Factors that influence therapeutic outcomes in symptomatic gastroesophageal reflux disease

Nissen fundoplication and dyspeptic symptoms: is the water load test useful?

BACKGROUND

The water load test is a simple, cheap and standardized method to evaluate gastric distension and gastric motility responses. We have previously shown that in patients with mild erosive or non-erosive esophagitis this test is frequently abnormal, suggesting an altered gastric function. The aim was to evaluate the water load test score before and after Nissen fundoplication in reflux patients.

METHODS

Thirty-one patients (16 men, 15 women, mean age 46.5 y) were studied before and 3 months after Nissen fundoplication by stationary esophageal manometry, wireless Bravo pH system monitoring (48 hours), and water load test. A dyspepsia symptom questionnaire was also completed before and after surgery. Data were compared with those of 35 controls.

RESULTS

All patients had pH-monitoring positive for pathological acid exposure and/or related-reflux symptoms in the absence of motility disorders. Basal symptoms scores were higher in patients compared to controls and improved after surgery, except than postprandial fullness, early satiation, and bloating, that were significantly increased. At baseline, all patients ingested significantly lower water volumes than controls, with a tendency to early onset of fullness and nausea, respectively. After surgery, the water volumes were significantly lower than presurgery.

CONCLUSIONS

In patients with reflux-related symptoms, with or without esophagitis, the water load test is frequently abnormal, suggesting an altered gastric function. Nissen fundoplication is associated with a relatively higher incidence of bloating, epigastric pain and fullness. These preliminary data could explain the incomplete resolution of symptoms after surgery in some patients, and suggest the use of additional studies to explore the gastric function in presurgical evaluation.

[Differentiation therapy for non-acidic gastroesophageal reflux disease]

AIM

To investigate the clinical and pathogenetic features of the non-acidic types of gastroesophageal reflux disease (GERD) and to evaluate the impact of combined therapy versus monotherapy on the course of this disease.

SUBJECTS AND METHODS

The investigation enrolled 62 patients with non-acidic GERD. The follow-up period was 6 weeks. The patients were divided into 2 groups: 1) weakly acidic gastroesophageal refluxes (GER); 2) weakly alkaline GER. Then each group was distributed, thus making up 4 groups: 1) 19 patients with weakly acidic GER who received monotherapy with rabeprazole 20 mg/day; 2) 21 patients with weakly acidic GER had combined therapy with rabeprazole 20 mg and itopride; 3) 8 patients with weakly alkaline GER who received ursodeoxycholic acid (UDCA) monotherapy; and 4) 14 patients with weakly alkaline GER who had combined therapy with UDCA and itopride, The clinical symptoms of the disease, the endoscopic pattern of the upper gastrointestinal tract (GIT) mucosa, histological changes in the esophageal and gastric mucosa, and the results of 24-hour impedance pH monitoring were assessed over time.

RESULTS

During differentiation therapy, the majority of patients reported positive clinical changes and an improved or unchanged endoscopic pattern. Assessment of impedance pH monitoring results revealed decreases in the overall number of GERs, the presence of a bolus in the esophagus, and the number of proximal refluxes. These changes were noted not only in patients taking proton pump inhibitors (PPIs), but also in those treated with UDCA monotherapy or combined PPI and prokinetic therapy.

CONCLUSION

A differentiated approach to non-acidic GER treatment contributes to its efficiency. Adding the prokinetic itomed (itopride hydrochloride) to PPI therapy in a patient with weakly acidic GER enhances the efficiency of treatment, by positively affecting upper GIT motility. The mainstay of therapy for GERD with a predominance of weakly alkaline refluxes is UDCA, the combination of the latter and the prokinetic can exert a more pronounced effect on the clinical and endoscopic pattern and upper GIT motility.

Non-erosive and uncomplicated erosive reflux diseases: Difference in physiopathological and symptom pattern

AIM: To investigate differences in the physiopathological findings (manometry and pH monitoring) and symptoms between cases of non-erosive reflux disease (NERD) and erosive reflux disease (ERD) found positive at 24 h pH monitoring.

METHODS: For a total of 670 patients who underwent 24 h pH monitoring, esophageal manometry and upper endoscopy were retrospectively evaluated, assessing the reflux symptoms, manometric characteristics of the lower esophageal sphincter (LES) and esophageal body and the presence or absence of esophagitis and hiatal hernia. Typical and atypical symptoms were also evaluated. For inclusion in the study, patients had to have NERD or ERD and be found positive on pH monitoring (NERD+). Patients with Gastroesophageal reflux disease (GERD) complicated by stenosis, ulcers or Barrett's esophagus were ruled out.

RESULTS: 214 patients were involved in the study, i.e. 107 cases of NERD+ and 107 of ERD. There were no significant gender- or age-related differences between the two groups. The ERD group had more cases of hiatal hernia (P = 0.02) and more acid reflux, both in terms of number of reflux episodes (P = 0.01) and as a percentage of the total time with a pH < 4 (P = 0.00), when upright (P = 0.007) and supine (P = 0.00). The NERD+ cases had more reflux episodes while upright (P = 0.02) and the ERD cases while supine (P = 0.01). The LES pressure was higher in cases of NERD+ (P = 0.03) while the amplitude and duration of their esophageal peristaltic waves tended to be better than in the ERD group (P >0.05). The NERD+ patients presented more often with atypical symptoms (P = 0.01).

CONCLUSION: The NERD+ patients’ fewer reflux episodes and the fact that they occurred mainly while in the upright position (unlike the cases of ERD) may be two factors that do not favor the onset of esophagitis. The frequently atypical symptoms seen in patients with NERD+ need to be accurately evaluated for therapeutic purposes because patients with GERD and atypical symptoms generally respond only partially to medical and surgical treatments.

[Clinical analysis of recurrence rate and symptom improvement in gastro-esophageal reflux disease patients]

BACKGROUND/AIMS

Gastro-esophageal reflux disease (GERD) is a chronic condition, with 50-80% of patients experiencing recurrence within one year following completion of initial treatment. The present study aimed to estimate recurrence rate and treatment response in GERD patients treated with proton pump inhibitor.

METHODS

A total of 207 symptomatic GERD patients, which were confirmed by endoscopy from July 2008 till January 2009, were enrolled. They were divided into non-erosive reflux disease (NERD) group and erosive reflux disease (ERD) group by endoscopic findings. Patients were treated with lansoprazole 15 mg (NERD group) or 30 mg (ERD group) once daily for 8 weeks. The presence of symptoms was assessed in each patient at baseline and post-treatment using a questionnaire. Subsequent symptomatic recurrence on the cessation of therapy in each improved patients was checked by telephone survey or outpatient interview.

RESULTS

Ninety-four patients and 113 patients were first diagnosed with NERD and ERD, respectively. The mean post-treatment follow-up period was 24.4+/-8.5 weeks. Recurrence rate was 40.0% (NERD, 43.8%; ERD, 37.1% (p=0.224)). Recurrence time was 10.1+/-5.8 weeks (NERD 9.6 weeks; ERD, 10.6 weeks (p=0.444)). Regarding the symptom improvement after 8 week therapy with lansoprazole, 89.4% (NERD, 85.1%; ERD, 92.9% (p=0.056)) of total patients were symptomatically improved.

CONCLUSIONS

Forty percentage of GERD patients recurred within 6 months following the completion of 8 week therapy with lansoprazole. Recurrence rate, recurrence time, and rate of symptom improvement were not significantly different between NERD group treated with half dose and ERD group treated with full dose lansoprazole.

Abdominal ultrasonography as a new modality for the diagnosis of gastroesophageal reflux disease

BACKGROUND AND AIMS

Thickening and abnormal architecture of the esophageal wall in gastroesophageal reflux disease (GERD) have been reported using endoscopic ultrasonography (US), but whether extracorporeal abdominal US is a useful diagnostic modality has not been investigated.

METHODS

Subjects were 37 GERD, 24 non-erosive reflux disease (NERD) patients and 32 controls who visited our hospital from 2006-2009 and underwent upper gastrointestinal endoscopy and extracorporeal abdominal US. The US operator was unaware of any clinical information and examined the following: (i) thickness (>or=5 mm) and (ii) architecture of the esophageal wall; and (iii) presence of reflux. GERD was diagnosed when two or more of these items were positive.

RESULTS

Thickening of the lower esophageal wall in erosive GERD, NERD and controls was 5.7 +/- 0.6, 4.4 +/- 0.8 and 4.7 +/- 0.9 mm, respectively. The thickness in erosive GERD was significantly greater (P < 0.05) than that in NERD patients and controls. Sensitivity, specificity and accuracy of abdominal US diagnosis for erosive GERD and NERD (vs control) was 84.6% (11/13), 25% (6/24), 91.1% (31/34) and 91.1% (31/34), 89.4% (42/47) and 63.8% (37/58), respectively.

CONCLUSION

Extracorporeal abdominal US could be a new useful modality for diagnosing GERD.

Functional heartburn, nonerosive reflux disease, and reflux esophagitis are all distinct conditions—A debate: Pro

Gastroesophageal reflux disease (GERD) traditionally has been approached as a spectrum-continuum, suggesting that patients may progress over time and develop a more severe esophageal mucosal involvement. The spectrum-continuum conceptual model had a profound impact on the research priorities in GERD, as well as on proposed diagnostic algorithms and therapeutic strategies. Natural course studies in GERD are almost always retrospective and commonly afflicted with a plethora of shortcomings. Factors that affect quality of natural course studies in GERD include the following: index endoscopy results are taken at face value; antireflux treatment is consumed until index endoscopy and/or offered during the follow-up phase; pathophysiologic, anatomic, and genetic factors are overlooked; and lack of confirmation of the durability of the new esophageal mucosal finding. Functional heartburn is common and likely to affect a large subset of patients presenting with heartburn. Evidence to support progression of functional heartburn to nonerosive reflux disease (NERD), erosive esophagitis, or Barrett's esophagus is very scarce. The largest population-based or longest-duration natural course studies report that only 10% of patients progress from NERD to erosive esophagitis over time. The other GERD patients remained within their respective phenotypic presentations of GERD.

Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment

OBJECTIVES

Whether patients with typical gastroesophageal reflux disease (GERD) symptoms and without alarm features should be treated empirically or undergo endoscopy first is a debated issue. In this study, our aim was to assess the efficacy, and to compare the direct costs and impact on health-related quality of life (HRQL), of two treatment strategies (empirical vs endoscopy-oriented treatment) in a large population of patients with GERD.

METHODS

In total, 612 patients were randomized to either empirical treatment with esomeprazole 40 mg once daily (od) (group 1, N = 309) or endoscopy and treatment according to endoscopic findings (group 2, N = 303, esomeprazole 40 mg od in patients with reflux esophagitis and esomeprazole 20 mg od in patients without esophagitis) for 4 wk, followed by esomeprazole 20 mg od maintenance treatment in both groups. Direct costs and HRQL were analyzed in both treatment arms.

RESULTS

At the end of the acute treatment phase (week 4), 267 patients in group 1 (86.4%) and 265 patients in group 2 (87.5%) were considered responders to treatment (intention-to-treat analysis, P= 0.878). Empirical treatment proved to be cost-effective by saving 38.72 euros per treated patient. At the end of the maintenance phase (week 24), a similar proportion of patients responded to treatment in the two groups (71.8%vs 68.3%, P= 0.389). HRQL improved from baseline to week 24 in both groups (difference between study groups not significant).

CONCLUSIONS

In patients with GERD, empirical treatment with esomeprazole proved to be cost-effective compared with endoscopy-oriented treatment, and did not negatively affect patient HRQL. These results should be taken into account in the management of GERD patients in clinical practice.

Babies with brain damage who can not swallow: surgical management

BACKGROUND: Neonates with severe neurological impairment are often unable to swallow, necessitating gastrostomy for feeding. Because of the risk of developing severe reflux, this procedure is often associated with fundoplication. OBJECTIVE: To assess the safety and efficacy of gastrostomy and Nissen fundoplication in 22 neonates with swallowing difficulties due to serious neurological impairment. METHOD: All children underwent an initial period of nasogastric feeding and after informed consent underwent gastrostomy and Nissen fundoplication. RESULTS: There were no significant intraoperative complications. There were two cases of postoperative periostomy leakage. Of the 22 neonates 16 were alive four months after surgery. Six neonates died of complications due to underlying disease. CONCLUSION: We concluded that gastrostomy and Nissen fundoplication are safe procedures and help parents give a better care to these children.

Water load test before and after PPI therapy in patients with gastro-oesophageal reflux disease

BACKGROUND

Patients with gastro-oesophageal reflux disease may complain of epigastric pain, bloating, early satiety, epigastric fullness, epigastric burning, nausea and vomiting.

AIMS

To evaluate the symptoms in response to gastric distension and its relationship to a therapeutic course in patients with gastro-oesophageal reflux disease using the water load test, compared to healthy controls.

METHODS

Thirty gastro-oesophageal reflux disease patients with grade A oesophagitis (studied before and after 4 weeks of therapy with esomeprazole, 40 mg per day) and 15 patients with reflux-related symptoms demonstrated at wireless pH monitoring (non-erosive reflux disease) were compared to 30 healthy volunteers.

RESULTS

Patients with grade A oesophagitis and with reflux-related symptoms ingested significantly lower water volumes than did controls, before onset of fullness, without statistically significant difference between erosive or non-erosive gastro-oesophageal reflux disease; this variable improved in patients after treatment. Nausea scores were higher basally in patients, pre- and post-therapy, and improved after therapy. Thirty-minute fullness and bloating scores improved after therapy in all gastro-oesophageal reflux disease patients compared to controls and pre-therapy. In all pre-treatment patients, a significant correlation was found only with epigastric fullness; after treatment, there was no significant relationship between the water load and the symptom scores.

CONCLUSIONS

In patients with reflux-related symptoms, with or without grade A oesophagitis, the water load test is frequently abnormal, suggesting an altered gastric function. This could explain the incomplete resolution of symptoms after treatment in some patients, and should lead to additional studies aimed at exploring gastric function in gastro-oesophageal reflux disease patients.

Studying the overlap between IBS and GERD: a systematic review of the literature

Evidence points to a significant overlap between irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). In this study, we evaluate this overlap by conducting a systematic review of the literature. Six electronic databases from 1966 through January 2005 were screened by multiple search terms to identify all epidmiological evidence linking IBS and GERD. In addition, AGA meeting abstracts for 2003 and 2004 were also screened. All studies were validated by the authors and data extracted according to predefined criteria. As a separate search strategy, studies evaluating the prevalence of IBS and GERD in the general population were sought. These articles were obtained to compare the prevalence of IBS and GERD in the community to the degree of overlap. The search identified 997 original titles with 15 publications that fulfilled our eligibility criteria. Among the 15 studies, 7 determined the GERD maximum mean prevalence in patients already diagnosed with IBS to be 39.3% and the weighted mean 30.3%. The other 7 studies examined the prevalence of IBS in patients already diagnosed with GERD. The maximum mean prevalence of IBS in subjects with known GERD was 48.8% and the weighted mean 60.5%. Based on the prevalence of IBS (12.1%) and GERD (19.4%) in the community, the rate of IBS in the non-GERD community was calculated to be only 5.1%. There is a strong overlap between GERD and IBS that exceeds the individual presence of each condition. In the absence of GERD, IBS is relatively uncommon.

Quality of life in acute and maintenance treatment of non-erosive and mild erosive gastro-oesophageal reflux disease

BACKGROUND

Quality of life has been assessed in a large, multicentre randomized, open label study.

AIM

To evaluate the economic and clinical consequences of two different maintenance treatment modalities, administered to 6017 gastro-oesophageal reflux disease patients at 451 gastroenterological centres in Italy.

METHODS

Adult gastro-oesophageal reflux disease patients received, at enrolment, an acute treatment of esomeprazole 40 mg/day for 4 weeks and, if successfully treated, were randomized into two maintenance treatment strategies: esomeprazole 20 mg/day or esomeprazole on demand for 6 months. A baseline endoscopy allowed the exclusion of grade II-IV oesophagitis according to Savary-Miller's classification. Burden of gastro-oesophageal reflux disease was measured at baseline by the generic questionnaire Short-Form 36 and by a disease specific instrument, quality of life in reflux and dyspepsia (QOLRAD), also administered at start and conclusion of maintenance period. Investigators were required to collect patient judgement about the degree of satisfaction with treatment effect on heartburn, with a 7-point scale.

RESULTS

A comparison between Short-Form 36 scores and the normative source of the Italian general population suggested that symptomatic gastro-oesophageal reflux disease patients experience a worse quality of life than the general population. At the end of the 4-week treatment with esomeprazole 40 mg all (QOLRAD) dimensions showed a statistically significant (P < 0.0001) and clinically meaningful improvement. Satisfaction level towards treatment was reported high in the total enrolled population after acute treatment with esomeprazole 40 mg/day (96.2% satisfied and 64.4% very satisfied). A statistically significant difference in (QOLRAD) scores was registered at the end of maintenance phase in favour of the continuous regimen, nevertheless the size of this difference was very small in all dimensions; similarly, the proportion of patients very satisfied was slightly higher in the continuous treatment arm (64.5%) than in the on-demand arm (59.7%).

CONCLUSIONS

Gastro-oesophageal reflux disease can significantly impair health-related quality of life and esomeprazole therapy allows immediate relief in the acute phase of the disease. Quality of life improvement was maintained during the 6-month follow-up with a slight difference in term of quality of life in reflux and dyspepsia scores and patients' satisfaction in favour of the continuous treatment strategy.

Review article: quality-of-life issues in gastro-oesophageal reflux disease

The purpose of this review is to explore issues relating to quality of life in gastro-oesophageal reflux disease, examining the range of generic and disease-specific instruments available, their applicability and limitations and to overview the effect of gastro-oesophageal reflux disease on quality of life. Whereas instruments have been developed to assist researchers, there is a paucity of reliable instruments for pragmatic use in the clinical setting. The situation is complicated because there is not necessarily a direct correlation between endoscopic findings and symptom severity and non-erosive reflux disease is now recognized as an important manifestation of gastro-oesophageal reflux disease. However, quality-of-life instruments are useful in evaluating the impact of therapies and interventions, although these are limited, particularly in surgical interventions. Impaired quality of life now forms part of a definition of gastro-oesophageal reflux disease, the impact of which goes beyond the symptoms alone. While the symptoms themselves have a negative effect on sufferers' lives, there are secondary effects caused by impaired physical, emotional and social functioning on productivity. Non-gastrointestinal problems caused by gastro-oesophageal reflux disease also impair quality of life. There is an ongoing need to develop instruments which truly measure the impact of gastro-oesophageal reflux disease and which are readily interpretable to the individual patient and clinician.

Characteristics of symptomatic GERD in Japanese patients based on 24-h pH monitoring

BACKGROUND

We assessed the characteristics of symptomatic gastroesophageal reflux disease (sGERD), defined as the presence of symptoms, but no endoscopic findings of reflux esophagitis, in Japanese.

METHODS

Sixty-three patients were diagnosed with sGERD, and underwent 24-h esophagogastric pH monitoring (32 men; mean age, 50.5 years). Patients were classified into the following three groups : reflux group (group R), minor reflux group (group MR), and a no-reflux group (group N) by the percentage of time at pH below 4 (group R, 4.0% or more; group MR, 2.0%-3.9%; group N, 0-1.9%). Hiatal hernia was assessed based on the Anatomy-Function-Pathology (AFP) classification, and the shape of the cardia was assessed based on valve factors (V0-V3).

RESULTS

There were 13 patients (21%) in group R, 17 (27%) in group MR, and 33 (52%) in group N. Hiatal hernia was present in 11 patients (85%) in group R, 14 (82%) in group MR, and 22 (67%) in group N. Patients grouped according to presence of V2/V3 (chalasia) accounted for 100% of those in group R, 71% of those in group MR and 70% of those in group N. Hiatal hernia was present in 10 (91%), 10 (83%), and 6 patients (86%) who had 50 or more episodes of esophageal acid reflux per day in group R, group MR, and group N, respectively.

CONCLUSIONS

Reflux (percentage of time below pH 4, 4%) was seen in only about 20% of the patients with sGERD, and this percentage of patients with reflux was lower compared to the data reported from the United States and Europe. The percentage of patients who had a hiatal hernia or chalasia was high in all these groups, and this seemed to be a characteristic cause of sGERD in Japanese.

Efficacy of famotidine and omeprazole in healing symptoms of non-erosive gastro-oesophageal reflux disease: randomized-controlled study of gastro-oesophageal reflux disease

BACKGROUND

The epidemiology and pathophysiology of non-erosive gastro-oesophageal reflux disease differs from erosive gastro-oesophageal reflux disease. There is a possibility that non-erosive gastro-oesophageal reflux disease treatment requires a different regimen/approach but it is not yet acknowledged.

AIM

To investigate the efficacy of famotidine and omeprazole in the treatment of gastro-oesophageal reflux disease, especially non-erosive gastro-oesophageal reflux disease.

PATIENTS AND METHODS

A randomized, open-label trial was conducted. Fifty-four gastro-oesophageal reflux disease patients were assigned to treatment with famotidine at a dosage of 20 mg twice daily; or omeprazole, 20 mg once daily, for a period of 8 weeks. The Short Form-36 Health Survey and Gastrointestinal Symptom Rating Scale administered at baseline and after 8 weeks of treatment as well as a symptom questionnaire were conducted daily.

RESULTS

Short Form-36 revealed that gastro-oesophageal reflux disease has severe impact on health-related quality of life. Thirty-nine subjects (77%) were endoscopically diagnosed as non-erosive gastro-oesophageal reflux disease. The mean Gastrointestinal Symptom Rating Scale abdominal pain, and indigestion score of non-erosive gastro-oesophageal reflux disease significantly improved in famotidine-treated patients (P < 0.05), but not in the omeprazole. There was no significant change regarding improved heartburn symptoms of non-erosive gastro-oesophageal reflux disease between treatments in the daytime or night-time.

CONCLUSION

Famotidine and omeprazole were both effective in improving symptoms of gastro-oesophageal reflux disease, particularly non-erosive gastro-oesophageal reflux disease.

Burden of illness in Italian patients with gastro-oesophageal reflux disease

OBJECTIVE

Gastro-oesophageal reflux disease (GORD), characterized by frequent episodes of heartburn, imposes considerable burdens on both patients and health services. In addition to both patients and health services. In addition to gastrointestinal symptoms, GORD may precipitate a variety of extra-oesophageal complications, such as asthma and chest pain, which can significantly impair patients' quality of life. This paper aims to describe the impact of heartburn on patients' health-related quality of life (HRQL) in Italy.

RESEARCH DESIGN AND METHODS

Consecutive patients from general practices and gastroenterology clinics who were experiencing heartburn were invited to complete a selection of standardized patient-reported outcomes instruments, including Italian translations of the Gastrointestinal Symptom Rating Scale (GSRS), Short-Form 36 (SF-36), Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD) and Hospital Anxiety and Depression (HAD) scale. Frequency and severity of heartburn in the preceding week were recorded.

RESULTS

Assessments were completed by 152 patients (mean age, 47 years), of whom 60% were female. Sixty-one per cent had moderate symptoms and 74% had symptoms on three or more days in the previous week. Patients were most bothered by reflux, abdominal pain and indigestion. As a result of their symptoms, patients experienced impaired vitality, sleep disturbance and other alimentary problems. This led to impaired HRQL across all but one SF-36 domain. According to the HAD scale, 21% of patients were depressed and 19% were anxious.

CONCLUSION

GORD substantially impairs many aspects of HRQL, including sleep, vitality and emotional health.

Clinical impact of upper endoscopy in the management of patients with gastroesophageal reflux disease

OBJECTIVE

Esophago-gastro-duodenoscopy (EGD) is frequently performed in patients with heartburn. However, the benefit of an EGD is unclear. The objective is to determine the clinical impact of performing an EGD in the management of GERD.

METHODS

Patients with alarm symptoms or persistent heartburn from primary care and gastroenterology clinics were invited to participate. Patients with known reflux complications or an EGD procedure within 3 yr were excluded. Endpoints for EGD-improving management were prospectively defined: change in medical therapy, dilating esophageal stricture, identifying Barrett's esophagus (BE), finding severe esophagitis (Hetzel-Dent grade 3 or 4), or finding cancer.

RESULTS

Two hundred and six patients (59 M/147 F; median age, 48 yr) were enrolled, in which, 124 had alarm symptoms and 82 had persistent heartburn. EGD improved the overall management in 40% of patients with alarm symptoms and 29% with persistent heartburn (p= NS). Medical therapy was altered in only 5% of patients, and no cancer was identified. EGD was more likely to improve management in males with alarm symptoms.

CONCLUSIONS

It was uncommon for an EGD to alter antireflux therapy. The management was improved in approximately one-third of the patients by dilating esophageal stricture, finding BE to initiate surveillance, or finding severe esophagitis. EGD should be performed when alarm symptoms are present, especially in males.

Non-pharmacologic treatment strategies in gastroesophageal reflux disease

In the West, gastroesophageal reflux disease (GERD) is a common and well-recognized disease. Lately, it has been described as an emerging problem in the East as well. While it is not a rapidly fatal illness, it causes a myriad of disturbing symptoms that remarkably reduce the patients' quality of life (QOL). The economic impact that results from multiple consultations, diagnostic investigations, and administration of a variety of treatment regimens, including surgery, is enormous. The operative management for GERD is fundoplication, for example Toupet (270 degree wrap of the distal esophagus) and Nissen (360 degree wrap of the distal esophagus). These surgical procedures are aimed at permanently controlling acid reflux by reconstructing the gastroesophageal junction. Currently, the ease, aesthetic advantages, and the comparable outcomes achieved by minimally invasive laparoscopic fundoplication have rekindled interest in the operative alternatives of GERD management. Fundoplication controls or diminishes considerably the severity of the symptoms associated with GERD. However, appearance of new symptoms i.e. dysphagia, 'gas-bloat syndrome', etc. as postoperative events have been reported. Recently, several innovative endoluminal treatment modalities have been introduced, namely; endoscopic plicator/suturing devices, bulking injections, and radiofrequency treatment. They are focused on enhancing the performance of a malfunctioning lower esophageal sphincter. While results of several case series reflect substantial improvements in GERD-HRQL scores, lack of long-term durability data is a major concern when recommending these novel, relatively simple, peroral techniques to a long suffering patient. It is clear that these therapies are still evolving and long-term outcomes of properly designed comparative efficacy trials are awaited.

Functional dyspepsia (FD) and non-erosive reflux disease (NERD): overlapping or discrete entities?

As the incidence of both gastric cancer and peptic ulcer disease have declined, that of gastro-oesophageal reflux disease (GORD) and non-ulcer, or functional dyspepsia (FD) have reached virtually epidemic proportions. As we come to appreciate the expression of these disorders in the community, the real spectrum of each disease has become evident. FD and non-erosive reflux disease (NERD), the most prevalent manifestation of GORD, frequently overlap. Where then does GORD end and FD begin? Is it realistic, or even clinically relevant, to attempt a clear separation between these entities? These are more than issues of mere semantics; therapeutic options may be dictated by the classification of the patient as one or the other. Recent work indicates clearly that NERD is a heterogeneous disorder incorporating some patients who may well harbour subtle manifestations of oesophagitis and others who have entirely normal 24-hour pH studies. These differences may be crucial to the concept of NERD/FD overlap. While evidence in support of this concept is far from complete, it would appear that this overlap is most relevant to those NERD patients who do not exhibit abnormal esophageal acid exposure. These patients truly belong in the spectrum of functional gastrointestinal disorders rather than in GORD; attempts to shoe-horn these individuals into the spectrum of GORD will result in therapeutic disappointment and surgical disaster.

Review article: epidemiology and management of gastro-oesophageal reflux in children

The management of gastro-oesophageal reflux disease (GERD) continues to garner vast amounts of attention among physicians who care for adults. However, there is an increasing awareness of the fact that this disease, as well as several other lifelong digestive diseases (i.e. Crohn's disease) may actually have their origins in childhood. Paediatric gastro-oesophageal reflux (GER) is likely to share a similar pathophysiology to adult GER, and mounting evidence from published preliminary data suggests a genetic susceptibility to GERD. However, further studies will be necessary to confirm this hypothesis. In children, GER has a distinct presentation from that in adults, with the diagnostic work-up based upon the patient's age as well as their presenting signs and symptoms. Like their adult counterparts, the early detection and treatment of GER in children may result in a better long-term outcome, improved quality-of-life, and a reduction in overall healthcare burden. While the treatment of GER in infants tends to be conservative (i.e. positioning during feeding, smaller feedings), its management in older children parallels that of adults and includes lifestyle changes and pharmacological therapy. However, with persistent symptoms, acid suppression is the mainstay of GERD management in both children and adults. Several studies in children have verified that acid suppression with a proton pump inhibitor is superior to histamine-2 receptor antagonists. Among the proton pump inhibitors, both lansoprazole and omeprazole have been the subject of published adult and paediatric studies demonstrating their short and long-term safety, in addition to their efficacy in a variety of oesophageal and supra-oesophageal GERD related conditions. These two proton pump inhibitors are manufactured as capsules containing enteric-coated granules that can be emptied into soft foods or liquids without compromising their pharmacological effects or pharmacokinetic properties. Lansoprazole is also available as a strawberry-flavoured suspension that is acceptable to children and as an oral disintegrating tablet.

Repercusión de la enfermedad en pacientes con reflujo gastroesofágico. Evidencia de un estudio metodológico reciente en España

INTRODUCTION

The clinical and socioeconomic burden of gastroesophageal reflux disease (GERD) is considerable.

AIM

The aim of this study was to describe the impact of heartburn on patients' health-related quality of life (HRQL) in Spain, using validated generic and disease-specific instruments to measure patient-reported outcomes.

PATIENTS AND METHODS

Patients with symptoms of heartburn completed the Spanish versions of the Gastrointestinal Symptom Rating Scale (GSRS), the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), the Short Form-36 (SF-36) and the Hospital Anxiety and Depression (HAD) scale. The frequency and severity of heartburn in the previous 7 days were also recorded.

RESULTS

One hundred fifty-eight patients completed the assessments (mean age: 51 years, SD = 16; 58% female). Sixty-one percent of the patients had moderate symptoms and 73% had symptoms on three or more days in the previous week. Patients were most bothered by symptoms of reflux (mean GSRS score of 3.8 on a scale of 1 [not bothered] to 7 [very bothered]), abdominal pain (3.1) and indigestion (3.1). As a result of their symptoms, patients experienced problems with food and drink (mean QOLRAD score of 4.5 on a scale of 1 to 7, where 1 represents the most severe impact on daily functioning), impaired vitality (4.7) and emotional distress (4.8). This led to impaired overall HRQL across all domains (mean SF-36 score of this heartburn population compared with a general population in Spain). The HAD scale showed that 28% of patients were anxious and 13% were depressed.

CONCLUSION

There is consistent evidence that GERD substantially impairs all aspects of HRQL.

Impact of endoscopically minimal involvement on IL-8 mRNA expression in esophageal mucosa of patients with non-erosive reflux disease

AIM: Little has been known about the pathogenesis of non-erosive reflux disease (NERD). Recent studies have implicated interleukin 8 (IL-8) in the development and progression of gastroesophgeal reflux disease (GERD). The purpose of this study was to determine IL-8 RNA expression levels in NERD patients with or without subtle mucosal changes.

METHODS: We studied 26 patients with NERD and 13 asymptomatic controls. Biopsy sample was taken from the esophagus 3 cm above the gastroesophageal junction and snap frozen for measurement of IL-8 mRNA levels by real-time quantitative polymerase chain reaction (PCR). We also examined mRNA expression of IL-8 receptors, CXCR-1 and -2 by reverse transcriptase PCR. The patients were endoscopically classified into grade M (mucosal color changes without visible mucosal break) and N (neither minimal involvement nor mucosal break) of the modified Los Angeles classification.

RESULTS: The relative IL-8 mRNA expression levels were significantly higher in esophageal mucosa of NERD patients than those of the controls. There was a significant difference in IL-8 mRNA levels between grade M and N. The CXCR-1 and -2 mRNAs were constitutively expressed in esophageal mucosa.

CONCLUSION: Our results suggest that high IL-8 levels in esophageal mucosa may be involved in the pathogenesis of NERD through interaction with its receptors. NERD seems to be composed of a heterogeneous population in terms of not only endoscopically minimal involvement but also immune and inflammatory processes.

Intra-oesophageal distribution and perception of acid reflux in patients with non-erosive gastro-oesophageal reflux disease

BACKGROUND

The majority of patients with gastro-oesophageal reflux disease do not present with erosive oesophagitis and make up a heterogeneous group. Patients with non-erosive gastro-oesophageal reflux disease are less responsive than patients with oesophagitis to acid-suppressive therapy.

AIM

To assess the role of acid reflux in gastro-oesophageal reflux disease symptoms.

METHODS

The spatio-temporal characteristics of reflux events were analysed and related to reflux perception in 45 patients with non-erosive gastro-oesophageal reflux disease and 20 patients with erosive oesophagitis.

RESULTS

Compared with healthy controls, all patients showed a higher intra-oesophageal proximal spread of acid, which was prominent in patients with non-erosive gastro-oesophageal reflux disease (> 50% of events lasting for 1-2 min). Irrespective of mucosal injury, the risk of reflux perception was very high when acid reached proximal sensors (odds ratio, 7.6; 95% confidence interval, 4.6-12.5), being maximal in patients with non-erosive gastro-oesophageal reflux disease with normal acid exposure time (odds ratio, 11; 95% confidence interval, 5.2-22.3).

CONCLUSIONS

Patients with non-erosive gastro-oesophageal reflux disease are characterized by a significantly higher proportion of proximal acid refluxes and a higher sensitivity to short-lasting refluxes when compared with patients with oesophagitis. The highest proximal acid exposure and highest perception occurred in patients with non-erosive gastro-oesophageal reflux disease presenting with a normal pH-metric profile. The assessment of acid distribution and its perception in the oesophageal body can better identify reflux patients who should benefit from acid-suppressive treatment.

New developments in the pathophysiology of gastro-oesophageal reflux disease (GERD): implications for patient management

The spectrum of gastro-oesophageal reflux disease (GERD) has expanded; indeed the majority of individuals with symptomatic GERD do not have erosive reflux disease (ERD); this group has been referred to as nonerosive or negative-endoscopy reflux disease (NERD). There may be important differences between NERD and ERD in terms of pathophysiology and management. Thus, NERD patients appear relatively resistant to proton pump inhibitors and may not be good surgical candidates. The clinician caring for patients with GERD must therefore be aware of the full spectrum of GERD and of the pathophysiological and therapeutic implications of NERD. Recent twin studies have revealed that genetic factors play a role in GERD and form the basis for future studies on the role of inheritance in the various manifestations of GERD. Several recent investigations have reaffirmed the primacy of acid reflux in the pathogenesis of GERD and have also provided insights into the pathophysiology of postprandial heartburn. Transient lower oesophageal sphincter relaxations and hiatal hernias have emerged as major and interacting factors in the genesis of reflux events and in the potentiation of acid exposure; the former are attracting considerable attention as a potential therapeutic target. Nocturnal acid breakthrough, which has been implicated in the failure of some patients to respond to high doses of proton pump inhibitors, appears, on further examination, to be a gastric rather than an oesophageal phenomenon, and may not be of clinical or therapeutic importance.