The effect of omeprazole on gastro-oesophageal reflux and symptoms during strenuous exercise

Gastroesophageal Reflux and Its Association With Atrial Fibrillation: A Traditional Review

Atrial fibrillation (AF) is a common arrhythmia, and gastroesophageal reflux disease (GERD) is a common gastroenterology disease; both are highly encountered daily in clinical practice. Since both share common predisposing factors, we can conclude that there is a link between them. To date, the precise mechanism of reflux disease as a possible cause of atrial fibrillation remains uncertain. However, some possibilities can be postulated, such as the inflammation process, and sympathovagal imbalance represents the main factors for how GERD can initiate AF. Vigorous aerobic exercise in healthy people can bring about acidic esophageal reflux, which is a common risk factor for AF. Various inflammatory markers such as C-reaction protein (CRP) and interleukins have been a central role in initiating AF. A large hiatal hernia (HH) can cause direct compression on the left atrium that is possibly predisposing to atrial arrhythmogenesis. It has been sporadically reported that using a proton pump inhibitor to treat GERD in patients with coexisting AF has a noticeable effect on decreasing symptoms of AF and recurrence with less cost and side effects.

Exercise-induced bronchoconstriction update-2016

The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.

Editorial: Reflux While Running: Something to Belch About

Running is the most popular form of exercise in the United States. Gastroesophageal reflux (GER) is common during exercise and may affect performance. Previous studies have focused on increased intra-abdominal pressure as a major determinant of acid reflux during physical exertion. In this issue, Herregods et al. examined the mechanisms of GER in healthy volunteers using simultaneous high-resolution manometry and pH impedance testing performed while running. Novel observations afforded by the utilization of state-of-the-art technology include the importance of transient lower esophageal sphincter relaxation ("belch reflex") and transient formation of hiatal hernia during exercise. The findings are provocative and lend credence to commonsense strategies to minimize the consequences of belching in runners.

Review article: the pathophysiology and management of gastrointestinal symptoms during physical exercise, and the role of splanchnic blood flow

BACKGROUND

The prevalence of exercise-induced gastrointestinal (GI) symptoms has been reported up to 70%. The pathophysiology largely remains unknown.

AIM

To review the physiological and pathophysiological changes of the GI-tract during physical exercise and the management of the most common gastrointestinal symptoms.

METHODS

Search of the literature published in the English and Dutch languages using the Pubmed database to review the literature that focused on the relation between splanchnic blood flow (SBF), development of ischaemia, postischaemic endotoxinemia and motility.

RESULTS

During physical exercise, the increased activity of the sympathetic nervous system (SNS) redistributes blood flow from the splanchnic organs to the working muscles. With prolonged duration and/or intensity, the SBF may be decreased by 80% or more. Most studies point in the direction of increased SNS-activity as central driving force for reduction in SBF. A severely reduced SBF may frequently cause GI ischaemia. GI-ischaemia combined with reduced vagal activity probably triggers changes in GI-motility and GI absorption derangements. GI-symptoms during physical exercise may be prevented by lowering the exercise intensity, preventing dehydration and avoiding the ingestion of hypertonic fluids.

CONCLUSIONS

Literature on the pathophysiology of exercise-induced GI-symptoms is scarce. Increased sympathetic nervous system activity and decreased splanchnic blood flow during physical exercise seems to be the key factor in the pathogenesis of exercise-induced GI-symptoms, and this should be the target for symptom reduction.

Current concepts: recognition and management of common activity-related gastrointestinal disorders

Sports medicine clinicians may encounter a wide variety of activity-related gastrointestinal (GI) disorders. The advancing ages and burgeoning obesity rates of the US population have generally increased the prevalence of GI conditions among adults. However, conditioned younger athletes with normal body mass indices also may experience disquieting activity-related GI disorders. While often mild and transient, some of these GI conditions may disrupt exercise routines or pose significant health risks to affected individuals. Gastroesophageal reflux occurs frequently during physical activity and should be empirically treated with activity reduction and dietary modifications in conjunction with antisecretory agents. Persistent or worrisome symptoms merit upper endoscopy, a thorough evaluation for non-GI causes and, rarely, surgery. Altered GI motility commonly occurs during vigorous activities that use dynamic or fluctuating body positions. Dietary and exercise modifications are usually enough to resolve these symptoms. Physical activity may also precipitate GI bleeding from upper and/or lower sources. Although mild or occult bleeding is most common, significant bleeding merits a thorough diagnostic evaluation after stabilization and treatment. Adequate hydration and gradual exercise progression may be particularly helpful to prevent the recurrence of bleeding. The judicious use of medications in conjunction with nonsteroidal anti-inflammatory drug avoidance may also be necessary. Fortunately, most activity-related GI disorders are self-limited and can be managed conservatively. After a brief period of modified activity, clinically stable individuals may progress their activity levels as symptoms allow.

Running, esophageal acid reflux, and atrial fibrillation: a chain of events linked by evidence from separate medical literatures

Using a previously described approach to generating novel medical hypotheses, this paper shows how two separate medical literatures taken together can suggest new information not apparent in either literature alone. Many studies have demonstrated that aerobic exercise in healthy people can induce esophageal acidic reflux that increases with the duration and intensity of exercise. Separately, independently of exercise, it has been shown that, in patients with gastroesophageal reflux, esophageal acid exposure can lead to atrial fibrillation (AF) and to other heart dysrhythmias. The two arguments together suggest that a regimen of excessive exercise may be conducive to AF mediated by acid reflux, an implicit, but unpublished, hypothesis. Proton pump inhibitors are widely used to treat gastroesophageal reflux. Remarkably, several small clinical trials of these drugs have been shown also to reduce symptoms and frequency of AF episodes in patients with comorbid acid reflux. Plausible mechanisms have been suggested. These small-scale tests in a highly restricted population may be of particular interest in the light of a possible exercise-reflux-AF causal chain of events in a broader population of athletes. Because the minimum degree of esophageal acidity exposure required to induce AF is unknown, further tests of proton pump inhibitors for that purpose are therefore merited without regard to any known prior reflux in a population of runners with lone AF. The prospect of reducing AF burden with a relatively benign agent is attractive in view of the limited options for effective treatment otherwise available. The study of arrhythmia and esophageal reflux in athletes may offer insights on the origin and natural history of lone atrial fibrillation.

Gastroesophageal reflux disease and physical activity

Gastroesophageal reflux disease (GERD) is one of the most common disorders in the general population. In recent years, a marked increase in the occurrence of the disease worldwide has been noted. Intense exercise belongs to factors that are known to exacerbate symptoms of GERD. Episodes of reflux seem to be associated with the length and the intensity of the physical activity undertaken. Experimental studies suggest that the gastroesophageal reflux may be increased in athletes due to: decreased gastrointestinal blood flow; alterations of hormone secretion; changes in the motor function of the oesophagus and the ventricle; and the constrained body position during exercise. Disturbances of the balance between two areas of opposite pressure: intra-abdominal and intrathoracic, have also been proven to influence GERD events. GERD is found in sportspeople of various disciplines, but specific types of exercise may have significantly different impacts on the gastroesophageal reflux.Basic prevention of GERD comprise lifestyle and dietary interventions. Adjustments of the exercise load and avoiding meals and drinks about the time of physical effort may ease the symptoms. Unfortunately, in most patients, pharmacological measures are necessary. These include occasional application of antacids and blockers of histamine H2 receptors in mild forms of the disease, and a regular therapy with proton pump inhibitors (PPI) in the majority of other cases. An average dose of PPI varies from 20 to 40 mg/day and should be continued for 4-8 weeks. Unfortunately, symptoms of GERD frequently return and in these situations long-term acid suppression with PPI is usually necessary. As regular physical activity exerts beneficial health effects, the necessity of establishing associations between moderate, recreational exercise and GERD is needed.

The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus

OBJECTIVES

A globally acceptable definition and classification of gastroesophageal reflux disease (GERD) is desirable for research and clinical practice. The aim of this initiative was to develop a consensus definition and classification that would be useful for patients, physicians, and regulatory agencies.

METHODS

A modified Delphi process was employed to reach consensus using repeated iterative voting. A series of statements was developed by a working group of five experts after a systematic review of the literature in three databases (Embase, Cochrane trials register, Medline). Over a period of 2 yr, the statements were developed, modified, and approved through four rounds of voting. The voting group consisted of 44 experts from 18 countries. The final vote was conducted on a 6-point scale and consensus was defined a priori as agreement by two-thirds of the participants.

RESULTS

The level of agreement strengthened throughout the process with two-thirds of the participants agreeing with 86%, 88%, 94%, and 100% of statements at each vote, respectively. At the final vote, 94% of the final 51 statements were approved by 90% of the Consensus Group, and 90% of statements were accepted with strong agreement or minor reservation. GERD was defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The disease was subclassified into esophageal and extraesophageal syndromes. Novel aspects of the new definition include a patient-centered approach that is independent of endoscopic findings, subclassification of the disease into discrete syndromes, and the recognition of laryngitis, cough, asthma, and dental erosions as possible GERD syndromes. It also proposes a new definition for suspected and proven Barrett's esophagus.

CONCLUSIONS

Evidence-based global consensus definitions are possible despite differences in terminology and language, prevalence, and manifestations of the disease in different countries. A global consensus definition for GERD may simplify disease management, allow collaborative research, and make studies more generalizable, assisting patients, physicians, and regulatory agencies.

Differential diagnosis of chest symptoms in the athlete

Chest pain is a common complaint of athletes in all age groups. In athletes, chest pain is often attributed to "chest tightness," and treatment for bronchospasm is considered. However, the causes of the pain are wide and varied, and the pain is referable to the many organ systems that localize to the thorax. Therefore, when treatment with bronchodilators fails, it becomes important to consider other nonasthmatic causes of the pain. These causes can be organized by system and are explained in this article. Cardiac causes are the most feared and, fortunately, are very rare in the adolescent setting. With a thorough knowledge of etiologies of chest pain, the physician can often make a diagnosis with only a history and a physical exam.

Chest pain from gastroesophageal reflux disease in patients with coronary artery disease

Management of patients with coronary artery disease is a major challenge for physicians, patients, and the healthcare system. Chest pain experienced by patients with coronary disease can be of noncardiac origin, and symptoms frequently related to gastroesophageal etiologies. The distal esophagus and the heart share a common afferent nerve supply, suggesting that location and radiation of perceived pain may be identical. In addition, there is substantial overlap between the prevalence of coronary disease and gastroesophageal reflux disease. Many physicians, including cardiologists, prescribe acid-reducing therapy to coronary patients. However, no prospective, randomized studies to date have evaluated the potential benefit of such treatments to prevent chest pain symptoms for these patients. We review the studies on noncardiac chest pain demonstrating reflux in patients with and without coronary disease. Also, the association of reflux with exertional chest pain and cardiac syndrome X is discussed. A rationale is presented for prevention of noncardiac chest pain in coronary patients, and the potential role of acid-suppressive therapy in managing these patients is discussed.

Beyond heartburn: a systematic review of the extra-oesophageal spectrum of reflux-induced disease

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a chronic condition affecting up to one-quarter of the Western population. GORD is characterized by heartburn and acid regurgitation, but is reported to be associated with a spectrum of extra-oesophageal symptoms.

OBJECTIVE

The aim of this systematic review was to critically evaluate postulated extra-oesophageal symptoms of GORD.

METHODS

Extra-oesophageal symptoms were identified from population-based studies evaluating their association with GORD (either defined as heartburn and/or acid regurgitation, or diagnosed in general practice). The response of these symptoms to acid-suppressive therapy was investigated using randomized, double-blind, placebo-controlled studies. Pathogenic mechanisms were evaluated using clinical and preclinical studies.

RESULTS

An association between GORD and symptoms or a diagnosis of chest pain/angina, cough, sinusitis and gall-bladder disease was evident from three eligible population-based studies of GORD. Randomized placebo-controlled studies (n=20) showed that acid-suppressive therapy provides symptomatic relief of chest pain, asthma and, potentially, chronic cough and laryngitis. Mechanistic models, based on direct physical damage by refluxate or vagally mediated reflexes, support a causal role for GORD in chest pain and respiratory symptoms, but not in gall-bladder disease.

CONCLUSION

GORD is likely to play a causal role in chest pain and possibly asthma, chronic cough and laryngitis. Further investigation is desirable, particularly for other potential extra-oesophageal manifestations of GORD such as chronic obstructive pulmonary disease, sinusitis, bronchitis and otitis. Acid-suppressive therapy is likely to benefit patients with non-cardiac chest pain, but further placebo-controlled studies are needed for other symptoms comprising the extra-oesophageal spectrum of GORD.

Training Room Management of Medical Conditions: Sports Gastroenterology

Gastrointestinal (GI) illnesses are common in athletes. Various causes include adverse physiologic adaptations of the gut during exercise; excess ingestion of carbohydrate drinks, alcohol, and anti-inflammatory medications; emotional stressors; exposure to pathogens in closed environments and during travel; trauma; and abdominal wall pressure overload. Unfortunately, evidence-based management of GI illnesses in athletes is limited because most studies have compared various GI illnesses between different sports, rather than comparing athletes to nonathletes. This article reviews the evidence that is available specifically relating to etiology, pathophysiology, clinical presentation, relevant differential diagnoses, acute management, and recommendations for specialist consultation of various GI illnesses in the training-room setting.

Exercise and gastrointestinal function and disease: an evidence-based review of risks and benefits

BACKGROUND & AIMS

Exercise is beneficial to health because it reduces the risk of cardiovascular and endocrine diseases, improves bone and muscle conditioning, and lessens anxiety and depression. However, the impact of exercise on the gastrointestinal system has been conflicting. This systematic literature review evaluates the effect of the different modes and intensity levels of exercise on gastrointestinal function and disease using an evidence-based approach. Although more applicable to trained athletes and individuals who are highly active and, as such, at risk to experience the side-effects of exercise, an effort was made to state the level or degree of exercise or the lack of such evidence.

RESULTS

Light and moderate exercise is well tolerated and can benefit patients with inflammatory bowel disease and liver disease. Physical activity can also improve gastric emptying and lower the relative risk of colon cancer in most populations. Severe, exhaustive exercise, however, inhibits gastric emptying, interferes with gastrointestinal absorption, and causes many gastrointestinal symptoms, most notably gastrointestinal bleeding.

CONCLUSIONS

This knowledge will enable physicians to prescribe physical exercise in health and disease and to better manage patients with exercise-related gastrointestinal disorders. Our understanding of exercise and its gastrointestinal manifestations as well as risks and benefits warrants further investigation.

Effects of exercise on gastric volume and pH in the proximal portion of the stomach of horses

OBJECTIVE

To assess effects of exercise on a treadmill with changes in gastric volume and pH in the proximal portion of the stomach of horses.

ANIMALS

3 healthy adult horses.

PROCEDURE

A polyester bag of approximately 1,600 mL was placed into the proximal portion of the stomach of each horse via a nasogastric tube. Changes in bag volume, determined by an electronic barostat, were recorded before, during, and after a training session on a treadmill with and without prior withholding of food. In separate experiments, pH in the proximal portion of the stomach was continuously recorded during exercise for fed and food-withheld conditions. Finally, changes in intra-abdominal and intragastric pressure were simultaneously recorded during a training session.

RESULTS

Bag volume rapidly decreased to nearly zero during trotting and galloping. Conversely, a return to walking resulted in a sharp increase in volume and a return to pre-exercise values. Intragastric and intra-abdominal pressures increased almost in parallel with walking, trotting, galloping, and galloping on a slope. Gastric pH decreased rapidly to < 4 at the beginning of walking, continued to decrease during trotting and galloping, and remained low until a return to walking.

CONCLUSIONS AND CLINICAL RELEVANCE

Increased intra-abdominal pressure during intense exercise in horses causes gastric compression, pushing acidic contents into the proximal, squamous-lined region of the stomach. Increased duration of acid exposure directly related to daily duration of exercise may be the reason that squamous lesions tend to develop or worsen when horses are in intensive training programs.

Physical activity and the gastrointestinal tract

Physical exercise is probably both beneficial and harmful for the gastrointestinal tract, depending partly on the training intensity. On the one hand, gastrointestinal symptoms such as heartburn, chest pain, nausea, vomiting, abdominal cramps, side ache and diarrhoea are common during heavy exercise. On the other hand, physical activity seems to protect from colon cancer, cholelithiasis and diverticular disease. Constipation has been shown to be related to inactivity. Despite this, no overwhelming evidence exists for a positive effect of physical exercise as a treatment option for chronic constipation. The reasons behind these somewhat discrepant effects are not understood fully. Altered gastrointestinal blood flow, effects on gastrointestinal motor function, neuroendocrine changes and mechanical effects are probably involved. Conflicting results exist regarding the effects of physical activity on gastrointestinal motility. Modern technologies now make motility studies in various parts of the gastrointestinal tract possible. More studies are needed to understand better the effects of physical exercise on the gastrointestinal tract. In particular, the relationship between the training intensity and duration and positive and negative alterations in gastrointestinal physiology needs to be addressed further.