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Visaggi P, Ghisa M, Barberio B, Chiu PW, Ishihara R, Kohn GP, Morozov S, Thompson SK, Wong I, Hassan C, Savarino EV. Gastro-esophageal diagnostic workup before bariatric surgery or endoscopic treatment for obesity: position statement of the International Society of Diseases of the Esophagus. Dis Esophagus 2024; 37:doae006. [PMID: 38281990 DOI: 10.1093/dote/doae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
Obesity is a chronic and multifactorial condition characterized by abnormal weight gain due to excessive adipose tissue accumulation that represents a growing worldwide challenge for public health. In addition, obese patients have an increased risk of hiatal hernia, esophageal, and gastric dysfunction, as well as gastroesophageal reflux disease, which has a prevalence over 40% in those seeking endoscopic or surgical intervention. Surgery has been demonstrated to be the most effective treatment for severe obesity in terms of long-term weight loss, comorbidities, and quality of life improvements and overall mortality decrease. The recent emergence of bariatric endoscopic techniques promises less invasive, more cost-effective, and reproducible approaches to the treatment of obesity. With the endorsement of the International Society for Diseases of the Esophagus, we started a Delphi process to develop consensus statements on the most appropriate diagnostic workup to preoperatively assess gastroesophageal function before bariatric surgical or endoscopic interventions. The Consensus Working Group comprised 11 international experts from five countries. The group consisted of gastroenterologists and surgeons with a large expertise with regard to gastroesophageal reflux disease, bariatric surgery and endoscopy, and physiology. Ten statements were selected, on the basis of the agreement level and clinical relevance, which represent an evidence and experience-based consensus of the International Society for Diseases of the Esophagus.
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Affiliation(s)
- Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Digestive Endoscopy Unit, Pisa University Hospital, Pisa, Italy
| | - Matteo Ghisa
- Digestive Endoscopy Unit, Department of Gastroenterology, Padua University Hospital, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Philip W Chiu
- Department of Surgery, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Geoffrey P Kohn
- Department of Surgery, Monash University Eastern Health Clinical School, Melbourne, Australia
- Melbourne Upper GI Surgical Group, c/o Cabrini Hospital, Malvern, Australia
| | - Sergey Morozov
- Department of Gastroenterology, Hepatology and Nutrition, Federal Research Center of Nutrition, Biotechnology and Food Safety, Moscow, Russia
| | - Sarah K Thompson
- College of Medicine & Public Health, Flinders University, Bedford Park, Australia
| | - Ian Wong
- Department of Surgery, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Biomedical Sciences, Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, Milan, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Padua, Italy
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Sachar M, Mautner Wizentier M, Risner E, Asmail H, Omara M, Chablaney S, Khan A, Knotts R. Risk factors associated with functional esophageal disorders (FED) versus gastroesophageal reflux disease (GERD). Surg Endosc 2024:10.1007/s00464-024-10714-0. [PMID: 38528263 DOI: 10.1007/s00464-024-10714-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 01/28/2024] [Indexed: 03/27/2024]
Abstract
INTRODUCTION Despite the high prevalence of typical symptoms of gastroesophageal reflux disease (GERD), approximately 30% of patients have functional esophageal disorders (FED) on ambulatory reflux monitoring, which may include reflux hypersensitivity (RH; defined as physiologic acid exposure but temporally correlated symptoms of reflux), or functional heartburn (FH; defined as physiologic acid exposure and negative symptom correlation). There are limited epidemiological data characterizing these conditions. We investigated demographic and socioeconomic factors as well as medical comorbidities which may predispose to FED versus pathologic GERD. METHODS Adult patients with reflux symptoms for at least 3 months were studied with 24-h pH-impedance testing from 11/2019 to 3/2021. Participants were categorized into pathologic GERD, FH, or RH using pH-impedance data and reported symptom correlation. Demographic data, including age, gender, race/ethnicity, zip code, insurance status, and medical comorbidity data were retrospectively retrieved from the electronic medical record on all participants. RESULTS 229 patients were included. Non-Hispanic Asian ethnicity (OR 5.65; p = 0.01), underweight BMI (OR 7.33; p = 0.06), chronic pain (OR 2.33; p < 0.01), insomnia (OR 2.83; p = 0.06), and allergic rhinitis (OR 3.90; p < 0.01) were associated with a greater risk for FED. Overweight BMI (OR 0.48; p = 0.03) and alcohol use (OR 0.57; p = 0.06) were associated with a decreased risk for FED. DISCUSSION This is the first report of a greater risk of FED in patients with underweight BMI, insomnia, chronic pain, allergic rhinitis, or of Asian or Hispanic ethnicities. The weak associations between female gender and anxiety are corroborated in other studies. Our findings enable clinicians to better screen patients with reflux for this disorder.
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Affiliation(s)
- Moniyka Sachar
- Department of Medicine, New York University Langone Health, 247 E 28th Street, New York, NY, 10016, USA.
| | | | - Emma Risner
- Department of Biostatistics, New York University School of Public Health, New York, USA
| | - Hannah Asmail
- Department of Biostatistics, New York University School of Public Health, New York, USA
| | - Mathew Omara
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for Esophageal Health, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Shreya Chablaney
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for Esophageal Health, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Abraham Khan
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for Esophageal Health, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Rita Knotts
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for Esophageal Health, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, USA
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Martínez Negro E, Martínez Cortijo S. Gastroesophageal reflux management after vertical sleeve gastrectomy. Cir Esp 2023; 101 Suppl 4:S52-S57. [PMID: 36781049 DOI: 10.1016/j.cireng.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
VSG is the most used surgical procedure in the world. Among the main complications linked to this procedure is GERD. It is apparent that endoscopic control protocols should be undertaken in all patients recovering from a VSG procedure. This is particularly key when taking into account the large number of patients suffering from GERD that show no symptoms, a situation that in many cases leads to severe esophagitis or even adenocarcinoma. Once the pertinent diagnostic tests have been carried out, the specialist should seek a conservative medical treatment including PPI. In the event that this treatment should fail, the next step to be considered should be a surgical procedure. In this case, the ideal procedure would be a reconversion to gastric bypass due to its low-risk and its results. There are other alternatives such as the Stretta, Linx or ARMS procedures; however, further research is necessary to prove their reliability.
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Affiliation(s)
- Ester Martínez Negro
- Hospital Nuestra Señora del Prado Talavera, Talavera de la Reina, Toledo, Spain.
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Yang Y, Lin JR, Li YQ, Wei YS, Duan ZJ. Effect of Body Weight and Obesity on Esophageal Function. Physiol Res 2023; 72:525-537. [PMID: 37795895 PMCID: PMC10634559 DOI: 10.33549/physiolres.935067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/19/2023] [Indexed: 01/05/2024] Open
Abstract
The incidence of obesity in the population is gradually increasing. Obesity can cause a variety of complications in the digestive system such as gastroesophageal reflux disease, and impacts the integrity of the esophageal mucosal barrier and esophageal motility. However, not many studies have focused on the effect of varying degrees of obesity on the esophagus. A total of 611 participants were included in this study. We divided them into three groups according to their body mass index (BMI): the normal weight group, the overweight group, and the obesity group. We performed a retrospective comparison between groups based on indicators from high resolution esophageal manometry (HREM) and 24-hour pH impedance monitoring, and did a correlation analysis on multiple indicators such as esophageal mucosal barrier, esophageal motility, and acid reflux. The mean nocturnal baseline impedance (MNBI) in the overweight and obesity groups was lower than that in the normal group. The MNBI of the subjects in Z5-Z6 channels in the overweight group was significantly lower than that in the normal group. With respect to Z3-Z6 channels, MNBI values in the obesity group were significantly lower than those in the normal group. 'The acid exposure time (AET), the DeMeester scores (DMS) and 24-hour total reflux episodes was significantly higher in the obesity group than those in the normal and overweight groups. The upper esophageal sphincter (UES) residual pressure, and intrabolus pressure (IBP) in the overweight and obesity groups were significantly higher than those in the normal group. In addition, lower esophageal sphincter (LES) resting pressure, and esophagogastric junction contractile integral (EGJ-CI) in the obesity group were significantly higher than those in the normal group. We found that increase in body weight affected the integrity of esophageal mucosa, and different degrees of increase associated with different degrees and different aspects of changes in esophageal motility.
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Affiliation(s)
- Y Yang
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, China
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The inappropriate use of proton pump inhibitors and its associated factors among community-dwelling older adults. Heliyon 2021; 7:e07595. [PMID: 34337188 PMCID: PMC8313491 DOI: 10.1016/j.heliyon.2021.e07595] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/13/2021] [Accepted: 07/14/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives Little is known about the inappropriate use of proton pump inhibitors (PPIs) and how mild cognitive impairment (MCI) and high comorbid burden relate to the inappropriate prescribing of PPIs. Therefore, the current study aimed to examine these associations among community-dwelling older adults in Jordan. Method This cross-sectional study was conducted on 215 community-dwelling older adults from three local healthcare centers located in Irbid, Jordan. Data about PPI use, including the name of medication, dose, frequency, duration, and indication, were collected retrospectively from a review of the participating older adults’ medication cards for November and December 2019. The collected data were evaluated based on the Food and Drug Administration (FDA) guidelines. MCI was measured using the Arabic version of the Montreal Cognitive Assessment, and comorbid burden was measured using the Cumulative Illness Rating Scale for Geriatrics. Results Forty-seven percent of the participants were found to have taken a PPI, with 68 % having taken one for a longer period than recommended by the FDA. Older adults with MCI or high comorbid burden were found to be more susceptible than other older adults to the long-term use of PPIs. The logistic regression revealed that MCI is a statistically significant predictor of inappropriate PPI use (p < 0.001). Conclusion Inappropriate PPI use is common among community-dwelling older adults in Jordan, with a significantly higher prevalence of inappropriate PPI use in people with MCI than in people with normal cognitive abilities. Future intervention studies are highly recommended to encourage optimal prescribing of PPIs for community-dwelling older adults.
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Tosetti C, Savarino E, Benedetto E, De Bastiani R. Elimination of Dietary Triggers Is Successful in Treating Symptoms of Gastroesophageal Reflux Disease. Dig Dis Sci 2021; 66:1565-1571. [PMID: 32578044 DOI: 10.1007/s10620-020-06414-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The relationship between aliments and pathophysiological abnormalities leading to gastroesophageal reflux disease (GERD) symptoms elicitation is unclear. Nevertheless, patients often report symptoms after ingestion of specific foods. AIMS To identify in primary care setting the presence of foods able to trigger GERD symptoms, and evaluate whether a consequent specific food elimination diet may result in clinical improvement. METHODS Diagnosis of GERD and quantification of reflux symptoms were done according to GERD-Q questionnaire (positive when > 8). During clinical data collection, patients were asked to report aliments associated with their symptoms. Also, a precompiled list of additional foods was administered to them. Then, patients were requested to eliminate the specific foods identified, and to come back for follow-up visit after 2 weeks when GERD-Q questionnaire and clinical data collection were repeated. RESULTS One-hundred GERD (mean GERD-Q score 11.6) patients (54 females, mean age 48.7 years) were enrolled. Eighty-five patients reported at least one triggering food, mostly spicy foods (62%), chocolate (55%), pizza (55%), tomato (52%), and fried foods (52%). At follow-up visit, the diagnosis of GERD was confirmed in only 55 patients, and the mean GERD-Q score decreased to 8.9. Heartburn reporting decreased from 93 to 44% of patients, while regurgitation decreased from 72 to 28%. About half of the patients agreed to continue with only dietary recommendations. CONCLUSIONS Most patients with GERD can identify at least one food triggering their symptoms. An approach based on abstention from identified food may be effective in the short term.
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Affiliation(s)
- Cesare Tosetti
- National Health System, Group for Primary Care Gastroenterology (GIGA-CP), Belluno, Italy
- Department of Primary Care Porretta Terme, Health Agency of Bologna, Bologna, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology - DiSCOG, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy.
| | - Edoardo Benedetto
- National Health System, Group for Primary Care Gastroenterology (GIGA-CP), Belluno, Italy
- Primary Care Gastroenterologist, National Health System, Cosenza, Italy
| | - Rudi De Bastiani
- National Health System, Group for Primary Care Gastroenterology (GIGA-CP), Belluno, Italy
- Department of Primary Care, Heath Agency of Belluno, Feltre, Italy
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Savarino V, Marabotto E, Zentilin P, Demarzo MG, de Bortoli N, Savarino E. Pharmacological Management of Gastro-Esophageal Reflux Disease: An Update of the State-of-the-Art. Drug Des Devel Ther 2021; 15:1609-1621. [PMID: 33907381 PMCID: PMC8064680 DOI: 10.2147/dddt.s306371] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/06/2021] [Indexed: 12/12/2022] Open
Abstract
Gastro-esophageal reflux disease (GERD) is a highly prevalent, chronic disorder, whose knowledge remains limited and the management of these patients changes continuously. This review provides a summary of the most recent advancements in the pathogenesis of this disease and the new drugs introduced into the market to overcome some of the unmet needs of traditional therapies. Nowadays, the most fruitful diagnostic examinations are 24-hour impedance-pH monitoring, which allows us to separate true NERD from esophageal functional disorders and high-resolution manometry, which helps to exclude the existence of motility disorders sharing the same symptoms of GERD. Proton pump inhibitors (PPIs) remain the first-choice therapy in the treatment of GERD, but a consistent proportion of these patients continue to experience symptoms despite their intake. These cases pertain mainly to the subpopulation with non-erosive reflux disease (NERD) and represent very challenging clinical situations, because it is mandatory to understand the reasons for PPI failure. The management of these difficult patients requires necessarily to test them and avoid the use of empiric treatments that are often unsuccessful, costly and potentially dangerous. Recently, several new drugs have been used to increase the defensive properties of this mucosa with promising results in randomized clinical trials.
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Affiliation(s)
- Vincenzo Savarino
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | | | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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Silveira FC, Poa-Li C, Pergamo M, Gujral A, Kolli S, Fielding GA, Ren-Fielding CJ, Schwack BF. The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease. Obes Surg 2020; 31:1139-1146. [PMID: 33244654 DOI: 10.1007/s11695-020-05111-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/30/2020] [Accepted: 11/10/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. OBJECTIVE To examine the effects of LSG on GERD symptoms. METHODS One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). RESULTS For the entire group, mean weight loss, %TWL, and reduction in BMI were 79 pounds, 28.1%, and 12.7 kg/m2 respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. CONCLUSION These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.
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Affiliation(s)
- Flavia Carvalho Silveira
- NYU Langone Health/ NYU Grossman School of Medicine, 530 First, Ave., Suite 10S, New York, NY, 10016, USA.
| | - Christina Poa-Li
- NYU Langone Health/ NYU Grossman School of Medicine, 530 First, Ave., Suite 10S, New York, NY, 10016, USA
| | - Matthew Pergamo
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Akash Gujral
- NYU Langone Health/ NYU Grossman School of Medicine, 530 First, Ave., Suite 10S, New York, NY, 10016, USA
| | - Sindhura Kolli
- Department of Internal Medicine, NYU Langone Comprehensive Program on Obesity, NYU School of Medicine, New York, NY, USA
| | - George A Fielding
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Christine J Ren-Fielding
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Bradley F Schwack
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
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Savarino E, Frazzoni M, Marabotto E, Zentilin P, Iovino P, Costantini M, Tolone S, Battaglia E, Cicala M, Usai-Satta P, de Bortoli N, Penagini R, Savarino V. A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring. Dig Liver Dis 2020; 52:966-980. [PMID: 32513632 DOI: 10.1016/j.dld.2020.04.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.
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Affiliation(s)
- Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Paola Iovino
- Gastroenterology Unit, University of Salerno, Salerno, Italy
| | - Mario Costantini
- Clinica Chirurgica III, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaja Hospital, Asti, Italy
| | - Michele Cicala
- Unit of Digestive Diseases, Campus Bio Medico University, Rome, Italy
| | | | - Nicola de Bortoli
- Gastrointestinal Unit-Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56124 Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit - Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico - University of Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Sleeve Gastrectomy, GERD, and Barrett's Esophagus: It Is Time for Objective Testing. Obes Surg 2020; 29:2312-2313. [PMID: 31062277 DOI: 10.1007/s11695-019-03902-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Ghisa M, Della Coletta M, Barbuscio I, Marabotto E, Barberio B, Frazzoni M, De Bortoli N, Zentilin P, Tolone S, Ottonello A, Lorenzon G, Savarino V, Savarino E. Updates in the field of non-esophageal gastroesophageal reflux disorder. Expert Rev Gastroenterol Hepatol 2019; 13:827-838. [PMID: 31322443 DOI: 10.1080/17474124.2019.1645593] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.
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Affiliation(s)
- Matteo Ghisa
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Marco Della Coletta
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Ilenia Barbuscio
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Brigida Barberio
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | | | - Nicola De Bortoli
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa , Pisa , Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Salvatore Tolone
- Surgery Unit, Department of Surgery, University of Campania Luigi Vanvitelli , Caserta , Italy
| | - Andrea Ottonello
- Department of Surgical Science and Integrated Diagnostics, University of Genoa , Genoa , Italy
| | - Greta Lorenzon
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
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Kim EJ, Lee OY, Lee KN, Lee SJ, Jang JY, Cho JW, Kim TO. Efficacy and Safety of AlbisD Compared With Omeprazole 20 mg in Patients With Non-erosive Reflux Disease: A Randomized, Open-label, Active-controlled, Pilot Study. J Neurogastroenterol Motil 2019; 25:403-412. [PMID: 31327222 PMCID: PMC6657924 DOI: 10.5056/jnm18185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/15/2019] [Accepted: 06/24/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Proton pump inhibitors (PPIs) are frequently used to treat non-erosive reflux disease (NERD), but their effect is limited. It is not known whether a potential alternative, AlbisD, containing ranitidine hydrochloride, sucralfate hydrate, and tripotassium dicitrato bismuthate, is effective and safe in treating NERD. The aim of the study is to evaluate the efficacy and safety of AlbisD compared with omperazole in patients with NERD. Methods This was a multicenter, randomized, open-label, parallel-group, non-inferiority comparative study. A total of 126 patients with NERD were randomly allocated to either AlbisD twice daily or omeprazole 20 mg once daily for 4 weeks from February 2016 to August 2016. The study patients had histories of heartburn or regurgitation of moderate severity (> score 2) and a frequency of at least 2 episodes per week, and had no mucosal breaks of the esophagus on endoscopy. The primary efficacy variable was complete cure of heartburn at week 4. Secondary efficacy variables evaluating symptoms of heartburn and acid reflux as well as safety profiles were compared in the 2 groups at week 2 and 4 after treatment. Results A total of 113 patients completed the study (57 and 56 in AlbisD and omeprazole groups, respectively). The proportion of patients with complete cure of heartburn at week 4 was not significantly different between the AlbisD and omeprazole groups (35.1% vs 32.1% respectively, P = 0.740). There were no significant differences between the 2 groups in the any secondary variables including proportions of days without heartburn or acid reflux over 4 weeks (including daytime and nighttime). Adverse events were similarly reported in the 2 groups (7 [12.3%] vs 6 [10.7%]), and there were no serious adverse events. Conclusions The efficacy and safety of AlibsD in treating NERD patients are not inferior to those of omeprazole. Therefore, AlbisD can be an alternative to PPIs for NERD.
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Affiliation(s)
- Eun Jin Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kang Nyeong Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Joon Lee
- Department of Internal Medicine, Kangwon National University College of Medicine, Seoul, Korea
| | - Jae-Young Jang
- Department of Internal Medicine, Kyunghee University College of Medicine, Seoul, Korea
| | - Jin Woong Cho
- Department of Internal Medicine, Presbyterian Medical Center, Chonju, Korea
| | - Tae-Oh Kim
- Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
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Chen C. Laparoscopic adjustable gastric banded plication for weight loss: The pros and cons. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Chien‐Lin Chen
- Department of Medicine, Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical Foundation, Tzu Chi University Hualien Taiwan
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Abstract
PURPOSE OF REVIEW Bariatric surgery is the best therapeutic approach to patients with morbid obesity, but there is mounting evidence that it is associated with esophageal dysfunctions, including gastroesophageal reflux disease (GERD) and motor disorders. In the present review, we summarize the existing information on the complex link between bariatric surgery and esophageal disorders. RECENT FINDINGS Although high-quality studies on these effects are lacking, because of evident methodological flaws and retrospective nature, the review of published investigations show that pure restrictive procedures, such as laparoscopic adjustable gastric banding (LAPG) and laparoscopic sleeve gastrectomy (LSG), are associated with de novo development or worsening of GERD. Moreover, LAGB is the procedure with the greatest frequency of esophageal motor disorders, including impairment of LES relaxation and ineffective esophageal peristalsis associated with esophageal dilation. LSG seems to be less associated with esophageal dysmotility, although evidence derived from studies with objective measurements of esophageal dysfunction is limited. Finally, RYGB seems to be the best procedure for improvement of GERD symptoms and preservation of esophageal function. SUMMARY Overall, the restrictive-malabsorptive approach represented by RYGB must be preferred to pure restrictive operations in order to avoid the negative consequences of bariatric surgery on esophageal functions.
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Abstract
BACKGROUND Recently, problems associated with proton pump inhibitor (PPI) use have begun to surface. PPIs influence the gut microbiota; therefore, PPI use may increase the risk of enteric infections and cause bacterial translocation. In this study, we investigated fecal microbiota composition, fecal organic acid concentrations and pH, and gut bacteria in the blood of the same patients before and after PPI use. METHODS Twenty patients with reflux esophagitis based on endoscopic examination received 8 weeks of treatment with PPIs. To analyze fecal microbiota composition and gut bacteria in blood and organic acid concentrations, 16S and 23S rRNA-targeted quantitative RT-PCR and high-performance liquid chromatography were conducted. RESULTS Lactobacillus species were significantly increased at both 4 and 8 weeks after PPI treatment compared with bacterial counts before treatment (P = 0.011 and P = 0.002, respectively). Among Lactobacillus spp., counts of the L. gasseri subgroup, L. fermentum, the L. reuteri subgroup, and the L. ruminis subgroup were significantly increased at 4 and 8 weeks after treatment compared with counts before treatment. Streptococcus species were also significantly increased at 4 and 8 weeks after PPI treatment compared with counts before treatment (P < 0.01 and P < 0.001, respectively). There was no significant difference in the total organic acid concentrations before and after PPI treatment. Detection rates of bacteria in blood before and after PPI treatment were 22 and 28%, respectively, with no significant differences. CONCLUSIONS Our quantitative RT-PCR results showed that gut dysbiosis was caused by PPI use, corroborating previous results obtained by metagenomic analysis.
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Savarino E, Zentilin P, Marabotto E, Bodini G, Della Coletta M, Frazzoni M, de Bortoli N, Martinucci I, Tolone S, Pellegatta G, Savarino V. A review of pharmacotherapy for treating gastroesophageal reflux disease (GERD). Expert Opin Pharmacother 2017; 18:1333-1343. [PMID: 28754071 DOI: 10.1080/14656566.2017.1361407] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Medical therapy of gastroesophageal reflux disease (GERD) is based on the use of proton pump inhibitors (PPIs) as first choice treatment. Despite their effectiveness, about 20-30% of patients report an inadequate response and alternative drugs are required. Areas covered: This review provides an overview of current pharmacotherapy for treating GERD by showing the results of PPIs, reflux inhibitors, antidepressants and mucosa protective medications. Expert opinion: Medical therapy of GERD does not definitely cure the disease, because even PPIs are not able to change the key factors responsible for it. However, they remain the mainstay of medical treatment, allowing us to alleviate symptoms, heal esophagitis and prevent complications in the majority of cases. Nevertheless, many patients do not respond, because acid does not play any pathogenetic role. Prokinetics and reflux inhibitors have the potential to control motor abnormalities, but the results of clinical trials are inconsistent. Antidepressant drugs are effective in specific subgroups of NERD patients with visceral hypersensitivity, but larger, controlled clinical studies are necessary. Protective drugs or medical devices have been recently adopted to reinforce mucosal resistance and preliminary trials have confirmed their efficacy either combined with or as add-on medication to PPIs in refractory patients.
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Affiliation(s)
- Edoardo Savarino
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Patrizia Zentilin
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Elisa Marabotto
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Giorgia Bodini
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Marco Della Coletta
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Marzio Frazzoni
- c Digestive Pathophysiology Unit , Baggiovara Hospital , Modena , Italy
| | - Nicola de Bortoli
- d Department of Translational Research and New Technology in Medicine and Surgery , University of Pisa , Pisa , Italy
| | - Irene Martinucci
- d Department of Translational Research and New Technology in Medicine and Surgery , University of Pisa , Pisa , Italy
| | - Salvatore Tolone
- e General and Bariatric Surgery Unit, Department of Surgery , Second University of Napoli , Napoli , Italy
| | - Gaia Pellegatta
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Vincenzo Savarino
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
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Ambulatory 24-hour multichannel intraluminal impedance-pH monitoring and high resolution endoscopy distinguish patients with non-erosive reflux disease from those with functional heartburn. PLoS One 2017; 12:e0175263. [PMID: 28384225 PMCID: PMC5383280 DOI: 10.1371/journal.pone.0175263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/23/2017] [Indexed: 12/13/2022] Open
Abstract
AIMS To assess the contribution of 24-h esophageal multichannel intraluminal impedance and pH (MII-pH) monitoring and high resolution endoscopy (HRE) with i-scan imaging in differentiating non erosive reflux disease (NERD) from functional heartburn (FH). METHODS This is a retrospective cohort study of patients with heartburn from the Endoscopy Unit. NERD patients and FH patients were defined by 24-h MII-pH monitoring and white light endoscopy. Minimal mucosal changes were assessed by HRE with i-scan imaging. RESULTS Total of 156 consecutive patients with heartburn but without esophageal mucosal erosions were studied. Forty-eight of these subjects had NERD, with increased acid exposure time (AET) and positive SAP and/or SI. Eighteen had FH with normal AET and negative SAP and SI. When compared to FH patients and healthy controls, NERD patients had significantly increased number of total acid reflux episodes, as well as increased number of weakly acidic reflux episodes (p<0.01). The rate of proximal reflux episodes in NERD patients was higher than that of FH patients and healthy controls (p<0.01). Irregular or blurring of the Z-line (58.3%) and white mucosal turbidity (47.9%) were the most common endoscopic findings of minimal mucosal changes observed in this study. NERD patients had more prevalent minimal changes than FH patients and the controls (87.5%vs. 66.6%vs. 61.9%; p = 0.004) with sensitivity of 87.5%. Histopathological evaluation showed that NERD patients had significantly higher average scores of intercellular spaces dilation (2.82±0.9 vs. 1.2±0.6, p = 0.005) and papillae elongation (2.65±1.0 vs. 1.5±0.8, p = 0.014), but not for basal cell proliferation (1.6±1.3 vs. 1.0±0.9, p = 0.070). The histological scores of the NERD patients were 7.1±1.2, which were higher than those of FH patients (3.4±1.0, p = 0.004). CONCLUSIONS Minimal mucosal changes could be useful markers to support clinical diagnosis of NERD. Combination of 24-h MII-pH monitoring and i-scan high resolution endoscopy can distinguish patients with NERD from those with FH.
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Savarino E, de Bortoli N, De Cassan C, Della Coletta M, Bartolo O, Furnari M, Ottonello A, Marabotto E, Bodini G, Savarino V. The natural history of gastro-esophageal reflux disease: a comprehensive review. Dis Esophagus 2017; 30:1-9. [PMID: 27862680 DOI: 10.1111/dote.12511] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus.
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Affiliation(s)
- E Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - N de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - C De Cassan
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - M Della Coletta
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - O Bartolo
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - M Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - A Ottonello
- Department of Surgical Medical Sciences and Integrated Diagnostic, University of Genoa, Genoa, Italy
| | - E Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - G Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - V Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Bor S, Erdogan A, Bayrakci B, Yildirim E, Vardar R. The impact of the speed of food intake on gastroesophageal reflux events in obese female patients. Dis Esophagus 2017; 30:1-6. [PMID: 27630010 DOI: 10.1111/dote.12499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Obesity increases the risk of gastroesophageal reflux disease (GERD). The majority of the reflux attacks occur postprandially. The influence of the speed of food intake on gastroesophageal reflux events is unclear in obese patients. To determine the influence of the speed of food intake on intraesophageal reflux events in obese patients with and without GERD. A total of 26 obese female patients were recruited. The patients underwent esophageal manometry to evaluate the upper limit of the lower esophageal sphincter and subsequently placement of a Multichannel intraluminal impedance-pH (MII-pH) catheter. All patients were asked to eat the same standard meal (double cheeseburger, 1 banana, 100 g yogurt and 200 mL water; total energy value, 744 kcal; 37.6% carbohydrates, 21.2% proteins and 41.2% lipids) within 5 or 30 minutes under observation in a random order on two consecutive days. All reflux episodes over a 3-hour postprandial period were manually analyzed and compared. The mean age was 46 ± 12 (18-66) years. The mean body mass index (BMI) was 39.9 ± 8.4 kg/m2. There was no difference between the fast- and slow-eating group in the number of refluxes within the 3-postprandial hours. The patients were divided into 2 groups according to the 24-hour MII-pH monitoring results, that is, 16 subjects with normal MII-pH monitoring and 10 patients with pathologic MII-pH monitoring. There was no effect of the speed of food intake in either the patients with or without GERD. In contrast to the general belief, this study suggested that the speed of food intake does not influence the number of refluxes in obese female patients with or without GERD.
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Affiliation(s)
- Serhat Bor
- Ege University Faculty of Medicine, Section of Gastroenterology & Ege Reflux Study Group, Izmir, Turkey
| | - Askin Erdogan
- Augusta University, Section of Gastroenterology, Georgia, USA
| | - Berna Bayrakci
- Karsiyaka Municipality Hospital, Section of Gastroenterology, Izmir, Turkey
| | - Esra Yildirim
- Ege University Faculty of Medicine, Section of Gastroenterology & Ege Reflux Study Group, Izmir, Turkey
| | - Rukiye Vardar
- Ege University Faculty of Medicine, Section of Gastroenterology & Ege Reflux Study Group, Izmir, Turkey
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de Bortoli N, Frazzoni L, Savarino EV, Frazzoni M, Martinucci I, Jania A, Tolone S, Scagliarini M, Bellini M, Marabotto E, Furnari M, Bodini G, Russo S, Bertani L, Natali V, Fuccio L, Savarino V, Blandizzi C, Marchi S. Functional Heartburn Overlaps With Irritable Bowel Syndrome More Often than GERD. Am J Gastroenterol 2016; 111:1711-1717. [PMID: 27644732 DOI: 10.1038/ajg.2016.432] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 08/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to evaluate the prevalence of irritable bowel syndrome (IBS) in patients with typical reflux symptoms as distinguished into gastroesophageal reflux disease (GERD), hypersensitive esophagus (HE), and functional heartburn (FH) by means of endoscopy and multichannel intraluminal impedance (MII)-pH monitoring. The secondary aim was to detect pathophysiological and clinical differences between different sub-groups of patients with heartburn. METHODS Patients underwent a structured interview based on questionnaires for GERD, IBS, anxiety, and depression. Off-therapy upper-gastrointestinal (GI) endoscopy and 24 h MII-pH monitoring were performed in all cases. In patients with IBS, fecal calprotectin was measured and colonoscopy was scheduled for values >100 mg/kg to exclude organic disease. Multivariate logistic regression analysis was performed to identify independent risk factors for FH. RESULTS Of the 697 consecutive heartburn patients who entered the study, 454 (65%) had reflux-related heartburn (GERD+HE), whereas 243 (35%) had FH. IBS was found in 147/454 (33%) GERD/HE but in 187/243 (77%) FH patients (P<0.001). At multivariate analysis, IBS and anxiety were independent risk factors for FH in comparison with reflux-related heartburn (GERD+HE). CONCLUSIONS IBS overlaps more frequently with FH than with GERD and HE, suggesting common pathways and treatment. HE showed intermediate characteristic between GERD and FH.
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Affiliation(s)
- Nicola de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, Division of Gastroenterology, University of Padua, Padua, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Irene Martinucci
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
| | | | - Salvatore Tolone
- Department of Surgery, Division of Surgery, Second University of Naples, Naples, Italy
| | | | - Massimo Bellini
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Elisa Marabotto
- Department of Internal Medicine (DIMI), Division of Gastroenterology, University of Genoa, Genoa, Italy
| | - Manuele Furnari
- Department of Internal Medicine (DIMI), Division of Gastroenterology, University of Genoa, Genoa, Italy
| | - Giorgia Bodini
- Department of Internal Medicine (DIMI), Division of Gastroenterology, University of Genoa, Genoa, Italy
| | - Salvatore Russo
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Lorenzo Bertani
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Veronica Natali
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Savarino
- Department of Internal Medicine (DIMI), Division of Gastroenterology, University of Genoa, Genoa, Italy
| | - Corrado Blandizzi
- Department of Internal Medicine, Division of Pharmacology and Chemotherapy, University of Pisa, Pisa, Italy
| | - Santino Marchi
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
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Savarino E, Ottonello A, Tolone S, Bartolo O, Baeg MK, Farjah F, Kuribayashi S, Shetler KP, Lottrup C, Stein E. Novel insights into esophageal diagnostic procedures. Ann N Y Acad Sci 2016; 1380:162-177. [PMID: 27681220 DOI: 10.1111/nyas.13255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/12/2016] [Accepted: 08/22/2016] [Indexed: 12/14/2022]
Abstract
The 21st century offers new advances in diagnostic procedures and protocols in the management of esophageal diseases. This review highlights the most recent advances in esophageal diagnostic technologies, including clinical applications of novel endoscopic devices, such as ultrathin endoscopy and confocal laser endomicroscopy for diagnosis and management of Barrett's esophagus; novel parameters and protocols in high-resolution esophageal manometry for the identification and better classification of motility abnormalities; innovative connections between esophageal motility disorder diagnosis and detection of gastroesophageal reflux disease (GERD); impedance-pH testing for detecting the various GERD phenotypes; performance of distensibility testing for better pathophysiological knowledge of the esophagus and other gastrointestinal abnormalities; and a modern view of positron emission tomography scanning in metastatic disease detection in the era of accountability as a model for examining other new technologies. We now have better tools than ever for the detection of esophageal diseases and disorders, and emerging data are helping to define how well these tools change management and provide value to clinicians. This review features novel insights from multidisciplinary perspectives, including both surgical and medical perspectives, into these new tools, and it offers guidance on the use of novel technologies in clinical practice and future directions for research.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Andrea Ottonello
- Department of Surgical and Diagnostic Integrated Sciences, University of Genoa, Genoa, Italy
| | - Salvatore Tolone
- Division of General and Bariatric Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - Ottavia Bartolo
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Myong Ki Baeg
- Division of Gastroenterology, Department of Internal Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, South Korea
| | - Farhood Farjah
- Division of Cardiothoracic Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Hospital, Maebashi, Japan
| | - Katerina P Shetler
- Division of Gastroenterology, Palo Alto Medical Foundation, Mountain View, California
| | - Christian Lottrup
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark.,Department of Medicine, North Jutland Regional Hospital, Hjørring, Denmark
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Savarino E, Ottonello A, Martinucci I, Dulbecco P, Savarino V. Ilaprazole for the treatment of gastro-esophageal reflux. Expert Opin Pharmacother 2016; 17:2107-13. [DOI: 10.1080/14656566.2016.1232389] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Savarino E, Villanacci V. Barrett's esophagus detection: Multiple biopsies are useful, even better if you have an "X" on your map. Dig Liver Dis 2016; 48:1041-2. [PMID: 27352982 DOI: 10.1016/j.dld.2016.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 06/08/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
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de Bortoli N, Ottonello A, Zerbib F, Sifrim D, Gyawali CP, Savarino E. Between GERD and NERD: the relevance of weakly acidic reflux. Ann N Y Acad Sci 2016; 1380:218-229. [DOI: 10.1111/nyas.13169] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/04/2016] [Accepted: 06/13/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery; University of Pisa; Pisa Italy
| | - Andrea Ottonello
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology; University of Padua; Padua Italy
| | - Frank Zerbib
- Department of Gastroenterology; CHU Bordeaux and Bordeaux University; Bordeaux France
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry; Queen Mary University of London; United Kingdom
| | - C. Prakash Gyawali
- Division of Gastroenterology; Washington University School of Medicine; St. Louis Missouri
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology; University of Padua; Padua Italy
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Fu MJ, Zhu LY. Risk factors for gastroesophageal reflux disease. Shijie Huaren Xiaohua Zazhi 2016; 24:2654-2660. [DOI: 10.11569/wcjd.v24.i17.2654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease, a common disease of the digestive tract that can be caused by various factors, seriously harms the patients' life quality due to the repeated episodes. Here we discuss the risk factors for gastroesophageal reflux disease, in order to assist in the prevention and treatment of the disease.
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de Bortoli N, Martinucci I, Bertani L, Russo S, Franchi R, Furnari M, Tolone S, Bodini G, Bolognesi V, Bellini M, Savarino V, Marchi S, Savarino EV. Esophageal testing: What we have so far. World J Gastrointest Pathophysiol 2016; 7:72-85. [PMID: 26909230 PMCID: PMC4753191 DOI: 10.4291/wjgp.v7.i1.72] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 12/02/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry (HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h pH-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and pH monitoring can detect acid and non-acid reflux events. EndoFLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal pH-metry. Future studies are required of these techniques to evaluate their diagnostic accuracy and usefulness, although the available data are promising.
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Tolone S, Savarino E, de Bortoli N, Frazzoni M, Furnari M, d'Alessandro A, Ruggiero R, Docimo G, Brusciano L, Gili S, Pirozzi R, Parisi S, Colella C, Bondanese M, Pascotto B, Buonomo N, Savarino V, Docimo L. Esophagogastric junction morphology assessment by high resolution manometry in obese patients candidate to bariatric surgery. Int J Surg 2015; 28 Suppl 1:S109-13. [PMID: 26718611 DOI: 10.1016/j.ijsu.2015.12.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 05/07/2015] [Accepted: 05/22/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and hiatal hernia development. Pure restrictive bariatric surgery should not be indicated in case of hiatal hernia and GERD. However it is unclear what is the real incidence of disruption of esophagogastric junction (EGJ) in patients candidate to bariatric surgery. Actually, high resolution manometry (HRM) can provide accurate information about EGJ morphology. Aim of this study was to describe the EGJ morphology determined by HRM in obese patients candidate to bariatric surgery and to verify if different EGJ morphologies are associated to GERD-related symptoms presence. METHODS All patients underwent a standardized questionnaire for symptom presence and severity, upper endoscopy, high resolution manometry (HRM). EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and < 2 cm); Type III, >2 cm separation. RESULTS One hundred thirty-eight obese (BMI>35) subjects were studied. Ninety-eight obese patients referred at least one GERD-related symptom, whereas 40 subjects were symptom-free. According to HRM features, EGJ Type I morphology was documented in 51 (36.9%) patients, Type II in 48 (34.8%) and Type III in 39 (28.3%). EGJ Type III subjects were more frequently associated to Symptoms than EGJ Type I (38/39, 97.4%, vs. 21/59, 41.1% p < 0.001). CONCLUSIONS Obese subjects candidate to bariatric surgery have a high risk of disruption of EGJ morphology. In particular, obese patients with hiatal hernia often refer pre-operative presence of GERD symptoms. Testing obese patients with HRM before undergoing bariatric surgery, especially for restrictive procedures, can be useful for assessing presence of hiatal hernia.
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Affiliation(s)
- Salvatore Tolone
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy.
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy.
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy.
| | - Marzio Frazzoni
- Division of Gastroenterology, Baggiovara Hospital, Modena, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy.
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy.
| | - Antonio d'Alessandro
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Roberto Ruggiero
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Giovanni Docimo
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Luigi Brusciano
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Simona Gili
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Raffaele Pirozzi
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Simona Parisi
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Carmine Colella
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Mariachiara Bondanese
- Division of Surgical Pathophysiology, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Beniamino Pascotto
- Division of Surgical Pathophysiology, Department of Surgery, Second University of Naples, Naples, Italy.
| | - NunzioMattia Buonomo
- Division of Surgical Pathophysiology, Department of Surgery, Second University of Naples, Naples, Italy.
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy.
| | - Ludovico Docimo
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.
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De Bortoli N, Tolone S, Savarino EV. Weight Loss Is Truly Effective in Reducing Symptoms and Proton Pump Inhibitor Use in Patients With Gastroesophageal Reflux Disease. Clin Gastroenterol Hepatol 2015; 13:2023. [PMID: 26044315 DOI: 10.1016/j.cgh.2015.05.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Nicola De Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Salvatore Tolone
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - Edoardo V Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Tamura Y, Funaki Y, Izawa S, Iida A, Yamaguchi Y, Adachi K, Ogasawara N, Sasaki M, Kaneko H, Kasugai K. Pathophysiology of functional heartburn based on Rome III criteria in Japanese patients. World J Gastroenterol 2015; 21:5009-5016. [PMID: 25945016 PMCID: PMC4408475 DOI: 10.3748/wjg.v21.i16.5009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/21/2014] [Accepted: 01/16/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the pathophysiology of functional heartburn (FH) in Japanese patients.
METHODS: A total of 111 patients with proton pump inhibitor (PPI)-refractory non-erosive gastroesophageal reflux disease underwent intraesophageal pressure testing and 24-h multichannel intraluminal impedance-pH (24MII-pH) testing. The patients also completed several questionnaires while they were receiving the PPI treatment, including the questionnaire for the diagnosis of reflux disease (QUEST), the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), the gastrointestinal symptoms rating scale (GSRS), SF-36, and the Cornell Medical Index (CMI). The subjects were classified into FH and endoscopy-negative reflux disease (ENRD) groups based on the Rome III criteria.
RESULTS: Thirty-three patients with esophageal motility disorder were excluded from this study, while 22 patients with abnormal esophageal acid exposure time (pH-POS) and 34 with hypersensitive esophagus (HE) were included in the ENRD group. The FH group included 22 patients with no reflux involvement. Sex, age, and body mass index did not differ significantly between the groups. The mean SF-36 values were < 50 (normal) for all scales in these groups, with no significant differences. The GSRS scores in these groups were not different and showed overlap with other gastrointestinal symptoms. The QUEST and the FSSG scores did not differ significantly between the groups. Neuroticism was diagnosed using the CMI questionnaire in 17 of the 78 included subjects within the pH-POS (n = 4), HE (n = 8), and FH (n = 5) groups, with no significant differences.
CONCLUSION: Clinical characteristics of the FH and PPI-refractory ENRD groups were similar. Therefore, esophageal function should be examined via manometry and 24MII-pH testing to differentiate between them.
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Savarino E, Bodini G, Marabotto E, Savarino V. Impedance-detected Symptom Association and Number of Reflux Episodes as Pre-treatment Parameters That Predict Outcomes of Gastroesophageal Reflux Disease Patients. J Neurogastroenterol Motil 2015; 21:292-3. [PMID: 25843082 PMCID: PMC4398243 DOI: 10.5056/jnm14156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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de Bortoli N, Guidi G, Martinucci I, Savarino E, Imam H, Bertani L, Russo S, Franchi R, Macchia L, Furnari M, Ceccarelli L, Savarino V, Marchi S. Voluntary and controlled weight loss can reduce symptoms and proton pump inhibitor use and dosage in patients with gastroesophageal reflux disease: a comparative study. Dis Esophagus 2014; 29:197-204. [PMID: 25516110 DOI: 10.1111/dote.12319] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A wide variety of pieces of evidence has suggested that obesity is associated with a significant increase in the risk for gastroesophageal reflux disease (GERD) symptoms and its complications. The aim of this study was to evaluate the effect of weight loss on reflux symptoms in overweight/obese patients with proven GERD. We enrolled overweight/obese patients with typical GERD symptoms and erosive esophagitis. At baseline, patients underwent detailed reflux symptoms evaluation and anthropometric assessment, and were divided into two treatment groups: group A received proton pump inhibitor (PPI) and a personalized hypocaloric diet and aerobic exercise; and group B received PPI and a 'standard of care diet'. The dietetic treatment was considered effective if at least 10% of weight loss was achieved within 6 months. All patients were evaluated in terms of anthropometric data, GERD symptoms, and PPI use. In group A, mean body mass index (BMI) decreased from 30.3 ± 4.1 to 25.7 ± 3.1 (P < 0.05), and mean weight decreased from 82.1 ± 16.9 kg to 69.9 ± 14.4 kg (P < 0.05). In group B, there was no change in BMI and weight. Symptom perception decreased (P < 0.05) in both groups during PPI therapy, but a higher improvement was recorded in group A. In group A, PPI therapy was completely discontinued in 27/50 of the patients, and halved in 16/50. Only 7/50 continued the same PPI dosage. In group B, 22/51 halved the therapy and 29/51 maintained full dosage of therapy, but none was able to discontinue PPI due to a symptom recurrence. Overall, weight loss of at least 10% is recommended in all patients with GERD in order to boost the effect of PPI on reflux symptom relief and to reduce chronic medication use.
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Affiliation(s)
- N de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - G Guidi
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - I Martinucci
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - E Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - H Imam
- Gastroenterology and Hepatology Unit, Internal Medicine Department, Assiut University Hospital, Assiut, Egypt
| | - L Bertani
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - S Russo
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - R Franchi
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - L Macchia
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - M Furnari
- Division of Gastroenterology, Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - L Ceccarelli
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - V Savarino
- Division of Gastroenterology, Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - S Marchi
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
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Comment on "impairment of chemical clearance is relevant to the pathogenesis of refractory reflux oesophagitis" by Marzio Frazzoni et al. [Digestive and Liver Disease 2014;46:596-602]. Dig Liver Dis 2014; 46:1052. [PMID: 25081845 DOI: 10.1016/j.dld.2014.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 06/26/2014] [Accepted: 06/28/2014] [Indexed: 12/11/2022]
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The placebo effect is a relevant factor in evaluating effectiveness of therapies in functional gastrointestinal disorders. J Gastroenterol 2014; 49:1362-3. [PMID: 24972668 DOI: 10.1007/s00535-014-0974-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 05/25/2014] [Indexed: 02/04/2023]
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Abstract
PURPOSE OF REVIEW In the last decade, with the advent of new oesophageal testing [i.e. 24-h impedance-pH monitoring, combined impedance-manometry, high-resolution manometry (HRM)], relevant progress in understanding the mechanisms contributing to the development of gastro-oesophageal reflux disease (GORD) has been made, allowing a better management of patients with this disorder. The aim of our review is to report the state-of-the-art about oesophageal motor disorders in patients with reflux disease and to stimulate new research in this field. RECENT FINDINGS Hypotensive lower oesophageal sphincter (LOS), transient LOS relaxations, impairment of oesophagogastric junction including hiatal hernia, oesophageal bolus transit abnormalities and presence of ineffective oesophageal motility have been strongly implicated in GORD development. In particular, the majority of recent studies carried out with HRM and impedance-pH testing reported that these motor abnormalities are increasingly prevalent with increasing severity of GORD, from nonerosive reflux disease and erosive oesophagitis to Barrett's oesophagus. SUMMARY Defining and characterizing oesophageal dysmotility in patients with reflux disease is of maximum importance in order to properly diagnose these patients and to treat them with the best management of care. New studies are needed in order to better understand the physiomechanic basis of oesophageal dysmotility in GORD patients.
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EAES recommendations for the management of gastroesophageal reflux disease. Surg Endosc 2014; 28:1753-73. [PMID: 24789125 DOI: 10.1007/s00464-014-3431-z] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux. METHODS The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session. RESULTS Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD. CONCLUSIONS Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.
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Association of symptoms of gastroesophageal reflux with metabolic syndrome parameters in patients with endocrine disease. ISRN GASTROENTEROLOGY 2014; 2014:863206. [PMID: 24624302 PMCID: PMC3929142 DOI: 10.1155/2014/863206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 12/11/2013] [Indexed: 01/10/2023]
Abstract
Background. Metabolic syndrome (MetS) and obesity are known risk factors for gastroesophageal reflux disease (GERD), which is often found in patients with endocrine disorders, such as thyroid dysfunction and hypopituitarism. To clarify the relationship of endocrine disease with GERD, we investigated the symptoms of GERD in patients with various endocrine diseases. Methods. Patients with various endocrine disorders who visited Kyushu University Hospital were included. GERD symptoms were examined using a self-administered questionnaire, the frequency scale for the symptoms of GERD (FSSG). Metabolic parameters, including body-mass index (BMI), waist circumference, blood pressure, hemoglobin A1c, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and triglycerides, and values of endocrine function, including thyroid stimulating hormone, free thyroxin, cortisol, and insulin-like growth factor-1, were assessed. Results. A total of 111 consecutive patients were recruited for the study. Among these, 18 (16.2%) patients were considered to have GERD. Among the parameters, BMI (P = 0.03) and triglycerides (P = 0.001) showed a positive association and HDL-C (P = 0.0007) showed an inverse association with the FSSG score. However, none of the endocrine values were associated with the FSSG score. Conclusion. Symptoms of GERD in patients with endocrine disorders might be attributed to MetS as comorbidity.
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Savarino E, Zentilin P, Furnari M, Bodini G, Marabotto E, Savarino V. Not All Patients With Non-erosive Reflux Disease Share Psychological Distress as Main Mechanism of Disease. J Neurogastroenterol Motil 2014; 20:129-30. [PMID: 24466456 PMCID: PMC3895601 DOI: 10.5056/jnm.2014.20.1.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Patrizia Zentilin
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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de Bortoli N, Martinucci I, Savarino E, Bellini M, Bredenoord AJ, Franchi R, Bertani L, Furnari M, Savarino V, Blandizzi C, Marchi S. Proton pump inhibitor responders who are not confirmed as GERD patients with impedance and pH monitoring: who are they? Neurogastroenterol Motil 2014; 26:28-35. [PMID: 23992024 DOI: 10.1111/nmo.12221] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 07/31/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND A short-course of proton pump inhibitors (PPIs) is often used to confirm gastroesophageal reflux disease (GERD). However, some patients with PPI responsive heartburn do not seem to have evidence of GERD on impedance-pH monitoring (MII-pH). The aim of the study was to evaluate patients with reflux symptoms and a negative endoscopy, who well respond to PPIs with MII-pH. METHODS We enrolled 312 patients with GERD symptoms and negative endoscopy: 144 reported well-controlled symptoms after 8-week PPIs and 155 were non-responders. Symptom relief was evaluated with GERD Impact Scale and visual analog scale score. All patients underwent MII-pH off-therapy. Thirteen patients were excluded from analysis. Patients were grouped as follows: non-erosive reflux disease (NERD; increased acid exposure time, AET); hypersensitive esophagus (HE; normal AET, positive symptom association, SI/SAP); MII-pH-/PPI+ (normal AET, negative SI/SAP) in the responder group; MII-pH-/PPI- in non-responders. KEY RESULTS MII-pH in PPI responders (symptom relief during PPI therapy > 75%) showed: 79/144 NERD (54.9%); 37/144 HE (25.7%); 28/144 MII-pH-/PPI+ (19.4%). MII-pH-/PPI+ patients reported the same symptom relief when compared with NERD and HE. In non-responder (symptom relief during PPI therapy < 50%) group, 27/155 patients were NERD (17.4%); 53/155 were HE (34.2%); 75/155 were MII-pH-/PPI- (48.4%). NERD diagnosis was significantly higher in responder group (p < 0.01). CONCLUSIONS & INFERENCES In a substantial subgroup of patients responding to PPI with typical reflux symptoms, the diagnosis of GERD cannot be confirmed with pH-impedance monitoring. Proton pump inhibitor response and presence of typical symptoms are thus not reliable predictors of the diagnosis and antireflux surgery should always be preceded by reflux monitoring.
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Affiliation(s)
- N de Bortoli
- Division of Gastroenterology, University of Pisa, Pisa, Italy
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Locke GR, Horwhat J, Mashimo H, Savarino E, Zentilin P, Savarino V, Zerbib F, Armbruster SP, Wong RK, Moawad F. Endotherapy for and tailored approaches to treating GERD, and refractory GERD. Ann N Y Acad Sci 2013; 1300:166-186. [PMID: 24117641 DOI: 10.1111/nyas.12240] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This paper presents commentaries on how endoluminal antireflux procedures compare to laparoscopic fundoplication; new endoscopic procedures being studied to treat refractory gastroesophageal reflux disease (GERD); the new Stretta; the relationship between obesity and proton pump inhibitor (PPI) resistance; data concerning acid hypersensitivity and sensory receptors (vallinoid, TRPV1) causing refractory GERD; whether microscopic esophagitis is relevant in determining symptoms of non-erosive reflux disease (NERD); how concomitant functional gastrointestinal disorders affect the PPI response in NERD; the evidence that a functional esophagus is associated with inflammatory bowel syndrome (IBS); the role of GABA agonists in the treatment of refractory GERD; the role of biofeedback and antidepressants in refractory GERD; and endoluminal fundoplication using the EsophyX device.
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Affiliation(s)
- G Richard Locke
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John Horwhat
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Hiroshi Mashimo
- VA Boston Healthcare System/Harvard Medical School, Boston, Massachusetts
| | - Edoardo Savarino
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | | | | | - Frank Zerbib
- Department of Gastroenterology, CHU Bordeaux, Saint Andre Hospital, Bordeaux, France
| | - Steven P Armbruster
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Roy K Wong
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Fouad Moawad
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
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Martinucci I, de Bortoli N, Savarino E, Nacci A, Romeo SO, Bellini M, Savarino V, Fattori B, Marchi S. Optimal treatment of laryngopharyngeal reflux disease. Ther Adv Chronic Dis 2013; 4:287-301. [PMID: 24179671 DOI: 10.1177/2040622313503485] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Laryngopharyngeal reflux is defined as the reflux of gastric content into larynx and pharynx. A large number of data suggest the growing prevalence of laryngopharyngeal symptoms in patients with gastroesophageal reflux disease. However, laryngopharyngeal reflux is a multifactorial syndrome and gastroesophageal reflux disease is not the only cause involved in its pathogenesis. Current critical issues in diagnosing laryngopharyngeal reflux are many nonspecific laryngeal symptoms and signs, and poor sensitivity and specificity of all currently available diagnostic tests. Although it is a pragmatic clinical strategy to start with empiric trials of proton pump inhibitors, many patients with suspected laryngopharyngeal reflux have persistent symptoms despite maximal acid suppression therapy. Overall, there are scant conflicting results to assess the effect of reflux treatments (including dietary and lifestyle modification, medical treatment, antireflux surgery) on laryngopharyngeal reflux. The present review is aimed at critically discussing the current treatment options in patients with laryngopharyngeal reflux, and provides a perspective on the development of new therapies.
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Zalar A, Haddouche B, Antonietti M, Alhameedi R, Iwanicki-Caron I, Lecleire S, Ducrotté P. Lack of Correlation Between Morbid Obesity and Severe Gastroesophageal Reflux Disease in Candidates for Bariatric Surgery: Results of a Large Prospective Study. Obes Surg 2013; 23:1939-41. [DOI: 10.1007/s11695-013-1064-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Ottonello A, Savarino V, Savarino E. Non-erosive reflux disease patients are more complex than the sole endoscopy tells us. Clin Oral Investig 2013; 17:1965-6. [PMID: 23929362 DOI: 10.1007/s00784-013-1071-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 07/23/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Andrea Ottonello
- Sezione di Clinica Odontostomatologica, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, University of Genoa, Genoa, Italy
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de Bortoli N, Martinucci I, Giacchino M, Blandizzi C, Marchi S, Savarino V, Savarino E. The pharmacokinetics of ilaprazole for gastro-esophageal reflux treatment. Expert Opin Drug Metab Toxicol 2013; 9:1361-9. [PMID: 23802731 DOI: 10.1517/17425255.2013.813018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Approximately 20% of the Western population is affected by gastro-esophageal reflux disease (GERD). To date, proton pump inhibitors (PPIs) represent the mainstay of GERD medical treatment. However, despite their undoubted benefit, about 40% of GERD patients display an inadequate response to these drugs. Recently, a new PPI, ilaprazole , at oral doses of 10 mg has shown higher suppression of gastric acid secretion, more prolonged plasma half-life, and similar safety compared to 20 mg omeprazole. AREAS COVERED This review provides an update on the following points: pharmacokinetic profile and metabolism of ilaprazole in relation to its pharmacodynamic properties; comparative data on the pharmacokinetics and pharmacodynamics of ilaprazole with currently available PPIs; and implications for studies on the therapeutic efficacy of ilaprazole in GERD. EXPERT OPINION Different studies show that ilaprazole, a benzimidazole derivative, has an extended plasma half-life in comparison with all other approved PPIs. In addition, ilaprazole metabolism is not significantly influenced by CYP2C19, compared to the available PPIs. Furthermore, the pharmacological characteristics of ilaprazole confer theoretical advantages that are expected to translate into an improved acid control, particularly at night time. However, studies comparing the clinical pharmacokinetics and pharmacodynamics of ilaprazole with those of second-generation PPIs are insufficient. Moreover, further investigations assessing the efficacy of ilaprazole in the management of GERD are required. In healthy volunteers, as well as in patients with gastric or duodenal ulcers, ilaprazole has not shown clinically relevant changes in hematology and biochemistry testing, nor significant treatment-related adverse symptoms.
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Affiliation(s)
- Nicola de Bortoli
- University of Pisa, Division of Gastroenterology, Department of Internal Medicine , Pisa , Italy
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Miele L, Cammarota G, Vero V, Racco S, Cefalo C, Marrone G, Pompili M, Rapaccini G, Bianco A, Landolfi R, Gasbarrini A, Grieco A. Non-alcoholic fatty liver disease is associated with high prevalence of gastro-oesophageal reflux symptoms. Dig Liver Dis 2012; 44:1032-6. [PMID: 22963909 DOI: 10.1016/j.dld.2012.08.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 08/03/2012] [Accepted: 08/05/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux symptoms are usually reported by patients with obesity and metabolic syndrome. Aim of this study was to assess the prevalence and clinical characteristics of gastro-oesophageal reflux symptoms in subjects with non-alcoholic fatty liver disease. METHODS Cross-sectional, case-control study of 185 consecutive patients with non-alcoholic fatty liver disease and an age- and sex-matched control group of 112 healthy volunteers. Participants were interviewed with the aid of a previously validated questionnaire to assess lifestyle and reflux symptoms in the 3 months preceding enrolment. Odds ratios were determined before and after adjustment for body mass index, increased waist circumference, physical activity, metabolic syndrome and proton pump inhibitors and/or antiacid medication. RESULTS The prevalence of heartburn and/or regurgitation and of at least one of gastro-oesophageal reflux symptoms was significantly higher in the non-alcoholic fatty liver disease group. Non-alcoholic fatty liver disease subjects were associated to higher prevalence of heartburn (adjusted odds ratios: 2.17, 95% confidence intervals: 1.16-4.04), regurgitation (adjusted odds ratios: 2.61, 95% confidence intervals: 1.24-5.48) and belching (adjusted odds ratios: 2.01, 95% confidence intervals: 1.12-3.59) and had higher prevalence of at least one GER symptom (adjusted odds ratios: 3.34, 95% confidence intervals: 1.76-6.36). CONCLUSION Non-alcoholic fatty liver disease is associated with a higher prevalence of gastro-oesophageal reflux symptoms.
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Affiliation(s)
- Luca Miele
- Department of Internal Medicine, Catholic University of the Sacred Heart, Rome, Italy.
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Savarino E, Zentilin P, Tutuian R, Pohl D, Gemignani L, Malesci A, Savarino V. Impedance-pH reflux patterns can differentiate non-erosive reflux disease from functional heartburn patients. J Gastroenterol 2012; 47:159-68. [PMID: 22038553 DOI: 10.1007/s00535-011-0480-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 08/23/2011] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Symptom association is important to distinguish non-erosive reflux disease [NERD; abnormal oesophageal acid exposure time (AET) and/or positive symptom association] from functional heartburn (FH; normal AET and negative symptom association). Asymptomatic patients during reflux monitoring are challenging as symptom association cannot be assessed. AIM To evaluate whether impedance-pH reflux patterns are useful to differentiate NERD from FH. METHODS Endoscopy-negative reflux patients underwent impedance-pH off-therapy. Oesophageal AET, characteristics of reflux episodes and symptom association probability (SAP) were measured. Twenty patients asymptomatic during the first test repeated a second examination. RESULTS Of 329 patients, 130 (40%) were pH-POS, 120 (36%) pH-NEG/SAP+ (hypersensitive oesophagus = HO) and 79 (24%) pH-NEG/SAP- (FH). Total and acid reflux episodes were significantly higher (p < 0.01) in pH-POS compared to pH-NEG/SAP+, pH-NEG/SAP- and healthy volunteers (HVs). Patients pH-NEG/SAP+ had a significantly increased number of weakly acidic reflux episodes compared to pH-POS, pH-NEG/SAP- and HVs (p < 0.01). The rate of proximal reflux episodes in pH-POS (50%) and pH-NEG/SAP+ (47%) was higher (p < 0.01) than in pH-NEG/SAP- (33%) and HVs (33%). Measuring AET, number of reflux episodes and percentage of proximal reflux events permits to identify FH in 70% of cases and HO in 80% of cases who repeated the examination. CONCLUSION In patients with normal AET and SAP+, increased number of weakly acidic reflux and higher rate of proximal reflux are the main discriminant features. There is large overlap between FH and HVs. These differences can be of help in diagnosing patients with normal oesophageal acid exposure who fail to have symptoms during MII-pH testing.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy.
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