Role of endoscopy in the management of GERD

A Study on the Correlation Between Endoscopic Findings and Symptoms of Gastroesophageal Reflux Disease (GERD)

Background Gastroesophageal reflux disease is a common disorder affecting a large section of the community. In addition, the numerous complications of chronic gastroesophageal reflux disease (GERD) necessitate adequate diagnosis and treatment of this common entity. Thus, to analyze the spectrum of GERD on the basis of symptoms and endoscopic findings along with the contributory effects of various risk factors including obesity, this specific study has been carried out. Study design A descriptive type of observational study was conducted on the patients visiting the outpatient department (OPD) at Acharya Vinoba Bhave Rural Hospital (AVBRH), affiliated with Datta Meghe Institute of Medical Sciences (DMIMS), Wardha, Maharashtra. The clinical symptoms, suspected risk factors, and endoscopic findings of the patients were studied, assessed, and correlated. Methods and material Patients, more than 18 years of age complaining of a minimum of two typical symptoms of GERD for at least one month, were included in the study. Demographic data, clinical symptomatology, and personal history of the patients were noted. All the patients were subjected to esophagogastroduodenoscopy, and findings were recorded. Correlation and analysis were done on clinical and endoscopic findings. Statistical analysis This descriptive study has been conducted after the approval of the Ethics Committee Department of Medical Education, Jawaharlal Nehru Medical College, Deemed University, Sawangi (DMIMS(DU)/IEC/Sept-2019/8403). The outcomes were recorded and analyzed at the end of the study using a Microsoft Excel Spreadsheet (version 16.40, Microsoft Corporation, Redmond, Washington, USA). Results and conclusion A total of 100 patients were included in the study. A number of male patients (58%) were more than that of female patients. Most of the patients were in the age group of 30-60 years (70%). The most common symptoms were epigastric pain (78%), regurgitation (71%), and heartburn (63%). Forty-five percent of the patients had erosive lesions suggestive of reflux esophagitis on endoscopic evaluation.

BRAZILIAN PHYSICIANS' PRACTICES ON THE MANAGEMENT OF SYMPTOMS SUGGESTING GASTROESOPHAGEAL REFLUX DISEASE: A MULTIDISCIPLINARY SURVEY

BACKGROUND

Clinical guidelines are available to steer decisions regarding diagnosis, management and treatment of gastrointestinal disorders. Despite this, variations in physician's practices regarding gastroesophageal reflux disease (GERD) symptoms are well described in the literature.

OBJECTIVE

To describe practices of physicians from different specialties on the management of patients with typical symptoms of GERD (heartburn and regurgitation) in a Brazilian sample.

METHODS

National online survey enrolling a sample of general practitioners, gastroenterologists, cardiologists and otolaryngologists. The survey was conducted from August 6th to September 12th, 2018. Subjects answered a structured questionnaire addressing variables regarding physicians' profile (age, sex, specialty, practice setting, years in practice, type of medical expense reimbursement), their patients characteristics and prescribing behaviors.

RESULTS

The final weighted sample was comprised of 400 physicians, 64% male, with an average of 15 years of experience. Physicians' estimates of gastroesophageal symptoms prevalence among their pool of patients was 37.6% for the total sample, reaching 70.3% among gastroenterologists. The medical specialty with lower average percentage of patients presenting gastroesophageal symptoms was otolaryngology (24.5%). Physicians reported that they request ancillary tests for 64.5% of patients with GERD typical symptoms. The most common diagnostic test was endoscopy (69.4%), followed by video nasolaryngoscopy (16.6%). The percentage of patient to whom endoscopy is performed was significantly higher among gastroenterologists and general practitioners as compared to otolaryngologists and cardiologists, while video nasolaryngoscopy is markedly more frequent among otolaryngologists. In terms of therapeutic options, the most frequently reported strategy was lifestyle modifications followed by proton pump inhibitors.

CONCLUSION

Overall patients' profile and patterns of GERD diagnosis and management seem different between gastroenterologists, general practitioners, otolaryngologists, and cardiologists. Clinical guidelines should address this variability and include other medical specialties besides gastroenterologists in their scope.

HISTORICAL PERSPECTIVE OF GASTROESOPHAGEAL REFLUX DISEASE CLINICAL TREATMENT

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal diseases. GERD generates significant impairment in patients' quality of life and it is associated to relevant medical resources utilization. A better understanding of GERD pathophysiology in the past five decades has favored the evolution of therapeutic strategies from non-drug interventions and antacids to more efficacious and safer alternatives.

OBJECTIVE

To summarize data about the historical evolution of GERD management in Brazil, focusing on medical therapy and addressing evidence on efficacy and safety of drug classes currently recommended.

METHODS

A narrative review was conducted by systematizing information about discoveries on GERD pathophysiology. We also addressed efficacy and safety of medications currently used to reduce symptoms and improve endoscopic healing of esophageal lesions. A structured search on Pubmed was performed to identify systematic reviews and meta-analysis investigating GERD outcomes positively impacted by proton pump inhibitors (PPIs), the first choice of pharmacotherapy for the disease.

RESULTS

The chronological development of therapeutic measures for GERD in Brazil evolved from lifestyle interventions with relative poor effect on symptoms related to esophageal acid exposure, particularly heartburn, to effective and safe pharmacological interventions such as histamine H2-receptor antagonists and PPIs. In the present days, some drug classes play a minor role in disease management, namely prokinetics and antacids, due to their reduced efficacy and relevant safety concerns (particularly with prokinetics). The main challenge for prescribers and researchers seems to be finding long-acting acid suppressants strategies able to ameliorate patients' symptoms and quality of life, thereafter, reducing medical resource consumption. The dual delayed-release PPI dexlansoprazole seems to respond for some of the limitations other PPIs have.

CONCLUSION

Recognizing the historical evolution of GERD management can help care providers to better understand therapeutic options for their patients, as well as focus on unmet needs that deserve further attention. PPIs are still the first choice therapy, with good evidence in favor of their efficacy, despite some safety concerns. However, as with any medical intervention, it is recommended to prescribe PPIs for patients with clear indication, using adequate dosing and monitoring for adverse events.

Effect of Implementation of Standard Clinical Practice Guideline on Management of Gastrointestinal Bleeding Patients in Emergency Department; a Cross-Sectional Study

INTRODUCTION

A clinical practice guideline (CPG) is developed with the aim of improving the quality of health care and reducing unnecessary interventions, hospitalization time, and related costs.

OBJECTIVE

This study attempted to design a standard protocol for gastrointestinal bleeding (GIB) patients.

METHODS

This was a cross-sectional study conducted during 2013 and 2014 in an educational medical center in Isfahan, Iran. A checklist containing questions about waiting time for the services, hospitalization time, and costs was completed for the GIB patients. After this primary data gathering, a CPG was designed, codified, underwent several revisions, and finally implemented. Thereafter, the checklist was completed by GIB patients and compared with the previous ones.

RESULTS

Fifty patients in each of the two phases were included. The mean age and sex of the studied patients were not different.The time from emergency departments (ED) arrival until the first visit (14 ± 9.8 Vs. 19.4 ± 13.4 minutes; p = 0.03), hospitalization (73.7 ± 49.2 Vs. 116.2 ± 7.2 hours; p=0.003) and costs (1.3 ± 0.81 Vs. 3.68 ± 3.51 million rials; p < 0.001) were significantly reduced following the CPG implementation. The time from admission until conducting endoscopy was not different in the two study periods (16.5 ± 7.8 Vs. 23.9 ± 24.5 hours, p = 0.89).

CONCLUSION

The implementation of the CPG for the management of GIB patients in the ED resulted in a reduction in the waiting time for the services and, further, reduction of hospitalization time and related costs.

25 Years of Proton Pump Inhibitors: A Comprehensive Review

Proton pump inhibitors (PPIs) were clinically introduced more than 25 years ago and have since proven to be invaluable, safe, and effective agents for the management of a variety of acid-related disorders. Although all members in this class act in a similar fashion, inhibiting active parietal cell acid secretion, there are slight differences among PPIs relating to their pharmacokinetic properties, metabolism, and Food and Drug Administration (FDA)-approved clinical indications. Nevertheless, each is effective in managing gastroesophageal reflux disease and uncomplicated or complicated peptic ulcer disease. Despite their overall efficacy, PPIs do have some limitations related to their short plasma half-lives and requirement for meal-associated dosing, which can lead to breakthrough symptoms in some individuals, especially at night. Longer-acting PPIs and technology to prolong conventional PPI activity have been developed to specifically address these limitations and may improve clinical outcomes.

Persistent gastro-oesophageal reflux symptoms despite proton pump inhibitor therapy

About one-third of patients with suspected gastro-oesophageal reflux disease (GERD) do not respond symptomatically to proton pump inhibitors (PPIs). Many of these patients do not suffer from GERD, but may have underlying functional heartburn or atypical chest pain. Other causes of failure to respond to PPIs include inadequate acid suppression, non-acid reflux, oesophageal hypersensitivity, oesophageal dysmotility and psychological comorbidities. Functional oesophageal tests can exclude cardiac and structural causes, as well as help to confi rm or exclude GERD. The use of PPIs should only be continued in the presence of acid reflux or oesophageal hypersensitivity for acid reflux-related events that is proven on functional oesophageal tests.

The efficacy and safety of proton-pump inhibitors in treating patients with non-erosive reflux disease: a network meta-analysis

Proton-pump inhibitors (PPIs) have been proved as safe and effective ways to treat patients with non-erosive reflux disease (NERD). However, less is known about the comparisons among different PPIs and their best dosage. We aimed to synthesize the available evidence through network meta-analysis to investigate the efficacy and safety of different PPIs in treating patients with NERD. Fifteen studies with 6309 patients were included in the meta-analyses. For the rate of symptomatic relief, compared with control groups, all interventions except rabeprazole 5 mg significantly increased rate of symptomatic relief. Among the comparisons of different interventions, omeprazole 20 mg group was associated with a higher rate of symptomatic relief in contrast to omeprazole 10 mg group (odds ratio, OR: 1.89, 95% confidence interval, CI: 1.34, 2.67; p-value: 0.0005) or rabeprazole 5 mg group (OR: 2.51, 95%CI: 1.16, 5.42; p-value: 0.019); dexlansoprazole 30 mg therapy significantly improved the rate of symptomatic relief compared with rabeprazole 5 mg group (OR: 2.64, 95%CI: 1.08, 6.43; p-value: 0.03). For the rate of adverse events, there was no significant difference among all interventions.

Approach to Patients with Epigastric Pain

Epigastric pain is an extremely common complaint in the emergency department and has an associated broad differential diagnosis. In the differential it is important to consider cardiac causes that may be mistaken for gastrointestinal disorders as well as various serious intra-abdominal causes. This article highlights the limitations in laboratory testing and guides providers through the appropriate considerations for advanced imaging. Special attention is focused on acute pancreatitis, esophageal emergencies, and peptic ulcer disease/gastritis and their associated complications.

The role of endoscopy in the management of GERD

We recommend that uncomplicated GERD be diagnosed on the basis of typical symptoms without the use of diagnostic testing, including EGD. We recommend EGD for patients who have symptoms suggesting complicated GERD or alarm symptoms. We recommend that EGD not be routinely performed solely for the assessment of extraesophageal GERD symptoms. We recommend that endoscopic findings of reflux esophagitis be classified according to an accepted grading scale or described in detail. We suggest that repeat EGD be performed in patients with severe erosive esophagitis after at least an 8-week course of PPI therapy to exclude underlying BE or dysplasia. 44BB We recommend against obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude BE in adults. We suggest that endoscopy be considered in patients with multiple risk factors for Barrett’s esophagus. We recommend that tissue samples be obtained to confirm endoscopically suspected Barrett’s esophagus. We suggest that endoscopic antireflux therapy be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options.

Gastroesophageal Reflux Disease Diagnosis Using Hierarchical Heterogeneous Descriptor Fusion Support Vector Machine

A new computer-aided diagnosis method is proposed to diagnose the gastroesophageal reflux disease (GERD) from endoscopic images of the esophageal-gastric junction. To avoid the interferences of different endoscope devices and automatic camera white balance adjustment, heterogeneous descriptors computed from heterogeneous color models are used to represent endoscopic images. Instead of concatenating these descriptors to a super vector, a hierarchical heterogeneous descriptor fusion support vector machine (HHDF-SVM) framework is proposed to simultaneously apply heterogeneous descriptors for GERD diagnosis and overcome the curse of dimensionality problem. During validation, heterogeneous descriptors are extracted from test endoscopic images at first. The classification result is obtained by using HHDF-SVM with heterogeneous descriptors. As shown in the experiments, our method can automatically diagnose GERD without any manual selection of region of interest and achieve better accuracy compared to states-of-the-art methods.

In the Clinic. Gastroesophageal Reflux Disease

This issue provides a clinical overview of gastroesophageal reflux disease, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis

BACKGROUND & AIMS

A radiofrequency ablation technique known as Stretta was recommended by the Society of American Gastrointestinal and Endoscopic Surgeons as an alternative treatment for gastroesophageal reflux disease (GERD). However, randomized controlled trials of the efficacy of Stretta have produced conflicting findings, and those from previous systematic reviews were compromised as a result of deficiencies in study conduct and reporting of findings. We performed a systematic review to evaluate all evidence on the efficacy of Stretta for the management of GERD.

METHODS

We searched MEDLINE and the Cochrane Central Register of Controlled Trials (The Cochrane Library) from inception until February 28, 2014, along with other databases, for randomized controlled trials of Stretta in patients with GERD. Primary outcomes were physiologic parameters of GERD, including normalization of esophageal pH values and augmentation of lower esophageal sphincter pressure (LESP). Secondary outcomes were health-related quality of life (HRQOL) and ability to stop the use of proton pump inhibitors (PPIs). For quality assurance purposes, 2 investigators were involved throughout the study. Data were pooled under a random-effects model. The systematic review was performed as per the standards of the Cochrane collaboration.

RESULTS

We collected data from 4 trials and a total of 165 patients (153 patients were analyzed). Three trials compared Stretta vs sham, and 1 trial compared Stretta with PPI therapy. The overall quality of evidence was very low. The pooled results showed no difference between Stretta and sham or management with PPI in patients with GERD for the outcomes of mean (%) time the pH was less than 4 over a 24-hour time course, LESP, ability to stop PPIs, or HRQOL.

CONCLUSIONS

In a meta-analysis of trials, we found that Stretta for patients with GERD does not produce significant changes, compared with sham therapy, in physiologic parameters, including time spent at a pH less than 4, LESP, ability to stop PPIs, or HRQOL.

Risk of upper gastrointestinal cancers in patients with gastroesophageal reflux disease after a negative screening endoscopy

BACKGROUND & AIMS

Practice guidelines recommend a 1-time screening endoscopy for patients with gastroesophageal reflux disease (GERD) who are at high risk for Barrett's esophagus or malignancy. However, little is known about the risk of cancer in patients with negative findings from screening endoscopies.

METHODS

We conducted a retrospective cohort study using data from 121 Veterans Health Administration facilities nationwide to determine the incidence rate of esophageal adenocarcinoma (EA) separately, as well as any upper gastrointestinal cancers, in patients with an initial negative screening endoscopy (esophagogastroduodenoscopy [EGD]). We included veteran patients with GERD diagnosed between 2004 and 2009 who had a negative screening EGD within 1 year of diagnosis. We estimated the incidence rate of EA, and any upper gastrointestinal cancer, in patients with GERD who had a negative screening EGD. We examined differences in demographic, clinical, and facility factors among patients with and without cancer.

RESULTS

We identified 68,610 patients with GERD and a negative screening EGD (mean age, 55.5 y; 90% men; 67.5% white). During a mean follow-up period of 3.2 years, 10 patients developed EA and 29 patients developed any upper gastrointestinal malignancies, including EA. The incidence of subsequent EA in this group was 4.6/100,000 patient-years of follow-up evaluation, whereas the incidence of any upper gastrointestinal cancers was 13.2/100,000 patient-years of follow-up evaluation. Patients with a subsequent cancer were significantly older and had higher comorbidity scores than patients without cancer. Other clinical and facility factors did not differ significantly between these 2 groups.

CONCLUSIONS

The risk of cancer is low, over a mean 3-year period, for patients with GERD who had a negative screening endoscopy. These findings justify recommendations for a 1-time screening endoscopy for patients with GERD.

Partnership in optimizing management of reflux symptoms: a treatment algorithm for over-the-counter proton-pump inhibitors

BACKGROUND

Uncomplicated heartburn and acid regurgitation are increasingly treated and managed using over-the-counter medications. However, with over-the-counter availability of antacids, alginates, histamine 2 receptor antagonists (H2RAs), and proton-pump inhibitors (PPIs), consumers need guidance as to appropriate options and how to use them.

METHODS

Relevant guidelines, studies, and reviews were identified via literature searches of PubMed/Medline and Google Scholar, as well as cross-referencing from the identified papers.

RESULTS

Antacids, alginates, and H2RAs are best suited to management of occasional heartburn, taken either before provocative meals or other triggers or on demand when symptoms arise. Over-the-counter PPIs are appropriate options across the range of symptom severity/frequency typically encountered in the pharmacy, but may be particularly appropriate for treatment of those with frequent and/or very bothersome heartburn. A 2-4 week course of daily PPIs can lead to complete resolution of frequent heartburn. Counseling is important to ensure that patients understand that failure of symptoms to resolve or a rapid return of symptoms while taking a PPI is an indication to consult a doctor, whereas a return of symptoms after a period of months may be an indication for just another course of treatment. The need for effective communication and for ensuring use of the correct medication in the over-the-counter setting puts much of the responsibility for management of heartburn and acid regurgitation on the pharmacist. A proposed algorithm that details when and how to use available over-the-counter medications is presented. This algorithm also highlights alarm features and atypical symptoms indicative of other underlying conditions that should be referred directly to a physician.

CONCLUSION

Implementation of a simple algorithm will empower pharmacists and consumers alike and ensure consistent and appropriate care.

Risks, precipitants and clinical presentation of gastro-oesophageal reflux disease at the Kilimanjaro Christian medical centre in Tanzania [corrected]

Introduction

Risk factors and precipitants of gastro-oesophageal disease (GERD) differ widely in communities. We conducted an observational study to describe these risks, precipitants and clinical presentation of GERD patients at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania.

Methods

We consecutively recruited 92 GERD patients who were referred for endoscopy at KCMC from March to November 2008. By using structured questionnaire we enquired: risk factors, precipitants and symptoms of GERD and upper gastrointestinal endoscopic findings. Their upper gastrointestinal endoscopic findings were as well documented.

Results

The mean (± SD) age of the study population was 47.32 (±17) years. Reported symptoms included water brash (37%), dyspepsia (6%), chronic cough (11%) and hemoptysis (5%). More than half (56%) of the patients surveyed identified food precipitants for their GERD symptoms. Triggers of GERD symptoms were boiled beans 19%, spicy food 11%, sour/fermented meals 10%, roasted tomato 9%, silver cyprinid fish (dagaa) 5%, beans with cooked green banana (matoke) 2% and fermented milk 1%. Most of the studied patients had normal body mass index (52%), and 25% admitted to be consuming alcohol though they didn't associate it with their GERD symptoms. The most common endoscopy finding was “loose lower oesophageal sphincter” (85%).

Conclusion

Most GERD patients referred for endoscopy at KCMC were found to have water brash and “loose lower oesophageal sphincters” as described by endoscopists to denote mechanical abnormality of the lower oesophageal sphincter. GERD symptoms were precipitated by common locally available food and spices.

A catheter-based acoustic interrogation device for monitoring motility dynamics of the lower esophageal sphincter

This paper presents novel minimally-invasive, catheter-based acoustic interrogation device for monitoring motility dynamics of the lower esophageal sphincter (LES). A micro-oscillator actively emitting sound wave at 16 kHz is located at one side of the LES, and a miniature microphone is located at the other side of the sphincter to capture the sound generated from the oscillator. Thus, the dynamics of the opening and closing of the LES can be quantitatively assessed. In this paper, experiments are conducted utilizing an LES motility dynamics simulator. The sound strength is captured by the microphone and is correlated to the level of LES opening and closing controlled by the simulator. Measurements from the simulator model show statistically significant (p < 0.05) Pearson correlation coefficients (0.905 on the average in quiet environment and 0.736 on the average in noisy environment, D.O.F. = 9). Measuring the level of LES opening and closing has the potential to become a valuable diagnostic technique for understanding LES dysfunction and the disorders associated with it.

Nonalcoholic fatty liver disease increases risk for gastroesophageal reflux symptoms

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is now recognized as a leading cause of liver dysfunction. Gastroesophageal reflux disease (GERD) is a common disorder causing symptoms that often impair patients' quality of life. In recent years, the prevalence of both these diseases has increased, partially overlapping the rise of metabolic disorders.

AIMS

We investigated whether a relation does exist between NAFLD and GERD symptoms.

METHODS

Cross-sectional study among 206 outpatients diagnosed with NAFLD and 183 controls. We collected clinical and laboratory data, assessed severity and frequency of GERD symptoms and the esophageal endoscopic pattern.

RESULTS

The prevalence of GERD symptoms was higher in NAFLD patients than controls (61.2 vs. 27.9%, p < 0.001). We found a positive association between NAFLD and the experiencing of heartburn, regurgitation and belching. GERD symptoms were related to body mass index (BMI) and metabolic syndrome (MetS); a strong association persisted after adjustment for all the covariates (adjusted OR 3.49, 95 CI% 2.24-5.44, p < 0.001).

CONCLUSIONS

Our data show that the prevalence of GERD typical symptoms is higher in patients with NAFLD. GERD was associated with higher BMI and MetS, but not with age and diabetes type 2. NAFLD remained strongly associated with GERD, independently of a coexisting MetS status. Consistent with these findings, MetS can be considered a shared background, but cannot completely explain this correlation. We suggest NAFLD as an independent risk factor for GERD symptoms.

Guidance on the effective use of upper gastrointestinal histopathology

Given the ever-increasing demand for upper gastrointestinal endoscopy, for diagnosis and surveillance, there is a need to consider when it is appropriate, and when it is not appropriate, to take an endoscopic biopsy for histological evaluation. In this article, we consider this in relation to each of the anatomical compartments encountered during oesophagogastroduodenoscopy, and in relation to the common clinical scenarios and endoscopic abnormalities encountered. There are clear indications to biopsy suspicious ulceration or mass lesions and for investigation of some inflammatory conditions, such as eosinophilic oesophagitis and coeliac disease. Increasing guidance is available on optimal biopsy sites and biopsy numbers to maximise yield from histology. Outside these areas, the endoscopist should consider whether biopsy of normal or abnormal appearing mucosa is likely to contribute to patient management, to ensure effective use of limited healthcare resources.

Barrett's esophagus is frequently overdiagnosed in clinical practice: results of the Barrett's Esophagus Endoscopic Revision (BEER) study

BACKGROUND

The published prevalence of Barrett's esophagus (BE) varies from 0.9% to 25%, in part because of differences in the endoscopic interpretation of the disease.

OBJECTIVE

We studied the accuracy of diagnosis in 130 patients previously labeled as having BE. Our aim was to determine the interobserver consistency of endoscopic findings and assess the percentage of patients with confirmed BE versus those with a revised diagnosis.

DESIGN/SETTING/PATIENTS

Patients previously diagnosed with BE of any length and due for surveillance endoscopy were eligible for study.

INTERVENTIONS

After intensive consensus anatomic and endoscopic review, study patients underwent endoscopy and biopsy by 1 of 3 endoscopists. BE was defined as any length of columnar-lined esophagus with goblet cells.

MAIN OUTCOME MEASUREMENTS

Patients were photographed/videotaped for review by the other 2 endoscopists, and BE was either confirmed or revised.

RESULTS

Eighty-eight patients (67.7%) had confirmed BE, and 42 (32.3%) had their diagnosis revised to no BE (95% confidence interval, 24.4%-41.1%) because there was no visible columnar-lined esophagus proximal to the gastric folds or no goblet cells were found on biopsy. BE length, site of previous endoscopy, age, sex, and hiatal hernia size were predictors of revision. All 3 endoscopists agreed on all confirmed BE cases and 38 of 42 of those revised.

LIMITATIONS

Retrospective analysis, possible sampling error.

CONCLUSIONS

BE is overdiagnosed in clinical practice with important implications for patient care including increased costs, reduced insurability, and psychological stress. The true BE cancer risk may also be underestimated. This study suggests the need for a better definition of the gastroesophageal junction, stricter accountability for BE diagnosis, and improved endoscopic education.

Role of endoscopy in GERD

Endoscopy is commonly performed for the diagnosis and management of gastroesophageal reflux disease (GERD). Endoscopy allows the physician to evaluate esophageal mucosa for evidence of esophagitis and Barrett esophagus, to obtain mucosal biopsies for evaluation of such conditions as eosinophilic esophagitis and diagnosis and grading of Barrett esophagus, and to apply various therapies. In a patient with suboptimal response to GERD therapy, endoscopy excludes other etiologies as a cause of patients' symptoms. Newer endoscopic therapies for GERD are available or are in development. Advances in imaging techniques in development will improve the diagnostic yield of endoscopy and may replace the need for mucosal biopsies.

Gastric motility following ingestion of a solid meal in a cohort of adult asthmatics

BACKGROUND/AIMS

Asthmatics have abnormal esophageal motility and increased prevalence of gastroesophageal reflux disease (GERD). The contribution of gastric motility is less studied. We studied gastric myoelectrical activity, gastric emptying (GE) and their association with GERD symptoms and vagal function in adult asthmatics.

METHODS

Thirty mild, stable asthmatics and 30 healthy controls underwent real-time ultrasonography and 1 hour pre- and post-prandial cutaneous electrogastrography, following a test meal (480 kcal, 60% carbohydrate, 20% protein, 20% fat and 200 mL water). The percentage of normal slow waves and arrhythmias, dominant frequency and power, frequency of antral contractions, gastric emptying rate (GER) and antral motility index (MI) was calculated. Twenty-seven asthmatics underwent gastroscopy and in all subjects GERD symptoms were assessed by a validated questionnaire. Vagal function parameters were correlated with gastric motility parameters.

RESULTS

The asthmatics (37% male; 34.8 ± 8.4 years) and controls (50% male; 30.9 ± 7.7 years) were comparable. None had endoscopic gastric pathological changes. Twenty asthmatics described GERD symptoms. Twenty-two (73.3%) asthmatics showed a hypervagal response. Compared to controls, asthmatics had delayed GER and lower MI, lower percentage of normal gastric slow waves, more gastric dysrythmias and failed to increase the post-prandial dominant power. There was no correlation of GE and cutaneous electrogastrography parameters with presence of GERD symptoms or with vagal function.

CONCLUSIONS

Asthmatics showed abnormal gastric myoelectrical activity, delayed GE and antral hypomotility in response to a solid meal compared to controls. There was no association with vagal function or GERD symptom status.

Indirect comparison of randomised controlled trials: comparative efficacy of dexlansoprazole vs. esomeprazole in the treatment of gastro-oesophageal reflux disease

BACKGROUND

Dexlansoprazole is a new proton pump inhibitor (PPI) with a dual delayed-release system. Both dexlansoprazole and esomeprazole are an enantiomer of lansoprazole and omeprazole respectively. However, there is no head-to-head trial data or indirect comparison analyses between dexlansoprazole and esomeprazole.

AIM

To compare the efficacy of dexlansoprazole with esomeprazole in healing erosive oesophagitis (EO), the maintenance of healed EO and the treatment of non-erosive reflux disease (NERD).

METHODS

Randomised Controlled Trials (RCTs) comparing dexlansoprazole or esomeprazole with either placebo or another PPI were systematically reviewed. Random-effect meta-analyses and adjusted indirect comparisons were conducted to compare the treatment effect of dexlansoprazole and esomeprazole using a common comparator. The relative risk (RR) and 95% confidence interval (CI) were calculated.

RESULTS

The indirect comparisons revealed significant differences in symptom control of heartburn in patients with NERD at 4 weeks. Dexlansoprazole 30 mg was more effective than esomeprazole 20 mg or 40 mg (RR: 2.01, 95% CI: 1.15-3.51; RR: 2.17, 95% CI: 1.39-3.38). However, there were no statistically significant differences between the two drugs in EO healing and maintenance of healed EO. Comparison of symptom control in healed EO was not able to be made due to different definitions used in the RCTs.

CONCLUSIONS

Adjusted indirect comparisons based on currently available RCT data suggested significantly better treatment effect in symptom control of heartburn in patients with NERD for dexlansoprazole against esomeprazole. No statistically significant differences were found in other EO outcomes. However, these study findings need to be interpreted with caution due to small number of studies and other limitations.

Management of the patient with incomplete response to PPI therapy

Proton pump inhibitors (PPIs) remove most of the acid from the gastroesophageal refluxate. However, PPIs do not eliminate reflux and the response of specific GERD symptoms to PPI therapy depends on the degree to which acid drives those symptoms. PPIs are progressively less effective for heartburn, regurgitation, chest pain and extra-oesophageal symptoms. Hence, with an incomplete PPI response, obtaining an accurate history, detailing which symptoms are 'refractory' and exactly what evidence exists linking these symptoms to GERD is paramount. Reflux can continue to cause symptoms despite PPI therapy because of persistent acid reflux or weakly acidic reflux. Given these possibilities, diagnostic testing (pH or pH-impedance monitoring) becomes essential. Antireflux surgery is an alternative in patients if a clear relationship is established between persistent symptoms, particularly regurgitation, and reflux. Treating visceral hypersensitivity may also benefit the subset of GERD patients whose symptoms are driven by this mechanism.

GERD assessment including pH metry predicts a high response rate to PPI standard therapy

Background

Inadequate response to proton pump inhibitor (PPI) therapy in patients with gastroesophageal reflux disease (GERD) is reported in up to 40%. Patients with non erosive reflux disease (NERD) have lower response rates compared to patients with erosive reflux disease (ERD); pH metry contributes to GERD diagnosis and is critical for proper diagnosis of NERD.

Aim of the study was to assess the need for doubling esomeprazole standard dose (40 mg) for 4 weeks in PPI naive patients with typical reflux symptoms and diagnosis of GERD based on endoscopy and 48 hours, wireless pH metry.

Methods

All patients underwent upper GI endoscopy. Symptoms were recorded with a structured questionnaire (RDQ) and acid exposure was determined by 48 hours, wireless pH monitoring (BRAVO). In case of abnormal acid exposure, patients received a short term treatment with esomeprazole 40 mg q.d. for 4 weeks. If symptoms persisted, patients underwent a second pH metry on PPI and the dose was increased to 40 mg b.i.d.

Results

31 consecutive patients with typical reflux symptoms underwent 48 hours pH monitoring. 22 patients (71%) had abnormal acid exposure, 9 patients had normal pH metry (29%). Of the 9 patients with normal pH metry, 2 were found with erosive esophagitis and 7 without endoscopic abnormalities.

24 patients with documented GERD received esomeprazole treatment. 21 patients achieved complete symptom resolution with 40 mg q.d. after 4 weeks (88%). Only 2 patients required doubling the dose of esomeprazole for complete symptom resolution, 1 patient remained with symptoms.

Conclusions

Patients with typical reflux symptoms and abnormal acid exposure have a high response rate to standard dose esomeprazole regardless of whether they have ERD or NERD.

Quality improvement in gastroenterology clinical practice

An emphasis on quality improvement (QI) is vital to the cost-effective provision of evidence-based health care. QI projects in gastroenterology have typically focused on endoscopy to minimize or eliminate procedure-related complications or errors. However, a significant component of gastroenterology care is based on the management of chronic disease. Patients with chronic diseases are seen in many different outpatient practices in the community and academia. In an attempt to ensure that every patient receives high-quality care, major gastrointestinal societies have published guidelines on the management of common gastrointestinal complaints. However, adherence to these guidelines varies. We discuss common outpatient gastrointestinal illnesses with established guidelines for management that could benefit from active QI projects; these would ensure a consistently high standard of care for every patient.

PPI therapy is equally effective in well-defined non-erosive reflux disease and in reflux esophagitis: a meta-analysis

BACKGROUND

  Symptomatic response to proton pump inhibitor (PPI) therapy in patients with non-erosive reflux disease (NERD) is often reported as lower than in patients with erosive reflux disease (ERD). However, the definition of NERD differs across clinical trials. This meta-analysis aims to estimate the rate of symptom relief in response to PPI in NERD patients.

METHODS

MEDLINE (1966-2010), Cochrane Comprehensive Trial Register (1997-2010) and EMBASE (1985-2010) databases were searched and manual searches from studies' references were performed. Randomized clinical trials were selected that included patients with heartburn, and analyzed the effect of short-term PPI treatment. The primary outcome of selected studies was defined as complete or partial heartburn relief. Two reviewers independently extracted data and assessed study quality of selected articles. Random effects models and meta-regression were used to combine and analyze results.

KEY RESULTS

The pooled estimate of complete relief of heartburn after 4 weeks of PPI therapy in patients with ERD was 0.72 (95% CI 0.69-0.74) (32 studies), vs 0.50 (0.43-0.57) (eight studies) in empirically treated patients, 0.49 (0.44-0.55) (12 studies) in patients defined as non-erosive by negative endoscopy, and 0.73 (0.69-0.77) (two studies) in patients defined as non-erosive by both negative endoscopy and a positive pH-test.

CONCLUSIONS & INFERENCES

In well-defined NERD patients, the estimated complete symptom response rate after PPI therapy is comparable to the response rate in patients with ERD. The previously reported low response rate in studies with patients classified as NERD is likely the result of inclusion of patients with upper gastrointestinal symptoms that do not have reflux disease.

Advances in diagnostic options for refractory gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) that does not respond to treatment with proton pump inhibitors (PPIs) is widely accepted as refractory GERD, and it is one of the most stubborn digestive system diseases. In recent years, great efforts have been made to develop various diagnostic options for refractory GERD and to explore its pathogenesis. This article will review recent advances in diagnostic options and pathogenesis of refractory GERD.

24 Versus 48-hour bravo pH monitoring

BACKGROUND

Historical ambulatory pH monitoring systems for the evaluation of gastroesophageal reflux disease have been catheter based and uncomfortable for patients, commonly limiting both their diet and activities. Catheter-based studies have also been reported to underestimate the amount of reflux a patient may have in a normal, routine day. Compared with conventional catheter-based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patient's routine lifestyle, given the effects of sedation. Few studies have evaluated the merits of 24 versus 48-hour wireless pH monitoring.

AIMS

The aims of this study were (1) to identify differences in reflux parameters between 24 versus 48-hour testing as measured by wireless pH monitoring and (2) to assess the effect of 48-hour studies on the number of reflux episodes and symptom correlation as compared with 24-hour studies.

METHODS

A retrospective chart review of 124 consecutive patients who underwent 48-hour wireless esophageal pH monitoring studies was prepared. All patients underwent esophagogastroduodenoscopy using intravenous conscious sedation before wireless capsule placement. Acid reflux variables (including total reflux time, number of reflux episodes, and total percent time of pH<4) and symptom-association probability (SAP) scores were compared for day 1 versus day 2 versus total.

RESULTS

Forty-eight-hour SAP scores were significantly higher when compared with the first 24 hours for all reported primary symptoms. SAP scores were calculated at 24 and 48 hours, respectively for heartburn (56 vs. 65, P<0.0001), regurgitation (65 vs. 80, P<0.0001), chest pain (59 vs. 78, P=0.0009), and cough (55 vs. 64, P=0.0027). In addition, the percentage of SAP scores >95 was significantly higher for both heartburn and regurgitation (34% vs. 48%, P=0.003 and 38% vs. 62%, P=0.005). As expected, 48-hour testing also captured a significantly higher number of reflux episodes as compared with day 1 results alone (97 vs. 47, P<0.0001). There were no statistical differences noted between the 2 days for total percent time of pH <4.

CONCLUSIONS

Forty-eight-hour wireless (Bravo) pH monitoring strengthens symptom correlation as compared with 24-hour results alone and yields a greater percentage of SAP scores >95 for typical symptoms of gastroesophageal reflux disease. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48-hour studies for total percent time pH <4, 48-hour studies captured significantly more reflux episodes as compared with 24 hours of monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48-hour studies performed as a standard of practice.

Ablative therapies for Barrett's esophagus

Barrett's esophagus has gained increased clinical attention because of its association with esophageal adenocarcinoma, a cancer with increasing incidence and poor survival rates. The goals of ablating Barrett's esophagus are to decrease esophageal cancer rates and to improve overall survival and quality of life. Different techniques have been developed and tested for their effectiveness eradicating Barrett's epithelium. This review assesses the literature associated with different ablative techniques. The safety and efficacy of different techniques are discussed. This review concludes with recommendations for the clinician, including specific strategies for patient care decisions for patients with Barrett's esophagus with varying degrees of dysplasia.

Metabolic syndrome and gastro-esophageal reflux: A link towards a growing interest in developed countries

The aim of this Editorial is to describe the growing possibility of a link between gastro-esophageal reflux disease (GERD) and metabolic syndrome on the light of recent epidemiological and pathophysiological evidence. The state of the art of GERD is described, based on recent definitions, pathophysiological evidence, epidemiology in developed countries, clinical subtypes together with a diagnostic approach specifically focussed on the appropriateness of endoscopy. Metabolic syndrome is accurately defined and the pivotal role of insulin resistance is emphasized. The strong relationship between GERD and metabolic syndrome has been pathophysiologically analyzed, taking into account the role of obesity, mechanical factors and metabolic changes. Data collected by our group regarding eating habits and GERD are briefly summarized at the end of a pathophysiological analysis. The literature on the subject strongly supports the possibility that lifestyle and eating habits may be involved in both GERD and metabolic syndrome in developed countries.

An algorithm for diagnosis and treatment of refractory GERD

Patients with gastro-esophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade. Upper endoscopy appears to have a limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for weakly or residual acidic reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxation rate. Esophageal pain modulators are commonly offered to patients with functional heartburn although supportive clinical studies are still missing.

Metabolic syndrome and gastro-esophageal reflux: A link towards a growing interest in developed countries

The aim of this Editorial is to describe the growing possibility of a link between gastro-esophageal reflux disease (GERD) and metabolic syndrome on the light of recent epidemiological and pathophysiological evidence. The state of the art of GERD is described, based on recent definitions, pathophysiological evidence, epidemiology in developed countries, clinical subtypes together with a diagnostic approach specifically focussed on the appropriateness of endoscopy. Metabolic syndrome is accurately defined and the pivotal role of insulin resistance is emphasized. The strong relationship between GERD and metabolic syndrome has been pathophysiologically analyzed, taking into account the role of obesity, mechanical factors and metabolic changes. Data collected by our group regarding eating habits and GERD are briefly summarized at the end of a pathophysiological analysis. The literature on the subject strongly supports the possibility that lifestyle and eating habits may be involved in both GERD and metabolic syndrome in developed countries.

Gastroesophageal reflux disease

GERD is a common chronic gastrointestinal disorder, and its prevalence in Asia is increasing. Classical symptoms of heartburn and regurgitation are common presentations. There is no standard criterion for the diagnosis of GERD, and 24-h pH monitoring lacks sensitivity in NERD. Furthermore, diagnostic studies for gastroesophageal reflux disease have several limitations. A short course of PPI is often used in clinical practice as a diagnostic test for gastroesophageal reflux disease. Elderly patients with GERD usually present with atypical manifestations, and they tend to develop more severe disease. PPI remains the mainstay of treatment for GERD. In a subset of patients who wish to discontinue maintenance treatment, anti-reflux surgery is a therapeutic option.

Management of gastroesophageal reflux disease that does not respond well to proton pump inhibitors

PURPOSE OF REVIEW

Patients with gastroesophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade and presently pose a significant therapeutic challenge to the practicing physician. We reviewed newly accumulated information about the management of PPI failure that has been published over the past 2 years.

RECENT FINDINGS

There are diverse mechanisms that contribute to the failure of PPI treatment in GERD patients and they are not limited to residual reflux. Some of the causes of PPI failure may coincide in the same patient. Upper endoscopy appears to have limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for residual reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxations. Esophageal pain modulators are commonly offered to patients with functional heartburn, although supportive clinical studies are still missing.

SUMMARY

Management of refractory GERD patients remains an important clinical challenge. Recent studies have cemented the value of impedance-pH testing in pursuing proper treatment. Presently, the most promising therapeutic development for this patient population is transient lower esophageal sphincter relaxation reducers.

Upper GI tract findings in patients with heartburn in whom proton pump inhibitor treatment failed versus those not receiving antireflux treatment

BACKGROUND

Failure of proton pump inhibitor (PPI) treatment in patients with heartburn is very common. Because endoscopy is easily accessible, it is commonly used as the first evaluative tool in these patients.

OBJECTIVE

To compare GERD-related endoscopic and histologic findings in patients with heartburn in whom once-daily PPI therapy failed versus those not receiving antireflux treatment.

DESIGN

Cross-sectional study.

SETTING

A Veterans Affairs hospital.

PATIENTS

Heartburn patients from the GI outpatient clinic.

INTERVENTION

Recording of endoscopic results.

MAIN OUTCOME MEASUREMENTS

Endoscopic findings and association between PPI treatment failure and esophageal mucosal injury by using logistic regression models.

RESULTS

A total of 105 subjects (mean age 54.7 +/- 15.7 years; 71 men, 34 women) were enrolled in the PPI treatment failure group and 91 (mean age 53.4 +/- 15.8 years; 68 men, 23 women) were enrolled in the no-treatment group (P = not significant). Anatomic findings during upper endoscopy were significantly more common in the no-treatment group compared with the PPI treatment failure group (55.2% vs 40.7%, respectively; P = .04). GERD-related findings were significantly more common in the no-treatment group compared with the PPI treatment failure group (erosive esophagitis: 30.8% vs 6.7%, respectively; P < .05). Eosinophilic esophagitis was found in only 0.9% of PPI treatment failure patients. PPI treatment failure was associated with a significantly decreased odds ratio of erosive esophagitis compared with no treatment, adjusted for age, sex, and body mass index (adjusted odds ratio 0.11; 95% CI, 0.04-0.30).

CONCLUSIONS

Heartburn patients in whom once-daily PPI treatment failed demonstrated a paucity of GERD-related findings compared with those receiving no treatment. Eosinophilic esophagitis was uncommon in PPI therapy failure patients. Upper endoscopy seems to have a very low diagnostic yield in this patient population.

Gastroesophageal reflux disease: medical or surgical treatment?

BACKGROUND

Gastroesophageal reflux disease is a common condition with increasing prevalence worldwide. The disease encompasses a broad spectrum of clinical symptoms and disorders from simple heartburn without esophagitis to erosive esophagitis with severe complications, such as esophageal strictures and intestinal metaplasia. Diagnosis is based mainly on ambulatory esophageal pH testing and endoscopy. There has been a long-standing debate about the best treatment approach for this troublesome disease.

METHODS AND RESULTS

Medical treatment with PPIs has an excellent efficacy in reversing the symptoms of GERD, but they should be taken for life, and long-term side effects do exist. However, patients who desire a permanent cure and have severe complications or cannot tolerate long-term treatment with PPIs are candidates for surgical treatment. Laparoscopic antireflux surgery achieves a significant symptom control, increased patient satisfaction, and complete withdrawal of antireflux medications, in the majority of patients.

CONCLUSION

Surgical treatment should be reserved mainly for young patients seeking permanent results. However, the choice of the treatment schedule should be individualized for every patient. It is up to the patient, the physician and the surgeon to decide the best treatment option for individual cases.

Barrett's Esophagus and esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has risen dramatically over the past three decades in western countries. The importance of Barrett's esophagus (BE) derives from its potential to transform to adenocarcinoma. BE is characterized by endoscopically recognized displacement of the squamocolumnar junction proximal to the gastroesophageal junction, with replacement of squamous mucosa with columnar lined mucosa. Adenocarcinomas of the esophagus appear to arise from Barrett's mucosa through progressive degrees of dysplasia, but the pathogenesis and natural history of this process are still unclear. Much of our knowledge regarding BE and the risk of EAC is based on observational and cross-sectional analyses, and recommendations regarding management have traditionally represented "expert opinion." The past few years have seen an explosion in new information and the initiation of longitudinal studies to define the risk of adenocarcinoma in BE, the identification of predictive and prognostic markers of cancer risk, sensitive and cost-effective methods of surveillance, and methods of management of dysplasia and early neoplasia including disease prevention.

Receipt of previous diagnoses and endoscopy and outcome from esophageal adenocarcinoma: a population-based study with temporal trends

OBJECTIVES

Endoscopic screening of the at-risk population with chronic gastroesophageal reflux disease (GERD) for the presence of intestinal metaplasia or Barrett's esophagus has been suggested as a method to reduce mortality from esophageal adenocarcinoma. There are only limited data regarding the use, effectiveness, and temporal trends of this strategy.

METHODS

All patients aged 68 years and older with a new diagnosis of adenocarcinoma of the esophagus from 1994 to 2002 were identified from a linked tumor registry health claims database. Using claims from 1991 to 2002, the use of endoscopy as well as a diagnosis of GERD or Barrett's esophagus during the time interval from 3 years through 6 months prior to diagnosis were measured. The association of these measures with early-stage cancer (in situ, local) and long-term survival was determined, as well as changes over time.

RESULTS

We identified 2,754 patients, including 30.8% at early stage. Previous endoscopy had been performed in 11.5% of patients, and GERD and Barrett's esophagus diagnoses were recorded in 22.4 and 8.1% of patients, respectively. Barrett's esophagus diagnosis was strongly associated with both early-stage cancer (odds ratio 3.68, confidence interval (CI) 1.30-10.40) and survival (hazard ratio 0.45, CI 0.25-0.80). A GERD diagnosis was associated only with early stage, and endoscopy was associated only with survival. There was no association of year of diagnosis with stage or survival.

CONCLUSIONS

Although only a minority of at-risk patients were identified, the findings are consistent with the beneficial effects of recognition. Despite the development of practice guidelines, we were unable to demonstrate any temporal increases in diagnostic frequency or endoscopic utilization, which highlights the challenges that clinicians face.