the proportion of patients with stricture was significantly larger in the elderly group than in the non-elderly group. Nine out of 10 patients in the elderly group and all patients in the non-elderly group achieved healing after the 4-week administration of 20 mg vonoprazan. No significant differences were observed in healing rates between the groups.

CONCLUSION

Among patients with proton pump inhibitor-resistant reflux esophagitis, the rates of severe reflux esophagitis and complications (hemorrhage and/or stricture) were significantly higher in elderly patients than in non-elderly patients. Regardless of age, 20 mg vonoprazan was effective for proton pump inhibitor-resistant reflux esophagitis.

New evidence defining the pathology and pathogenesis of lower esophageal sphincter damage

Background

Present diagnosis and management of gastroesophageal reflux disease (GERD) has resulted in a dramatic increase in the incidence of esophageal adenocarcinoma. This is due to failure to identify pathologic changes of early GERD; at present, pathology is limited to management of Barrett esophagus (BE).

Methods

Convincing evidence have confirmed that cardiac mucosa distal to the squamocolumnar junction in the endoscopically normal person is a metaplastic GERD-induced esophageal epithelium, and not a normal proximal gastric epithelium.

Results

When cardiac mucosa is recognized as a metaplastic esophageal epithelium, it becomes self-evident that the present endoscopic definition of the gastro-esophageal junction is incorrect, and there exists a dilated distal esophagus (DDE) in what is incorrectly termed the “gastric cardia” presently mistaken for proximal stomach. It also becomes clear that the length of the DDE correlates with the presence and severity of GERD and represents the pathology of the entire spectrum of GERD. Further, it allows recognition that the DDE, measured as the gap between esophageal squamous epithelium and gastric oxyntic mucosa that is composed of cardiac mucosa, represents the pathologic anatomy of damage to the abdominal segment of the lower esophageal sphincter (LES).

Conclusion

The new understanding of the significance of cardiac mucosa provides a new and highly accurate histologic method of assessment of LES damage, the primary cause of GERD. This opens a new door to complete histologic assessment of GERD from its etiologic standpoint and to new research that permit early diagnosis of GERD at its outset. Ultimately, such early diagnosis has the potential to reverse the increasing trend of esophageal adenocarcinoma.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

BACKGROUND

Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals.

PURPOSE

A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

Influence of age on postoperative complications especially pneumonia after gastrectomy for gastric cancer

Background

The aim of this study was to investigate the influence of patients’ age on postoperative morbidities including pneumonia.

Methods

We reviewed the clinical records of 211 patients with stages I – III gastric cancer undergoing curative distal gastrectomy (DG) or total gastrectomy (TG). Patients were classified into an elderly (≧80 y.o.) or a control (< 80 y.o.) group. We compared patient characteristics (sex ratio, disease stage, degree of lymph node dissection, number of retrieved lymph nodes, and type of reconstruction) and early postoperative outcomes (operation time, intra-operative blood loss, and postoperative morbidity including pneumonia, and mortality) between the two groups separately in DG and TG.

Results

There were 134 and 77 patients who underwent DG and TG, respectively. The numbers of patients in the elderly and control groups were 25 and 109 in DG and 12 and 65 in TG. The percentage of female patients in the elderly group was greater than that in the control group in both DG and TG. The extent of lymph node dissection did not differ between two groups in TG; in contrast in DG, the rate of a D1 dissection was greater in the elderly group than in the control group. There were no differences between the two groups in distribution of disease stage, number of retrieved lymph nodes, operation time, and blood loss in DG and in TG. Overall postoperative morbidity did not differ between two groups after DG and after TG. The rate of infectious complications in the elderly group was not different from that in the control group after DG and after TG. The incidence of pneumonia was more frequent in the elderly group compared to the control group after DG (8% vs. 1%, P < 0.05) but not after TG (17% vs. 5%). When patients were compared between the elderly and the control groups regardless of type of gastrectomy, the incidence of pneumonia in the elderly group (4/37 (11%)) was greater than that in the control group (4/174 (2%), P < 0.05).

Conclusions

These results suggest that pneumonia is increased in patients older than 80 years after DG.

The Utility of Esophageal Motility Testing in Gastroesophageal Reflux Disease (GERD)

PURPOSE OF REVIEW

Here, we discuss how esophageal motor testing plays important roles in patients with suspected gastroesophageal reflux disease (GERD). In addition to guiding appropriate placement of catheters for ambulatory reflux monitoring, esophageal high-resolution manometry (HRM) rules out confounding diagnoses, such as achalasia spectrum disorders, that can present with symptoms similar to that of GERD, but are managed very differently.

RECENT FINDINGS

HRM performed with impedance in the post-prandial setting (PP-HRIM) can assess for rumination syndrome or supragastric belching, which should be directed towards behavioral interventions. The recent GERD Classification of Motor Function recommends a hierarchical approach, focusing on (1) the esophagogastric junction (EGJ), (2) the esophageal body, and (3) esophageal contraction reserve, which can be assessed with provocative maneuvers at HRM, such as multiple rapid swallows (MRS). This approach can inform the appropriate tailoring of antireflux surgery. Novel esophageal motility metrics, such as the EGJ-contractile integral from HRM, or post-reflux swallow-induced peristaltic wave indices from 24-h pH-impedance monitoring, may also assist with GERD diagnosis. Assessment of esophageal motor function can contribute in a significant manner to the care of patients with suspected GERD, particularly when esophageal symptoms do not improve with antisecretory therapy, and/or when surgical or endoscopic antireflux therapies are under consideration.