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Ocampo AA, Genta RM, Dellon ES. Mast Cell Esophagitis: A Novel Entity in Patients with Unexplained Esophageal Symptoms. Dysphagia 2024; 39:360-368. [PMID: 37605054 PMCID: PMC10879451 DOI: 10.1007/s00455-023-10616-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Abstract
It is not known whether esophageal mast cells may be a cause of unexplained esophageal symptoms. We aimed to determine the prevalence of esophageal mastocytosis in patients without other underlying causes of symptoms and assess the relationship between symptoms and mast cells. In this retrospective study, we identified adults with esophageal symptoms, a normal endoscopy, normal esophageal biopsies, and no definitive diagnosis during clinical evaluation. We quantified mast cell density (mast cells/mm2) in archived esophageal biopsies using tryptase immunohistochemistry, and compared mast cell levels by clinical features and physiologic testing. In the 87 patients identified (mean age 37, 72% female, 63% white, 92% non-Hispanic), common symptoms were dysphagia (76%), heartburn (71%), and chest pain (25%). Overall, the mean esophageal epithelial mast cell count was 83.0 ± 51.8 mast cells/mm2; 60% of patients had ≥ 60 mast/mm2, and 17% had ≥ 120 masts/mm2. There were no differences in mast cell counts by type of esophageal testing. Mast cell levels did not differ significantly by type of symptoms, atopic status, medications, smoking status, or alcohol use. There were also no major differences in clinical characteristics by mast cell quartiles or thresholds. In conclusion, esophageal mast cell infiltration was common in patients with symptoms unexplained by prior testing, and levels were higher than previously published values for patients with no underlying esophageal condition. Mast cell esophagitis could be a novel cause of unexplained esophageal symptoms in a subset of patients, though it reamins to be determined if such patients benefit from mast cell-targeted treatment.
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Affiliation(s)
- Adolfo A Ocampo
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, CB#7080, Bioinformatics Building, 130 Mason Farm Rd.,UNC-CH, Chapel Hill, NC, 27599-7080, USA
| | - Robert M Genta
- Inform Diagnostics, Irving, TX, USA
- Departments of Pathology and Medicine (Gastroenterology), Baylor College of Medicine, Houston, TX, USA
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, CB#7080, Bioinformatics Building, 130 Mason Farm Rd.,UNC-CH, Chapel Hill, NC, 27599-7080, USA.
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease,, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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2
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Al-Momani H, Aolymat I, Al Haj Mahmoud S. Critical appraisal of how COVID-19 infection and imposed lockdowns have impacted gastroesophageal reflux: A review. Medicine (Baltimore) 2024; 103:e38074. [PMID: 38728518 PMCID: PMC11081575 DOI: 10.1097/md.0000000000038074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/10/2024] [Indexed: 05/12/2024] Open
Abstract
Previous literature has demonstrated that COronaVIrus Disease of 2019 (COVID-19) impacts an individual gastrointestinal tract (GIT), causing symptoms like nausea, diarrhea, and loss of appetite. Severe acute respiratory syndrome coronavirus RNA has been discovered in the stool of infected individuals in earlier research. It was discovered that severe acute respiratory syndrome coronavirus was significantly expressed in the GIT, indicating that the virus can also infect the digestive system. Angiotensin-converting enzyme 2 functions as the viral receptor. The chronic illness known as gastroesophageal reflux disease (GERD) is typified by frequent reflux of stomach acid into the esophagus. By triggering the sensitized esophageal-bronchial neuronal circuit or aspirating into the airways (microaspiration), GER exacerbates respiratory diseases. Aspiration is a well-known risk to be considered when treating patients in intensive care units. Strong genetic correlations have been identified between COVID-19 infection and GERD susceptibility, suggesting a shared genetic basis for both conditions. Nonetheless, even though GERD, extraesophageal reflex, and COVID-19 have a number of significant risk factors and exhibit similar symptoms, the relationship between these illnesses has not yet been examined in depth. This review is the first of its kind to critically examine the association between the COVID-19 epidemic and GER and its associated diseases. The key objective of this work is to promote the creation of prevention plans, treatment plans, and guidelines while also enhancing and optimizing our understanding of the relationship between COVID-19 and GERs.
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Affiliation(s)
- Hafez Al-Momani
- Department of Microbiology, Pathology and Forensic Medicine, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Iman Aolymat
- Department of Anatomy, Physiology & Biochemistry, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Sameer Al Haj Mahmoud
- Department of Basic Medical Science, Faculty of Medicine, Al-Balqa’ Applied University, Al-Salt, Jordan
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3
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Ying LN, Sun Y, Cui LY, Zhang ZY, Li RF, Zhang J. Recent advances in the knowledge of the mechanism of reflux hypersensitivity. Scand J Gastroenterol 2024; 59:518-523. [PMID: 38343278 DOI: 10.1080/00365521.2024.2310177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/20/2024] [Indexed: 04/26/2024]
Abstract
Reflux hypersensitivity (RH) is a subtype of gastroesophageal reflux disease. The Rome IV criteria separated RH from the original nonerosive reflux disease subgroup and classified it as a new functional oesophageal disease. Recently, the pathogenesis of RH has become the focus of research. According to the latest research reports, upregulation of acid-sensitive receptors, distribution of calcitonin gene-related peptide-positive nerve fibres, and psychiatric comorbidity have key roles in the pathogenesis of RH. This work reviews the latest findings regarding RH mechanisms.
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Affiliation(s)
- Li Na Ying
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, P.R. China
| | - Yan Sun
- Department of Gastroenterology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, P.R. China
| | - Li Yang Cui
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, P.R. China
| | - Zhen Yu Zhang
- Graduate School of Bengbu Medical University, Bengbu, Anhui, P.R. China
| | - Rui Fang Li
- People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P.R. China
| | - Jun Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, P.R. China
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4
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Buckley DP, Vojtech JM, Stepp CE. Relative Fundamental Frequency in Individuals with Globus Syndrome and Muscle Tension Dysphagia. J Voice 2024; 38:612-618. [PMID: 34823980 PMCID: PMC9124719 DOI: 10.1016/j.jvoice.2021.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Relative fundamental frequency (RFF) has been investigated as an acoustic measure to assess for changes in laryngeal tension. This study aimed to assess RFF in individuals with globus syndrome, individuals with muscle tension dysphagia (MTDg), and individuals with typical voices. METHODS RFF values were calculated from the speech acoustics of individuals with globus syndrome (n = 12), individuals with MTDg (n = 12), and age- and sex-matched controls with typical voices (n = 24). An analysis of variance was performed on RFF values to assess the effect of group. RESULTS There was no statistically significant effect of group on RFF values, with similar values for individuals with globus syndrome, individuals with MTDg, and control participants. CONCLUSIONS These results suggest that individuals with these disorders do not appear to possess paralaryngeal muscle tension in a locus and/or manner that directly impacts voice production.
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Affiliation(s)
- Daniel P Buckley
- Department of Speech, Language, and Hearing Sciences, Boston University, Boston, Massachusetts; Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts.
| | - Jennifer M Vojtech
- Department of Speech, Language, and Hearing Sciences, Boston University, Boston, Massachusetts; Department of Biomedical Engineering, Boston University, Boston, Massachusetts; Delsys, Inc., Natick, Massachusetts; Altec, Inc., Natick, Massachusetts
| | - Cara E Stepp
- Department of Speech, Language, and Hearing Sciences, Boston University, Boston, Massachusetts; Department of Biomedical Engineering, Boston University, Boston, Massachusetts
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5
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Kahrilas PJ, Anastasiou F, Barrett K, Beh L, Chinzon D, Doerfler B, López-Pintor E, Maimin J, Mendive JM, Taft T, Hungin AP. Assessment and treatment of reflux-like symptoms in the community: a multidisciplinary perspective. Br J Gen Pract 2024; 74:232-235. [PMID: 38664044 PMCID: PMC11060810 DOI: 10.3399/bjgp24x737349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Affiliation(s)
- Peter J Kahrilas
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, US
| | - Foteini Anastasiou
- 24th Local Primary Care Team, Municipality Practice and Academic Practice of Heraklion, Crete, Greece
| | | | - Lovy Beh
- Malaysian Community Pharmacy Guild (MCPG), Malaysia
| | - Decio Chinzon
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Bethany Doerfler
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, US
| | - Elsa López-Pintor
- Department of Engineering, Area of Pharmacy and Pharmaceutical Technology, Universidad Miguel Hernández, Alicante, Spain; CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
| | - Jacqueline Maimin
- Independent Community Pharmacy Association NPC, Cape Town, South Africa
| | - Juan M Mendive
- La Mina Primary Care Academic Centre, Catalan Health Institute, University of Barcelona, Spain
| | - Tiffany Taft
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, US
| | - A Pali Hungin
- Primary Care and General Practice, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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6
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Komatsu Y, Miura H, Iwama Y, Urita Y. Beneficial Effect of Heat-Killed Lactic Acid Bacterium Lactobacillus johnsonii No. 1088 on Temporal Gastroesophageal Reflux-Related Symptoms in Healthy Volunteers: A Randomized, Placebo-Controlled, Double-Blind, Parallel-Group Study. Nutrients 2024; 16:1230. [PMID: 38674920 PMCID: PMC11054138 DOI: 10.3390/nu16081230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/12/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
A randomized, placebo-controlled, double-blind, parallel-group clinical study was conducted to examine the effects of ingesting a heat-killed lactic acid bacterium, Lactobacillus johnsonii No. 1088 (LJ88) on temporal gastroesophageal reflux-related symptoms in healthy volunteers. A total of 120 healthy Japanese volunteers of both sexes, aged between 21 and 63 years, whose Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) total score was 8 or greater, but who were not diagnosed with functional dyspepsia according to the Rome IV classification, were enrolled. They were randomly assigned to either the LJ88 or placebo group and instructed to ingest the test food (1 billion heat-killed LJ88 or placebo) once a day for six weeks. Gastroesophageal reflux-related symptoms were evaluated using FSSG scores as a primary endpoint. The Gastrointestinal Symptoms Rating Scale (GSRS), stomach state questionnaire, and serum gastrin concentration were used as secondary endpoints. In the FSSG evaluation, the heartburn score was significantly improved at 6 weeks in the LJ88 group compared to the placebo group. No severe adverse events related to the test food were observed. In conclusion, daily ingestion of heat-killed LJ88 improved temporal heartburn symptoms in non-diseased individuals.
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Affiliation(s)
| | | | - Yoshitaka Iwama
- Nihonbashi Cardiology Clinic, Chuo-ku, Tokyo 103-0001, Japan;
| | - Yoshihisa Urita
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Ota-ku, Tokyo 143-8541, Japan;
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7
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Zerbib F. High resolution manometry as a diagnostic tool for gastro-esophageal reflux: A step forward but not yet ready for clinical use. United European Gastroenterol J 2024. [PMID: 38638028 DOI: 10.1002/ueg2.12573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Affiliation(s)
- Frank Zerbib
- Gastroenterology Department, CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
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8
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Matsumura T, Sonoda M, Okimoto K, Dao HV, Takahashi S, Akizue N, Horio R, Goto C, Kurosugi A, Kaneko T, Ohta Y, Taida T, Kikuchi A, Fujie M, Kato J, Kato N. Differences Between Patients with Heartburn Refractory to Vonoprazan and Those Refractory to Proton Pump Inhibitors. Dig Dis Sci 2024:10.1007/s10620-024-08411-y. [PMID: 38622462 DOI: 10.1007/s10620-024-08411-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Vonoprazan, a potassium-competitive acid blocker, demonstrates more potent acid inhibition than proton pump inhibitors (PPIs). This study aimed to evaluate the effect of vonoprazan in patients with unproven gastroesophageal reflux disease (GERD) by comparing patients with vonoprazan-refractory heartburn with those with PPI-refractory heartburn. METHODS This study included 104 consecutive patients with vonoprazan- or PPI-refractory heartburn (52 patients each), no erosive esophagitis on endoscopy and who underwent combined multichannel intraluminal impedance-pH (MII-pH) testing with vonoprazan/PPI discontinuation. Patients' backgrounds, symptom scores from four questionnaires, MII-pH results and high-resolution manometry results were compared between the two groups. RESULTS The vonoprazan group demonstrated significantly higher GERD symptoms and scores of abdominal pain and diarrhea on the Gastrointestinal Symptom Rating Scale questionnaire. MII-pH results revealed that the vonoprazan group demonstrated 40.4%, 17.3%, and 42.3% and the PPIs group exhibited 26.9%, 17.3%, and 55.8% of abnormal acid reflux [true non-erosive reflux disease (NERD)], reflux hypersensitivity and functional heartburn, respectively. The vonoprazan group demonstrated higher true NERD rates but with no significant difference (p = 0.307). Among the vonoprazan group, eight patients with true NERD underwent another MII-pH test on vonoprazan, and all cases demonstrated normal acid exposure times (0.0% [0.0-0.3]). CONCLUSION Patients with unproven GERD with vonoprazan-refractory heartburn demonstrated more symptoms, including not only GERD symptoms but also functional dyspepsia and irritable bowel syndrome symptoms, than those with PPI-refractory heartburn.
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Affiliation(s)
- Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan.
| | - Michiko Sonoda
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Hang Viet Dao
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
- Internal Medicine Faculty, Hanoi Medical University, Hanoi, Vietnam
- The Institute of Gastroenterology and Hepatology, Hanoi, Vietnam
| | - Satsuki Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Ryosuke Horio
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Chihiro Goto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Akane Kurosugi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Tatsuya Kaneko
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Atsuko Kikuchi
- Department of Clinical Engineering Center, Chiba University Hospital, Chiba, Japan
| | - Mai Fujie
- Department of Clinical Engineering Center, Chiba University Hospital, Chiba, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
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Buckley DP, Borders JC, Pisegna JM. Muscle Tension Dysphagia: An Expanded Investigation of Clinical Presentations and Swallowing Kinematics. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024:1-9. [PMID: 38573246 DOI: 10.1044/2024_ajslp-23-00415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE This study retrospectively examined patient-reported symptoms, quality of life, and swallowing kinematics in individuals with presumed muscle tension dysphagia (MTDg). METHOD Twenty-six individuals met the inclusion criteria. Data were gathered from patient-reported outcome measures (PROs), symptomology, clinician reports of palpation, and hyolaryngeal and hyoid movements measured on a 20-ml thin liquid bolus during videofluoroscopic swallowing studies. RESULTS All PROs were outside of typical limits, except for the Voice Handicap Index-10. Mean hyoid excursion was 1.52 cm (SD = 0.46, range: 0.76-2.43), and hyolaryngeal excursion was 0.77 cm (SD = 0.44, range: -0.42-1.68). A minority of participants (4%-19%) demonstrated atypical hyoid and/or hyolaryngeal excursion compared to the available normative reference value sets. CONCLUSIONS Individuals demonstrated abnormalities in the clinical evaluation of the areas of palpation and reported perilaryngeal discomfort and symptoms of laryngeal hyperresponsiveness, with a negative impact on their quality of life across various PROs. Atypical hyoid and/or hyolaryngeal excursion during swallowing was rare when compared to available normative reference values. The clinical evaluation of MTDg may be enhanced by including components related to muscle tension and laryngeal hyperresponsiveness in order to differentiate MTDg from idiopathic functional dysphagia and lead the patient to the otolaryngology/speech-language pathology clinic for intervention and management.
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Affiliation(s)
- Daniel P Buckley
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, MA
- Department of Speech, Language and Hearing Sciences, Boston University, MA
- Department of Otolaryngology, Boston Medical Center, MA
| | - James C Borders
- Laboratory for the Study of Upper Airway Dysfunction, Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY
| | - Jessica M Pisegna
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, MA
- Department of Speech, Language and Hearing Sciences, Boston University, MA
- Department of Otolaryngology, Boston Medical Center, MA
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10
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Guadagnoli L, Yadlapati R, Pandolfino J, Bedell A, Pandit AU, Dunbar KB, Fass R, Gevirtz R, Gyawali CP, Lupe SE, Petrik M, Riehl ME, Salwen-Deremer J, Simons M, Tomasino KN, Taft T. Behavioral Therapy for Functional Heartburn: Recommendation Statements. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00285-4. [PMID: 38518891 DOI: 10.1016/j.cgh.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND & AIMS Brain-gut behavior therapies (BGBT) are increasingly recognized as effective therapeutic interventions for functional heartburn. However, recommendations regarding candidacy for treatment, initial treatment selection, and navigating treatment non-response have not been established for functional heartburn specifically. The aim of this study was to establish expert-based recommendations for behavioral treatment in patients with functional heartburn. METHODS The validated RAND/University of California, Los Angeles Appropriateness Method was applied to develop recommendations. A 15-member panel composed of 10 gastrointestinal psychologists and 5 esophageal specialists ranked the appropriateness of a series of statements on a 9-point interval scale over 2 ranking periods. Statements were within the following domains: pre-therapy evaluation, candidacy criteria for BGBT, selection of initial BGBT, role of additional therapy for initial non-response to BGBT, and role of pharmacologic neuromodulation. The primary outcome was appropriateness of each intervention based on the recommendation statements. RESULTS Recommendations for psychosocial assessment (eg, hypervigilance, symptom-specific anxiety, health-related quality of life), candidacy criteria (eg, motivated for BGBT, acknowledges the role of stress in symptoms), and treatment were established. Gut-directed hypnotherapy or cognitive behavioral therapy were considered appropriate BGBT for functional heartburn. Neuromodulation and/or additional BGBT were considered appropriate in the context of non-response. CONCLUSIONS Gut-directed hypnotherapy and/or cognitive behavioral therapy are recommended as appropriate behavioral interventions for heartburn symptoms, depending on clinical indication, specific gut-brain targets, and preferred treatment modality (pharmacologic vs non-pharmacologic). Pre-therapy evaluation of psychosocial processes and candidacy for BGBT are important to determine eligibility for referral to psychogastroenterology services.
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Affiliation(s)
- Livia Guadagnoli
- Laboratory for Brain-Gut Axis Studies (LaBGAS), Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium.
| | - Rena Yadlapati
- Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California
| | - John Pandolfino
- Kenneth C. Griffin Esophageal Center, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alyse Bedell
- Departments of Psychiatry & Behavioral Neuroscience and Medicine (Section of Gastroenterology, Hepatology, and Nutrition), The University of Chicago, Chicago, Illinois
| | - Anjali U Pandit
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kerry B Dunbar
- Division of Digestive Diseases, University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Texas
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Case Western Reserve University, Cleveland, Ohio
| | - Richard Gevirtz
- Clinical PhD Program, CSPP@Alliant International University, San Diego, California
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Stephen E Lupe
- Department of Gastroenterology, Hepatology, and Nutrition, The Cleveland Clinic, Cleveland, Ohio
| | - Megan Petrik
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Megan E Riehl
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jessica Salwen-Deremer
- Departments of Psychiatry and Medicine (Section of Gastroenterology & Hepatology), Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Madison Simons
- Department of Gastroenterology, Hepatology, and Nutrition, The Cleveland Clinic, Cleveland, Ohio
| | - Kathryn N Tomasino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tiffany Taft
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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11
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Maronian N, Cabrera C, Dewey J, Meyer T. The Development of Head and Neck Cancer in Patients with the Isolated Complaint of Globus Pharyngeus. Laryngoscope 2024; 134:1147-1154. [PMID: 37737553 DOI: 10.1002/lary.31027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/20/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES Globus pharyngeus (GP) is a perplexing problem that accounts for 4% of referrals to otolaryngologists. Workup can be extensive and may not be definitive in terms of etiology. The concern that lingers is that of a subtle cancer, which can prolong anxiety and increase testing cost. The aim of this study was to identify the incidence of head and neck cancer (HNC) in patients diagnosed with GP. METHODS Longitudinal data were captured from two academic institutions, identifying patients with a new diagnosis of globus pharyngeus in 2015. The patient cohort was tracked for at least 4 years to assure follow-up and ability to determine if a HNC developed. Additional demographic data was also collected to determine most common consults, treatments, and testing employed. RESULTS Excluding patients with previous diagnosis of HNC, 377 patients were identified who presented with GP in 2015 that had at least 4 years of follow-up. Demographics were predominantly women (64.65%), with a mean age of 56.48 years at diagnosis, and the most common provider specialty on the first visit was otolaryngology (39.52%). Four patients ultimately developed HN cancer, for an overall incidence of 1% for the 4-year period of 2015-2019. CONCLUSIONS Given the long-term follow-up of this population, the overall incidence of developing a head and neck cancer, with a presenting symptom of globus, is low. This is the largest study to date to report the percentage of patients endorsing GP to then subsequently develop HNC. This helps otolaryngologists to reassure patients who have a normal comprehensive exam, flexible endoscopy, and targeted studies. LEVEL OF EVIDENCE 4 Laryngoscope, 134:1147-1154, 2024.
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Affiliation(s)
- Nicole Maronian
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
| | - Claudia Cabrera
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
| | - John Dewey
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Tanya Meyer
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, West Virginia, U.S.A
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Olmos JA, Pandolfino JE, Piskorz MM, Zamora N, Valdovinos Díaz MA, Remes Troche JM, Guzmán M, Hani A, Valdovinos García LR, Pitanga Lukashok H, Domingues G, Vesco E, Rivas MM, Ovalle LFP, Cisternas D, Vela MF. Latin American consensus on diagnosis of gastroesophageal reflux disease. Neurogastroenterol Motil 2024; 36:e14735. [PMID: 38225792 DOI: 10.1111/nmo.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts. METHODS This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard. KEY RESULTS A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination. CONCLUSIONS Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.
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Affiliation(s)
- Jorge A Olmos
- Neurogastroenterology Sector, Hospital de Clinicas Jose de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - María M Piskorz
- Neurogastroenterology Sector, Hospital de Clinicas Jose de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - Miguel A Valdovinos Díaz
- UNAM, Ciudad de Mexico, Mexico
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José M Remes Troche
- Institute of Medical Biological Research, Universidad Veracruzana, Veracruz, Mexico
| | - Mauricio Guzmán
- Neurogastroenterology Unit, Gastroenterology Service, Hospital San Martín de La Plata, Buenos Aires, Argentina
| | - Albis Hani
- Hospital San Ignacio-Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | - Hannah Pitanga Lukashok
- Digestive Motility Service, Instituto Ecuatoriano de Enfermedades Digestivas-IECED, Guayaquil, Ecuador
| | | | - Eduardo Vesco
- Neuromotility Unit, Clínica Angloamericana, Lima, Peru
- Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Mariel Mejia Rivas
- Internal Medicine, Gastroenterology and Digestive Endoscopy Service, Hospital Vivian Pellas, Managua, Nicaragua
| | - Luis F Pineda Ovalle
- Neurogastroenterology and Motility Service Motility Instituto Gut Médica, Bogotá, Colombia
| | - Daniel Cisternas
- Clínica Alemana de Santiago, School of Medicine, Universidad del Desarrollo, Clínica Alemana, Vitacura, Chile
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
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Fujita T, Umegaki E, Masuda A, Kobayashi M, Yamazaki Y, Terao S, Sanuki T, Okada A, Murakami M, Watanabe A, Obata D, Yoshinaka H, Kutsumi H, Azuma T, Kodama Y. Factors Associated with Overlap between Functional Dyspepsia and Nonerosive Reflux Disease in Endoscopy-based Helicobacter pylori-uninfected Japanese Health Checkup Participants: A Prospective, Multicenter Cross-sectional Study. Intern Med 2024; 63:639-647. [PMID: 37438139 PMCID: PMC10982007 DOI: 10.2169/internalmedicine.1786-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/01/2023] [Indexed: 07/14/2023] Open
Abstract
Objective We assessed the factors associated with overlap between functional dyspepsia (FD) and nonerosive reflux disease (NERD) in endoscopy-based Helicobacter pylori-uninfected Japanese health checkup participants. Methods We utilized baseline data from 3,085 individuals who underwent upper endoscopy for health screening in a prospective, multicenter cohort study. The participants were asked to complete a questionnaire detailing their upper abdominal symptoms and lifestyle. Anxiety was assessed using the State-Trait Anxiety Inventory (STAI) score. FD, postprandial distress syndrome (PDS), and epigastric pain syndrome (EPS) were defined according to the Rome III criteria. NERD was defined as heartburn or regurgitation ≥1 day/week without erosive esophagitis. Results Of the 3,085 participants, 73 (2.4%), 97 (3.1%), and 84 (2.7%) had FD alone, NERD alone, and FD-NERD overlap, respectively. Factors associated with FD-NERD-overlap participants compared with participants with neither FD nor NERD were women [odds ratio (OR): 2.08, 95% confidence interval (CI): 1.24-3.52], body mass index (BMI) <18.5 (OR: 2.87, 95% CI: 1.56-5.07), alcohol consumption ≥20 g/day (OR: 1.85, 95% CI: 1.06-3.15), and a high STAI score (OR: 2.53, 95% CI: 1.62-4.00). Increasing age (OR: 1.06, 95% CI: 1.01-1.11) and EPS symptoms [pure EPS (OR: 3.67, 95% CI: 1.65-8.51) and PDS-EPS overlap (OR: 11.6, 95% CI: 4.09-37.2)] were associated with FD-NERD overlap vs. FD alone. Women (OR: 3.17, 95% CI: 1.47-7.04), BMI <18.5 (OR: 3.03, 95% CI: 1.04-9.90), and acid reflux symptoms ≥2 days a week (OR: 3.57, 95% CI: 1.83-7.14) were associated with FD-NERD overlap vs. NERD alone. Conclusion Understanding the clinical features of overlap between FD and NERD will lead to better management.
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Affiliation(s)
- Tsuyoshi Fujita
- Department of Health Care, Yodogawa Christian Hospital, Japan
| | - Eiji Umegaki
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Japan
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Masao Kobayashi
- Department of Health Care, Kyoto Second Red Cross Hospital, Japan
| | | | - Shuichi Terao
- Department of Gastroenterology, Kakogawa Central City Hospital, Japan
| | - Tsuyoshi Sanuki
- Department of Gastroenterology, Kita-harima Medical Center, Japan
| | - Akihiko Okada
- Department of Gastroenterology, Saiseikai Nakatsu Hospital, Japan
| | - Manabu Murakami
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Akihiko Watanabe
- Department of Gastroenterology, Yodogawa Christian Hospital, Japan
| | - Daisuke Obata
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
- Center for Clinical Research and Advanced Medicine, Shiga University Medical Science, Japan
| | - Hayato Yoshinaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
- Center for Clinical Research and Advanced Medicine, Shiga University Medical Science, Japan
| | - Hiromu Kutsumi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
- Center for Clinical Research and Advanced Medicine, Shiga University Medical Science, Japan
| | - Takeshi Azuma
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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Kitasako Y, Tanabe T, Koeda M, Momma E, Hoshikawa Y, Hoshino S, Kawami N, Ikeda M, Iwakiri K. Patients with gastroesophageal reflux disease (both reflux oesophagitis and non-erosive reflux disease): Prevalence and severity of erosive tooth wear and saliva properties. J Oral Rehabil 2024; 51:305-312. [PMID: 37727994 DOI: 10.1111/joor.13595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/23/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND The prevalence between erosive tooth wear (ETW) in association with reflux oesophagitis (RO) has been reported. However, the severity of both diseases and the relationship between ETW and non-erosive reflux disease (NERD) is unclear. OBJECTIVES The prevalence and severity of ETW were investigated in RO, NERD and healthy controls. METHODS 135 patients with RO, 65 with NERD and 40 healthy controls were recruited for this case-control study. A modified tooth wear index was used to evaluate the prevalence and severity of ETW. Salivary secretion and buffer capacity were assessed prior to endoscopy. The prevalence and severity of ETW, saliva properties among each group were analysed using Pearson's chi-squared test. RESULTS A total of 135 cases (56.3%) were categorised as the patient with ETW (55 with mild RO, 49 with severe RO and 31 with NERD). There was a significant relationship between the prevalence of RO and ETW, while there was no significant correlation between the prevalence of NERD and ETW. There was a significant difference related to the severity between RO and ETW. For salivary secretion, there was a significant difference between with and without ETW in patients with mild RO, severe RO and NERD. There was a significant difference between with and without ETW for salivary buffer capacity in patients with mild and severe RO. CONCLUSION There was a significant association of the prevalence and severity between RO and ETW. Clinical signs such as ETW and salivary buffer capacity depended on the severity of RO.
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Affiliation(s)
- Yuichi Kitasako
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
- Cariology and Operative Dentistry, Department of Restorative Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Dental Clinic, Ministry of Foreign Affairs, Tokyo, Japan
| | - Tomohide Tanabe
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Mai Koeda
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Eri Momma
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Shintaro Hoshino
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Masaomi Ikeda
- Oral Prosthetic Engineering, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
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15
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Josefsson A, Simrén M, Smolak A, Sabbagh N, Törnblom H. Natural history of symptoms and prognostic information of the rapid drink challenge and solid bolus swallows in esophagogastric junction outflow obstruction defined by manometry. Neurogastroenterol Motil 2024; 36:e14720. [PMID: 38073000 DOI: 10.1111/nmo.14720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND/INTRODUCTION Esophagogastric junction outflow obstruction (EGJOO) is a condition characterized by poor relaxation of the lower esophageal sphincter (LES), which can manifest as dysphagia and chest pain. The best treatment of EGJOO is unknown as some patients improve without any specific therapy, whereas some patients undergo invasive therapy. Currently, prognostic factors are lacking. We aimed to assess the long-term prognosis and predictors of dysphagia and chest pain by the rapid drink challenge and solid bolus swallows in EGJOO. METHODS We retrospectively assessed high-resolution esophageal manometries (HRM) performed at our center between 2015 and 2018. The patients completed a dysphagia and chest pain questionnaire a median of 34 months after the HRM/baseline assessment, including the Impaction dysphagia questionnaire-10 (IDQ-10) complemented with questions regarding chest pain and esophageal treatments. Symptoms were compared with HRM findings. RESULTS In all, 980 HRMs were analyzed and 66 (6.5%) were identified as having HRM findings compatible with EGJOO. Of these, 27 patients with EGJOO (41%) completed the follow-up questionnaires and had no exclusion criteria, and 70% of these patients had dysphagia and 44% chest pain at least once a week. Dysphagia at follow-up was more common in patients with elevated integrated relaxation pressure (IRP) on all three HRM metrics (water swallows, solid bolus swallows, and rapid drink challenge) (p = 0.03, odds ratio: 8.4 (95% CI: 1.2-56.0)), but this was not seen for chest pain (p = 0.45). Abnormal motility patterns on rapid drink challenge or solid bolus swallows were not associated with dysphagia or chest pain at follow-up. CONCLUSIONS Having a high IRP on three HRM metrics-water swallows, solid bolus swallows, and rapid drink challenge-is associated with a worse prognosis in patients with EGJOO and could potentially be used to select candidates suitable for invasive procedures.
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Affiliation(s)
- Axel Josefsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Center for Functional GI and Motility Disorders, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam Smolak
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nour Sabbagh
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Nijhuis RABO, Kuipers T, Oors JM, Herregods TVK, Kessing BF, Schuitenmaker JM, Smout AJPM, Bredenoord AJ. The Effect of STW5 (Iberogast) on Reflux Symptoms in Patients With Concurrent Dyspeptic Symptoms: A Double-blind Randomized Placebo-controlled Crossover Trial. J Neurogastroenterol Motil 2024; 30:54-63. [PMID: 38043927 PMCID: PMC10774799 DOI: 10.5056/jnm23014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/03/2023] [Accepted: 08/07/2023] [Indexed: 12/05/2023] Open
Abstract
Background/Aims It has been suggested that STW5 (Iberogast) reduces heartburn symptoms in patients with functional dyspepsia, but underlying mechanisms of action are unclear. The aim of this study is to investigate whether STW5 affects esophageal sensitivity or esophageal motility, thereby reducing occurrence and perception of reflux events. Methods We performed a double-blind, randomized, placebo-controlled, crossover trial in patients with functional dyspepsia (Rome IV) and reflux symptoms. After 4 weeks of treatment with either placebo or STW5, patients were studied with an esophageal acid perfusion test and ambulatory 24-hour pH-impedance monitoring. Results A total of 18 patients (7 men, median age 54, range [19-76]), were included in the study. Although we found no statistical difference in our primary outcome the total Reflux Disease Questionnaire score 2.33 (0.25-4.33) vs 2.67 (1.17-4.00), P = 0.347, "gastroesophageal reflux disease" and "regurgitation" subscale scores were lower after STW5 treatment compared to placebo (P = 0.049 and P = 0.007). There was no statistical difference in number of reflux events, acid exposure time and acid sensitivity scores between STW5 and placebo. In a subgroup analysis of patients with pH-metry confirmed gastroesophageal reflux disease, treatment with STW5 significantly reduced the total number of acidic reflux events (P = 0.028). Moreover, in patients with reflux esophagitis, the median lag time to acid perception increased after STW5 treatment (P = 0.042). Conclusions We found some indications pointing towards a beneficial effect of STW5 on reflux symptoms in dyspeptic patients, with reduction of esophageal hypersensitivity as a potential underlying mechanism. Our findings will have to be confirmed in larger studies.
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Affiliation(s)
- Renske A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Thijs Kuipers
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jac M Oors
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Thomas V K Herregods
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Boudewijn F Kessing
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jeroen M Schuitenmaker
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Andreas J P M Smout
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Davis TA, Gyawali CP. Refractory Gastroesophageal Reflux Disease: Diagnosis and Management. J Neurogastroenterol Motil 2024; 30:17-28. [PMID: 38173155 PMCID: PMC10774805 DOI: 10.5056/jnm23145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/16/2023] [Indexed: 01/05/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.
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Affiliation(s)
- Trevor A Davis
- Division of Pediatric Gastroenterology, Washington University School of Medicine, Saint Louis Children’s Hospital, St. Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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18
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Gyawali CP, Yadlapati R, Fass R, Katzka D, Pandolfino J, Savarino E, Sifrim D, Spechler S, Zerbib F, Fox MR, Bhatia S, de Bortoli N, Cho YK, Cisternas D, Chen CL, Cock C, Hani A, Remes Troche JM, Xiao Y, Vaezi MF, Roman S. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut 2024; 73:361-371. [PMID: 37734911 PMCID: PMC10846564 DOI: 10.1136/gutjnl-2023-330616] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023]
Abstract
The Lyon Consensus provides conclusive criteria for and against the diagnosis of gastro-oesophageal reflux disease (GERD), and adjunctive metrics that consolidate or refute GERD diagnosis when primary criteria are borderline or inconclusive. An international core and working group was assembled to evaluate research since publication of the original Lyon Consensus, and to vote on statements collaboratively developed to update criteria. The Lyon Consensus 2.0 provides a modern definition of actionable GERD, where evidence from oesophageal testing supports revising, escalating or personalising GERD management for the symptomatic patient. Symptoms that have a high versus low likelihood of relationship to reflux episodes are described. Unproven versus proven GERD define diagnostic strategies and testing options. Patients with no prior GERD evidence (unproven GERD) are studied using prolonged wireless pH monitoring or catheter-based pH or pH-monitoring off antisecretory medication, while patients with conclusive GERD evidence (proven GERD) and persisting symptoms are evaluated using pH-impedance monitoring while on optimised antisecretory therapy. The major changes from the original Lyon Consensus criteria include establishment of Los Angeles grade B oesophagitis as conclusive GERD evidence, description of metrics and thresholds to be used with prolonged wireless pH monitoring, and inclusion of parameters useful in diagnosis of refractory GERD when testing is performed on antisecretory therapy in proven GERD. Criteria that have not performed well in the diagnosis of actionable GERD have been retired. Personalisation of investigation and management to each patient's unique presentation will optimise GERD diagnosis and management.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California in San Diego, La Jolla, California, USA
| | - Ronnie Fass
- Medicine/Section of Gastroenterology, Case Western Reserve University, Cleveland, Ohio, USA
| | - David Katzka
- Gastroenterology and Hepatology, Columbia University, New York, New York, USA
| | - John Pandolfino
- Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Department of Medical and Surgical Specialties, University of Padua, Padova, Italy
| | - Daniel Sifrim
- Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Stuart Spechler
- Division of Gastroenterology, Baylor Scott and White North Texas, Dallas, Texas, USA
| | - Frank Zerbib
- Gastroenterology, CHU de Bordeaux, Bordeaux, France
| | - Mark R Fox
- Gastroenterology, University of Zurich, Zurich, Switzerland
| | | | | | - Yu Kyung Cho
- Gastroenterology, Catholic University of Korea - Songsin Campus, Seoul, Korea (the Republic of)
| | - Daniel Cisternas
- Digestive System Research Unit, Universidad del Desarrollo Facultad de Medicina Clínica Alemana, Las Condes, Chile
| | - Chien-Lin Chen
- Department of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Charles Cock
- Department of Gastroenterology and Hepatology, Flinders University, Adelaide, South Australia, Australia
| | - Albis Hani
- Gastroenterology Unit, Department of Medicine, Pontificia Universidad Javeriana, Bogota, Colombia
| | | | - Yinglian Xiao
- Department of Gastroenterology, Sun Yan-sen University of Medical Sciences, Guangzhou, China
| | - Michael F Vaezi
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Sabine Roman
- Department of Digestive Physiology, Universite de Lyon, Lyon, France
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Jia X, Chen S, Hou X, Zhuang Q, Tan N, Zhang M, Wang J, Xing X, Xiao Y. Development and Validation of Serum Markers as Noninvasive Diagnostic Methods for Achalasia. Clin Transl Gastroenterol 2024; 15:e00651. [PMID: 37787436 PMCID: PMC10810595 DOI: 10.14309/ctg.0000000000000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION Currently, the diagnosis of achalasia mainly relies on invasive or radioactive examinations. This study aimed to develop a noninvasive diagnostic method for achalasia based on specific serum markers. METHODS Serum levels of profilin-1, galectin-10, immunoglobulin heavy variable 3-9, vasodilator-stimulated phosphoprotein, and transgelin-2 were measured in patients with achalasia and controls by enzyme-linked immunosorbent assay. The diagnostic values and thresholds were determined by the receiver operating characteristic curve analysis. Then, patients with dysphagia were prospectively enrolled to validate the ability of these molecules for achalasia diagnosing. RESULTS A total of 142 patients with achalasia and 50 nonachalasia controls (healthy volunteers and patients with reflux esophagitis) were retrospectively included. The serum levels of profilin-1, galectin-10, and transgelin-2 in patients with achalasia were significantly higher than those in healthy volunteers and patients with reflux esophagitis ( P all < 0.001). Profilin-1, galectin-10, and transgelin-2 were of good performance in diagnosing achalasia, with optimal thresholds of 2,171.2, 33.9, and 1,630.6 pg/mL, respectively. Second, 40 patients with dysphagia were prospectively enrolled to the validation of achalasia. For profilin-1, the positive predictive value, negative predictive value, sensitivity, and specificity were 100.0%, 64.5%, 45.0%, and 100.0%, respectively. The figures for transgelin-2 were 65.5%, 90.9%, 95.0%, and 50.0%. When both increased, the positive predictive value reached to 100.0%. When both indexes were normal, the negative predictive value was 100.0%. DISCUSSION Profilin-1 and transgelin-2 were promising biomarkers for achalasia diagnosis and performed better in combination. Further multicenter studies are necessary to verify their application as preliminary screening tools for achalasia.
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Affiliation(s)
- Xingyu Jia
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Songfeng Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Xun Hou
- Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Qianjun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Niandi Tan
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Mengyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Jinhui Wang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Xiangbin Xing
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
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Hoshikawa Y, Momma E, Koeda M, Tanabe T, Hoshino S, Kawami N, Iwakiri K. Among females older than 50 years, saliva secretion is significantly lower in non-erosive reflux disease patients than in healthy controls. Esophagus 2024; 21:76-82. [PMID: 37843630 DOI: 10.1007/s10388-023-01025-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Saliva secretion is significantly lower in patients with non-erosive reflux disease (NERD) than in healthy controls (HC). A previous study on HC showed that saliva secretion was lower in females than in males. Saliva secretion may be lower in female patients with NERD than in male patients. Therefore, the present study investigated sex differences in saliva secretion in patients with NERD. METHODS Subjects older than 50 years were included in the present study and consisted of 20 male patients with NERD, 19 male HC, 25 female patients with NERD, and 23 female HC. Saliva secretion was assessed as follows: each patient chewed sugar-free gum for 3 min prior to endoscopy, and the amount and pH of saliva before and after acid loading as an index of the acid-buffering capacity were measured. RESULTS In males, no significant differences were observed in the amount of stimulated saliva secretion or salivary pH between NERD patients and HC. However, the acid-buffering capacity (NERD: 6.1 [5.9-6.5], HC: 6.4 [6.2-6.6]) was significantly lower in NERD patients than in HC. In females, the amount of stimulated saliva secretion (NERD: 2.6 [2.0-4.1], HC: 5.8 [3.7-7.5]), salivary pH (NERD: 7.0 [6.8-7.2], HC: 7.2 [7.0-7.2]), and the acid-buffering capacity (NERD: 5.8 [5.4-6.2], HC: 6.2 [6.0-6.5]) were significantly lower in NERD patients than in HC. CONCLUSION Among females older than 50 years, saliva secretion was significantly lower in NERD patients than in HC. This reduction in saliva secretion may contribute to the pathophysiology of NERD in females.
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Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Eri Momma
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Mai Koeda
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Tomohide Tanabe
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Shintaro Hoshino
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, Japan.
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21
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Wada M, Minoda Y, Ihara E, Tsuru H, Hata Y, Nagatomo S, Esaki M, Bai X, Tanaka Y, Chinen T, Ogino H, Ogawa Y. Development of a new endoscopy system to visualize bilirubin for the diagnosis of duodenogastroesophageal reflux. Dig Endosc 2023. [PMID: 38130063 DOI: 10.1111/den.14749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Reflux hypersensitivity (RH) is a form of refractory gastroesophageal reflux disease in which duodenogastroesophageal reflux (DGER) plays a role. This study aimed to determine the usefulness of an endoscopy system equipped with image-enhanced technology for evaluating DGER and RH. METHODS The image enhancement mode for detecting bilirubin and calculated values were defined as the Bil mode and Bil value, respectively. First, the visibility of the Bil mode was validated for a bilirubin solution and bile concentrations ranging from 0.01% to 100% (0.002-20 mg/dL). Second, visibility scores of the Bil mode, when applied to the porcine esophagus sprayed with a bilirubin solution, were compared to those of the blue laser imaging (BLI) and white light imaging (WLI) modes. Third, a clinical study was conducted to determine the correlations between esophageal Bil values and the number of nonacid reflux events (NNRE) during multichannel intraluminal impedance-pH monitoring as well as the utility of esophageal Bil values for the differential diagnosis of RH. RESULTS Bilirubin solution and bile concentrations higher than 1% were visualized in red using the Bil mode. The visibility score was significantly higher with the Bil mode than with the BLI and WLI modes for 1% to 6% bilirubin solutions (P < 0.05). The esophageal Bil value and NNRE were significantly positively correlated (P = 0.031). The area under the receiver operating characteristic curve for the differential diagnosis of RH was 0.817. CONCLUSION The Bil mode can detect bilirubin with high accuracy and could be used to evaluate DGER in clinical practice.
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Affiliation(s)
- Masafumi Wada
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yosuke Minoda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirotaka Tsuru
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shuzaburo Nagatomo
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mitsuru Esaki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Xiaopeng Bai
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshimasa Tanaka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takatoshi Chinen
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Haruei Ogino
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Sararu ER, Peagu R, Fierbinteanu-Braticevici C. Association between Mean Nocturnal Baseline Impedance (MNBI) and Post-Reflux Swallow-Induced Peristaltic Wave Index (PSPW) in GERD Patients. Diagnostics (Basel) 2023; 13:3602. [PMID: 38132186 PMCID: PMC10742549 DOI: 10.3390/diagnostics13243602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 12/23/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders in the world. Two parameters, mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPW), have been recently proposed to help differentiate GERD phenotypes. Our study aimed to assess whether there is any correlation between the two parameters, while also taking a look at their ability to distinguish between GERD phenotypes. We recruited 81 patients who were divided into 4 groups based on their GERD phenotype: erosive reflux disease (ERD), non-erosive reflux disease (NERD), reflux hypersensitivity (RH), and functional heartburn (FH). Both MNBI (AUROC 0.855) and PSPW (AUROC 0.835) had very good performances in separating ERD patients from non-ERD patients. PSPW (AUROC 0.784) was superior to MNBI (AUROC 0.703) in distinguishing NERD patients from patients with RH or FH. The PSPW index (AUROC 0.762) was more effective than MNBI (AUROC 0.668) in separating RH from FH. We found that PSPW and MNBI have a strong statistical correlation (Pearson correlation coefficient, r = 0.722, p < 0.001). Furthermore, PSPW predicted pathological MNBI (<2292 Ω) with good performance (AUROC 0.807). MNBI and PSPW are useful in distinguishing GERD phenotypes, with a strong correlation between the two parameters.
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Affiliation(s)
- Elena Roxana Sararu
- Internal Medicine II and Gastroenterology Department, Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Razvan Peagu
- Internal Medicine Department, Sanador Hospital, 010991 Bucharest, Romania
| | - Carmen Fierbinteanu-Braticevici
- Internal Medicine II and Gastroenterology Department, Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Dantas RO, Alves LMT, Silva ACV, Cassiani RA, Alves DC, Nascimento WV. Eating Assessment Tool (EAT-10) Scores to Detect Self-Reported Dysphagia in Brazilians. Dysphagia 2023; 38:1609-1614. [PMID: 37272949 DOI: 10.1007/s00455-023-10588-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/02/2023] [Indexed: 06/06/2023]
Abstract
The Eating Assessment Tool (EAT-10) detects swallowing impairments (dysphagia) self-reported by patients according to their perception. This noninvasive, inexpensive, self-administered instrument is quickly and easily filled out. The objective of this investigation was to evaluate the scores, sensitivity, and specificity of the method to define self-reported dysphagia in Brazilians. EAT-10 scores were evaluated in 443 healthy individuals (273 women and 170 men), aged 20 to 84 years, with no swallowing difficulties or diseases, and 72 patients with diseases that cause dysphagia (35 women and 37 men), aged 29 to 88 years. Each of the 10 instrument items has a 0-4 rating scale, in which 0 indicates no problem and 4, a severe problem; total results range from 0 to 40. The median EAT-10 score of healthy subjects was 0 (range: 0-20), and that of patients was 14.5 (range: 1-40). Considering a ≥ 3 cutoff score to define dysphagia risk, it was self-reported by 97.2% of patients with dysphagia and 9.5% of no-disease individuals (97.2% sensitivity and 90.7% specificity). The positive predictive value of the test was 63% and the negative predictive value was 99.5%. Healthy women had higher scores (median 0, range: 0-20) than healthy men (median 0, range: 0-8, p < 0.01) and more results indicative of self-reported dysphagia (11.7%) than healthy men (5.9%). The EAT-10 cutoff score to detect self-reported dysphagia in Brazilians should be 3, as previously considered. Healthy women complain more of self-reported dysphagia than healthy men. The test has high sensitivity and specificity.
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Affiliation(s)
- Roberto Oliveira Dantas
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, SP, Brazil.
- , Ribeirão Preto, Brazil.
| | | | | | | | | | - Weslania Viviane Nascimento
- Laboratory of Gastrointestinal Physiology, Department of Surgery, Hospital of Mataró, Universitat Autonoma de Barcelona, Mataró, Spain
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24
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Kindt S, Surmont M. Manual censoring of impedance tracings by the Wingate consensus reduces the number of impedance episodes, impacting on reflux categorization. Neurogastroenterol Motil 2023; 35:e14683. [PMID: 37793130 DOI: 10.1111/nmo.14683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND The Lyon consensus classifies the evidence of gastroesophageal reflux (GERD) based on endoscopic features and results of pH/impedance monitoring (pH-MII) including the post-reflux swallow-induced peristaltic wave index (PSPWI) and mean nocturnal baseline impedance (MNBI). The Wingate consensus established criteria to reduce inter-reviewer variability when assessing reflux episodes and PSPWI by impedance. This study aims to assess the influence of the Wingate criteria on the different pH-MII parameters obtained by automated analysis. METHODS Thirty consecutive pH-MII off PPI were reviewed according to Wingate criteria. Number of impedance episodes and PSPWI were compared before and after censoring from automatic analysis. Reflux categorization according to Lyon consensus between censored and uncensored data was compared. Pearson correlations between impedance parameters and censored episodes were calculated. KEY RESULTS Censoring the tracings significantly reduced the number of reflux episodes (66 [42-90.25] vs. 44.5 [21.5-61.5], p = 0.0105). Reasons for censoring were as follows: 1/ anterograde episode: 9.5 [6-13], 2/ impedance drop <50%: 1 [0-3], 3/ duration <4 s: 1 [0-2], 4/ <2 distal channels: 2.5 [1-4], and 5/ artifacts: 2 [1-5]. Censored episodes were in majority non-acid (16.5 [13-26.5] vs. 2 [0-4], p < 0.00001). Censoring altered the categorization of impedance episodes (<40 episodes, 6 vs. 13 for resp. uncensored vs. censored tracings, 40-80 episodes: 13 vs. 13, and >80 episodes: 11 vs. 4, p = 0.0264), but not the symptom index, the symptom association probability, or the categorization according to the Lyon consensus. Nevertheless, individual tracings were affected. The percentage of censored episodes was inversely correlated with the number of acidic impedance episodes (r = -0.62, p = 0.0002). CONCLUSION AND INFERENCES Manual interpretation of impedance tracings based on the Wingate consensus reduces the number of impedance episodes, impacting on reflux categorization. Acidic reflux episodes are less likely to be censored, harboring a potential at improving automatic pH-MII analysis.
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Affiliation(s)
- Sébastien Kindt
- Department of Gastroenterology and Hepatology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Magali Surmont
- Department of Gastroenterology and Hepatology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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25
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Voulgaris T, Hoshino S, Sifrim D, Yazaki E. Improved diagnosis of reflux hypersensitivity. Neurogastroenterol Motil 2023; 35:e14680. [PMID: 37731341 DOI: 10.1111/nmo.14680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/04/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Reflux hypersensitivity (RH) is characterized by normal esophageal exposure to acid and positive correlation of symptoms to reflux episodes. Positivity of Symptomatic Index (SI) and/or Symptom Association Probability (SAP) is used diagnostically, though experts support that concordance of both is needed. We evaluated differences among patients with RH and concordance of SI/SAP or not. METHODS Patients with typical reflux symptoms without previous GERD diagnosis, submitted simultaneously to Ph-Impedance off PPI and high resolution manometry were included. Self-response to PPI was evaluated. Patients showing SI and/or SAP positivity were considered having RH and further classified to definite RH if both SI/SAP were positive or indefinite if only one positive. KEY RESULTS Totally 2659 patients (M/F: 35.6%/64.7%, mean age: 45 ± 14) were included. Final diagnosis was; FH: 21.8%, RH: 29.3% (definite: 14.3%/indefinite: 15%), GERD: 36% and inconclusive GERD: 12.9%. Patients with definite RH showed increased total reflux time, total number of reflux episodes and length of hiatus hernia, and also numerically but not statistically significant increased rates of PPI responsiveness versus indefinite RH and decreased mean nocturnal baseline impedance. Moreover, they showed significantly increased rate of PPI response versus patients with functional heartburn (FH). CONCLUSION & INFERENCES Some PPI responsiveness is frequent among patients with RH as also with FH, and cannot discriminate those entities clinically when diagnosing RH using SI and/or SAP positive criterion. Patients with RH and SI/SAP concordance differ from patients without. Implementation of a strict RH definition (both SI and SAP positive) can better distinguish RH from FH and should be used in the future.
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Affiliation(s)
- Theodoros Voulgaris
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK
| | - Shintaro Hoshino
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK
| | - Etsuro Yazaki
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK
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26
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Quigley N, Mistry SG, Vasant DH, Vasani S. Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms. BMJ Open Gastroenterol 2023; 10:e000883. [PMID: 37996120 PMCID: PMC10668155 DOI: 10.1136/bmjgast-2022-000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation. DESIGN This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches. RESULTS The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed. CONCLUSION Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.
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Affiliation(s)
- Nathan Quigley
- Otolaryngology Department, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Sandeep G Mistry
- Department of Ear Nose and Throat, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Gastroenterology Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Sarju Vasani
- Otolaryngology Department, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
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Sawada A, Sifrim D, Fujiwara Y. Esophageal Reflux Hypersensitivity: A Comprehensive Review. Gut Liver 2023; 17:831-842. [PMID: 36588526 PMCID: PMC10651372 DOI: 10.5009/gnl220373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/01/2022] [Accepted: 10/18/2022] [Indexed: 01/03/2023] Open
Abstract
Reflux hypersensitivity (RH) is one of the phenotypes of gastroesophageal reflux disease. The latest Rome IV defines RH as a condition with typical reflux symptoms and positive reflux-symptom association despite normal acid exposure. Subsequently, the Lyon consensus proposed detailed cutoff values for the criteria on the basis of experts' consensus. Rome IV brought a clear-cut perspective into the pathophysiology of gastroesophageal reflux disease and the importance of esophageal hypersensitivity. This perspective can be supported by the fact that other functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia often overlap with RH. Although several possible pathophysiological mechanisms of esophageal hypersensitivity have been identified, there is still unmet medical needs in terms of treatment for this condition. This review summarizes the current knowledge regarding RH.
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Affiliation(s)
- Akinari Sawada
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Jodorkovsky D, Katzka DA, Gyawali CP. A perspective on the clinical relevance of weak or nonacid reflux. Neurogastroenterol Motil 2023; 35:e14671. [PMID: 37702263 DOI: 10.1111/nmo.14671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/04/2023] [Accepted: 08/21/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Advances in ambulatory esophageal reflux monitoring that incorporated impedance electrodes to pH catheters have resulted in better characterization of retrograde bolus flow in the esophagus. With pH-impedance monitoring, in addition to acid reflux episodes identified by pH drops below 4.0, weakly acid reflux (WAR, pH 4-7) and nonacid reflux (NAR, pH >7.0) are also recognized, although both may be included under the umbrella term NAR. However, despite identification of ambulatory pH-impedance monitoring, data on clinical relevance and prognostic value of NAR are limited. The Lyon Consensus, an international expert review that defines conclusive metrics for gastroesophageal reflux disease (GERD), identifies NAR as "supportive" but not conclusive for GERD. PURPOSE This review provides perspectives on whether NAR fulfills three criteria for clinical relevance: whether NAR sufficiently explains pathogenesis of symptoms, whether it is associated with meaningful manifestations of GERD, and whether it can predict treatment efficacy.
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Affiliation(s)
- Daniela Jodorkovsky
- Division of Gastroenterology, Mount Sinai West & Morningside, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, Missouri, USA
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29
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Ikebuchi Y, Sato H, Ikeda H, Abe H, Ominami M, Shiota J, Sato C, Fukuda H, Ogawa R, Tatsuta T, Yokomichi H, Isomoto H, Inoue H. Clinical characteristics of absent contractility and ineffective esophageal motility: a multicenter study in Japan. J Gastroenterol Hepatol 2023; 38:1926-1933. [PMID: 37391859 DOI: 10.1111/jgh.16268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/04/2023] [Accepted: 06/06/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND AND AIM Absent contractility (AC) and ineffective esophageal motility (IEM) are esophageal hypomotility disorders diagnosed using high-resolution manometry (HRM). Patient characteristics and disease course of these conditions and differential diagnosis between AC and achalasia are yet to be elucidated. METHODS A multicenter study involving 10 high-volume hospitals was conducted. Starlet HRM findings were compared between AC and achalasia. Patient characteristics including underlying disorders and disease courses were analyzed in AC and IEM. RESULTS Fifty-three patients with AC and 92 with IEM were diagnosed, while achalasia was diagnosed in 1784 patients using the Chicago classification v3.0 (CCv3.0). The cut-off integrated relaxation pressure (IRP) value at 15.7 mmHg showed maximum sensitivity (0.80) and specificity (0.87) for differential diagnosis of AC from type I achalasia. While most ACs were based on systemic disorders such as scleroderma (34%) and neuromuscular diseases (8%), 23% were sporadic cases. The symptom severity of AC was not higher than that of IEM. Regarding the diagnosis of IEM, the more stringent CCv4.0 excluded 14.1% of IEM patients than the CCv3.0, although patient characteristics did not change. In patients with the hypomotile esophagus, concomitance of reflux esophagitis was associated with low distal contractile integral and IRP values. AC and IEM transferred between each other, paralleling with the underlying disease course, although no transition to achalasia was observed. CONCLUSION A successful determination of the optimal cut-off IRP value was achieved using the starlet HRM system to differentiate AC and achalasia. Follow-up HRM is also useful for differentiating AC from achalasia. Symptom severity may depend on underlying diseases instead of hypomotility severity.
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Affiliation(s)
- Yuichiro Ikebuchi
- Department of Multidisciplinary Internal Medicine, Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, School of Medicine, Tohoku University, Sendai, Japan
| | - Hisashi Fukuda
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Hajime Isomoto
- Department of Multidisciplinary Internal Medicine, Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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30
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Chen J, Oshima T, Kondo T, Tomita T, Fukui H, Shinzaki S, Miwa H. Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study. J Neurogastroenterol Motil 2023; 29:446-454. [PMID: 37814435 PMCID: PMC10577468 DOI: 10.5056/jnm22184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/05/2023] [Accepted: 01/25/2023] [Indexed: 10/11/2023] Open
Abstract
Background/Aims Non-cardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of non-cardiac origin. Information about the epidemiology of NCCP in Japan is lacking. We aim to determine the prevalence and characteristics of NCCP in the Japanese general population. Methods Two internet-based surveys were conducted among the general population in March 2017. Questions investigated the characteristics of symptoms associated with chest pain and consultation behavior. Quality of life, anxiety, depression, and gastroesophageal reflux disease were analyzed. Results Five percent of the survey respondents reported chest pain. Subjects with chest pain showed higher frequencies of anxiety and depression and lower quality of life. Among subjects with chest pain, approximately 30% had sought medical attention for their symptoms. Among all consulters, 70% were diagnosed with NCCP. Females were less likely to seek consultations for chest pain than males. Further, severity and frequency of chest pain, lower physical health component summary score, and more frequent gastroesophageal reflux disease were associated with consultation behavior. Subjects with NCCP and cardiac chest pain experienced similar impacts on quality of life, anxiety, and depression. Among subjects with NCCP, 82% visited a primary-care physician and 15% were diagnosed with reflux esophagitis. Conclusions The prevalence of chest pain in this sample of a Japanese general population was 5%. Among all subjects with chest pain, less than one-third consulted physicians, approximately 70% of whom were diagnosed with NCCP. Sex and both the severity and frequency of chest pain were associated with consultation behavior.
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Affiliation(s)
- Junji Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Takashi Kondo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Toshihiko Tomita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hirokazu Fukui
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Shinichiro Shinzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hiroto Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
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Mittal RK, Zifan A. Why so Many Patients With Dysphagia Have Normal Esophageal Function Testing. GASTRO HEP ADVANCES 2023; 3:109-121. [PMID: 38420259 PMCID: PMC10899865 DOI: 10.1016/j.gastha.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Esophageal peristalsis involves a sequential process of initial inhibition (relaxation) and excitation (contraction), both occurring from the cranial to caudal direction. The bolus induces luminal distension during initial inhibition (receptive relaxation) that facilitates smooth propulsion by contraction travelling behind the bolus. Luminal distension during peristalsis in normal subjects exhibits unique characteristics that are influenced by bolus volume, bolus viscosity, and posture, suggesting a potential interaction between distension and contraction. Examining distension-contraction plots in dysphagia patients with normal bolus clearance, ie, high-amplitude esophageal peristaltic contractions, esophagogastric junction outflow obstruction, and functional dysphagia, reveal 2 important findings. Firstly, patients with type 3 achalasia and nonobstructive dysphagia show luminal occlusion distal to the bolus during peristalsis. Secondly, patients with high-amplitude esophageal peristaltic contractions, esophagogastric junction outflow obstruction, and functional dysphagia exhibit a narrow esophageal lumen through which the bolus travels during peristalsis. These findings indicate a relative dynamic obstruction to bolus flow and reduced distensibility of the esophageal wall in patients with several primary esophageal motility disorders. We speculate that the dysphagia sensation experienced by many patients may result from a normal or supernormal contraction wave pushing the bolus against resistance. Integrating representations of distension and contraction, along with objective assessments of flow timing and distensibility, complements the current classification of esophageal motility disorders that are based on the contraction characteristics only. A deeper understanding of the distensibility of the bolus-containing esophageal segment during peristalsis holds promise for the development of innovative medical and surgical therapies to effectively address dysphagia in a substantial number of patients.
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Affiliation(s)
- Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
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Guadagnoli L, Geeraerts A, Geysen H, Pauwels A, Vanuytsel T, Tack J, Van Oudenhove L. Psychological Processes, Not Physiological Parameters, Are Most Important Contributors to Symptom Severity in Patients With Refractory Heartburn/Regurgitation Symptoms. Gastroenterology 2023; 165:848-860. [PMID: 37394015 DOI: 10.1053/j.gastro.2023.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/03/2023] [Accepted: 06/12/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND & AIMS Physiological and psychological factors have been found to influence esophageal symptom reporting. We aimed to evaluate which of these factors are associated with 3 reflux symptom severity outcomes (ie, Total Reflux, Heartburn, and Sleep Disturbance) through a traditional statistical and a complementary machine-learning approach. METHODS Consecutive adult patients with refractory heartburn/regurgitation symptoms underwent standard 24-hour pH-impedance monitoring and completed questionnaires assessing past and current gastrointestinal and psychological health. In the traditional statistical approach, hierarchical general linear models assessed relationships of psychological and physiological variables (eg, total number of reflux episodes) with reflux severity scores. Mediation analyses further assessed pathways between relevant variables. In the machine-learning approach, all psychological and physiological variables were entered into 11 different models and cross-validated model performance was compared among the different models to select the best model. RESULTS Three hundred ninety-three participants (mean [SD] age, 48.5 [14.1] years; 60% were female) were included. General psychological functioning emerged as an important variable in the traditional statistical approach, as it was significantly associated with all 3 outcomes and mediated the relationship between childhood trauma and both Total Reflux and Heartburn Severity. In the machine-learning analyses, general psychological variables (eg, depressive symptoms) were most important for Total Reflux and Sleep Disturbance outcomes, and symptom-specific variables, like visceral anxiety, were more influential for Heartburn Severity. Physiological variables were not significant contributors to reflux symptom severity outcomes in our sample across reflux classifications and statistical methodology. CONCLUSIONS Psychological processes, both general and symptom-specific, should be considered as another important factor within the multifactorial processes that impact reflux symptom severity reporting across the reflux spectrum.
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Affiliation(s)
- Livia Guadagnoli
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Annelies Geeraerts
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hannelore Geysen
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ans Pauwels
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Gastroenterology Division, University Hospitals Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Gastroenterology Division, University Hospitals Leuven, Leuven, Belgium
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium; Consultation-Liaison Psychiatry, University Psychiatric Centre Katholieke Universiteit Leuven Campus Gasthuisberg, Leuven, Belgium; Cognitive and Affective Neuroscience Laboratory, Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire
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Geeraerts A, Guadagnoli L, Pauwels A, Geysen H, Neyens T, Van Oudenhove L, Vanuytsel T, Tack J. Psychological symptoms do not discriminate between reflux phenotypes along the organic-functional refractory GERD spectrum. Gut 2023; 72:1819-1827. [PMID: 37336632 DOI: 10.1136/gutjnl-2023-329673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Historically, psychological processes are associated with disorders at the functional end of the gastro-oesophageal reflux disease (GERD) spectrum. However, recent research suggests that psychological symptoms are relevant across the entire GERD spectrum. We aim to investigate whether psychological symptoms are associated with reflux phenotype (True GERD, Borderline GERD, reflux hypersensitivity, functional heartburn) along the GERD spectrum in a cohort of refractory reflux patients. DESIGN Consecutive adult patients with refractory reflux symptoms underwent standard 24-hour pH-impedance monitoring and completed questionnaires assessing demographic, clinical and psychological information. Bayesian one-way analysis of variance assessed whether psychological variables differed across reflux phenotypes. Next, we applied multinomial and ordinal logistic regressions with clinical, demographic and psychological variables set as independent variables and reflux phenotype as the outcome variable. The complementary machine-learning approach entered all demographic, clinical and psychological variables into models, with reflux phenotype set nominally and ordinally. Cross-validated model performance was used to select the best model. RESULTS 393 participants (mean (SD) age=48.5 (14.1); 60% female) were included. The Bayesian analyses found no difference in psychological variables across reflux phenotypes. Similarly, age, gender and proton pump inhibitor use were the only significant variables in the multinomial logistic regression and body mass index was significant in both regressions. Machine-learning analyses revealed poorly performing models with high misclassification rates (67-68%) in both models. CONCLUSION Psychological symptoms do not differ between nor predict reflux phenotype membership in refractory reflux patients. Findings suggest that psychological symptoms are relevant across the spectrum of GERD, rather than specific to functional oesophageal disorders.
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Affiliation(s)
- Annelies Geeraerts
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Livia Guadagnoli
- Laboratory for Brain-Gut Axis Studies (LaBGAS), Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Ans Pauwels
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Hannelore Geysen
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Thomas Neyens
- Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health & Primary Care, KU Leuven, Leuven, Belgium
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies (LaBGAS), Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- Department of Gastroenterology, UZ Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- Department of Gastroenterology, UZ Leuven, Leuven, Belgium
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Koop AH, Kahrilas PJ, Schauer J, Pandolfino JE, Carlson DA. The impact of primary peristalsis, contractile reserve, and secondary peristalsis on esophageal clearance measured by timed barium esophagogram. Neurogastroenterol Motil 2023; 35:e14638. [PMID: 37417394 DOI: 10.1111/nmo.14638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Primary and secondary peristalsis facilitate esophageal bolus transport; however, their relative impact for bolus clearance remains unclear. We aimed to compare primary peristalsis and contractile reserve on high-resolution manometry (HRM) and secondary peristalsis on functional lumen imaging probe (FLIP) Panometry with emptying on timed barium esophagogram (TBE) and incorporate findings into a comprehensive model of esophageal function. METHODS Adult patients who completed HRM with multiple rapid swallows (MRS), FLIP, and TBE for esophageal motility evaluation and without abnormal esophagogastric junction outflow/opening or spasm were included. An abnormal TBE was defined as a 1-min column height >5 cm. Primary peristalsis and contractile reserve after MRS were combined into an HRM-MRS model. Secondary peristalsis was combined with primary peristalsis assessment to describe a complementary neuromyogenic model. KEY RESULTS Of 89 included patients, differences in rates of abnormal TBEs were observed with primary peristalsis classification (normal: 14.3%; ineffective esophageal motility: 20.0%; absent peristalsis: 54.5%; p = 0.009), contractile reserve (present: 12.5%; absent: 29.3%; p = 0.05), and secondary peristalsis (normal: 9.7%; borderline: 17.6%; impaired/disordered: 28.6%; absent contractile response: 50%; p = 0.039). Logistic regression analysis (akaike information criteria, area under the receiver operating curve) demonstrated that the neuromyogenic model (80.8, 0.83) had a stronger relationship predicting abnormal TBE compared to primary peristalsis (81.5, 0.82), contractile reserve (86.8, 0.75), or secondary peristalsis (89.0, 0.78). CONCLUSIONS AND INFERENCES Primary peristalsis, contractile reserve, and secondary peristalsis were associated with abnormal esophageal retention as measured by TBE. Added benefit was observed when applying comprehensive models to incorporate primary and secondary peristalsis supporting their complementary application.
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Affiliation(s)
- Andree H Koop
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacob Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Fossmark R, Ness-Jensen E, Sørdal Ø. Is empiric proton pump inhibition in patients with symptoms of extraesophageal gastroesophageal reflux justified? BMC Gastroenterol 2023; 23:303. [PMID: 37674110 PMCID: PMC10483799 DOI: 10.1186/s12876-023-02945-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/04/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND The prevalence of gastroesophageal reflux disease (GERD) has had a marked increase in Western countries with a paralleling interest in extraesophageal (EE) manifestations of GERD, including laryngopharyngeal reflux (LPR). There are considerable differences in clinical practice between gastroenterologists, otolaryngologists and pulmonologists. METHODS In this narrative review we address some of these controversies concerning EE manifestations of GERD and LPR. RESULTS It is disputed whether there is causal relationship between reflux and the numerous symptoms and conditions suggested to be EE manifestations of GERD. Similarly, the pathophysiology is uncertain and there are disagreements concerning diagnostic criteria. Consequently, it is challenging to provide evidence-based treatment recommendations. A significant number of patients are given a trial course with a proton pump inhibitor (PPI) for several months before symptoms are evaluated. In randomized controlled trials (RCTs) and meta-analyses of RCTs PPI treatment does not seem to be advantageous over placebo, and the evidence supporting that patients without verified GERD have any benefit of PPI treatment is negligible. There is a large increase in both over the counter and prescribed PPI use in several countries and a significant proportion of this use is without any symptomatic benefit for the patients. Whereas short-term treatment has few side effects, there is concern about side-effects after long-term use. Although empiric PPI treatment for suspected EE manifestations of GERD instead of prior esophageal 24-hour pH and impedance monitoring is included in several guidelines by various societies, this practice contributes to overtreatment with PPI. CONCLUSION We argue that the current knowledge suggests that diagnostic testing with pH and impedance monitoring rather than empiric PPI treatment should be chosen in a higher proportion of patients presenting with symptoms possibly attributable to EE reflux.
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Affiliation(s)
- Reidar Fossmark
- Department of Clinical and Molecular Medicine, NTNU, Norwegian University of Science and Technology, Prinsesse Kristinas gate 1, Trondheim, 7030, Norway.
- Medicus Endoscopy, Trondheim, Norway.
| | - Eivind Ness-Jensen
- HUNT Research Center, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Khatri R, Patel J, Song J, Malik Z, Smith MS, Parkman HP. Esophageal Inlet Patch: Association with Barrett's Esophagus. Dig Dis Sci 2023; 68:3671-3678. [PMID: 37452980 DOI: 10.1007/s10620-023-08030-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Esophageal inlet patch (IP) with heterotopic gastric mucosa is an incidental finding on esophagogastroduodenoscopy (EGD). Although IP is thought to be embryologic in nature, IP has been associated with Barrett's esophagus (BE). AIMS The aim of this study was to compare prevalence, symptoms, demographic factors, and esophageal testing in patients with IP and BE. METHODS We retrospectively analyzed endoscopic findings of EGDs, high-resolution esophageal manometry and esophageal pH impedance studies from January 2010 to January 2021 at a single academic medical center. Patients were grouped by presence or absence of IP and BE. RESULTS Of 27,498 patients evaluated, 1.3% had endoscopic evidence of IP and 4.9% had BE. Of 362 patients with IP, 17.1% had BE; of 1356 patients with BE, 4.6% had IP. Both IP and BE patients presented primarily with heartburn and/or regurgitation. Patients with BE and/or IP were older and had higher BMI than those without (p < 0.001). Mean lower esophageal sphincter pressure was lower and mean acid exposure time (AET) was higher in patients with IP and/or BE than those without (p < 0.05). CONCLUSIONS Our study reports an IP prevalence of 1.3%, with 17.1% patients having concomitant BE; and a BE prevalence of 4.9%, with 4.6% also having IP. Patients with IP alone presented with similar symptoms to patients with concomitant BE. Esophageal function testing showed that patients with either IP or BE had decreased LES pressures and increased esophageal AET. During endoscopy, patients found to have one of these findings should be carefully examined for the other.
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Affiliation(s)
- Rishabh Khatri
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA.
- Gastroenterology Section, Temple University School of Medicine, Parkinson Pavilion, 8th Floor, Philadelphia, PA, 19140, USA.
| | - Jay Patel
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Jun Song
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Zubair Malik
- Department of Gastroenterology, Temple University Health System, Philadelphia, PA, USA
| | - Michael S Smith
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai West & Mount Sinai Morningside Hospitals, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Henry P Parkman
- Department of Gastroenterology, Temple University Health System, Philadelphia, PA, USA
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Hurtte E, Young J, Gyawali CP. Dysphagia. Prim Care 2023; 50:325-338. [PMID: 37516505 DOI: 10.1016/j.pop.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Dysphagia is an important clinical symptom that increases in prevalence with age. Both oropharyngeal and esophageal processes can contribute to dysphagia, and these can be differentiated with a careful history. Neuromuscular processes are more prevalent than structural causes in oropharyngeal dysphagia, therefore, investigation should start with a modified barium swallow. In contrast, structural processes dominate in esophageal dysphagia, and endoscopy can offer biopsy and therapy by way of dilation. Manometry is performed for esophageal dysphagia when no structural etiology is found. Specific management of dysphagia is dependent on the etiology and mechanism of dysphagia.
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Affiliation(s)
- Edward Hurtte
- Division of Gastroenterology, Washington University School of Medicine, Campus Box 8124, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Jocelyn Young
- United Health Services Hospitals, Johnson City, NY, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Campus Box 8124, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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Ruggiero L, Iovino P, Gargano D, Caloro A, De Leo L, D’Antonio A, Caputo A, Santonicola A. Upper Esophageal Sphincter Metrics across Eosinophilic Esophagitis, Gastroesophageal Reflux Disease and Functional Dysphagia: A Pilot Study. J Clin Med 2023; 12:5548. [PMID: 37685614 PMCID: PMC10488079 DOI: 10.3390/jcm12175548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Recent studies have evaluated the upper esophageal sphincter (UES) with high-resolution manometry (HRM) in some esophageal diseases, but not eosinophilic esophagitis (EoE). The aim of our study was to evaluate the function of the UES across EoE, gastroesophageal reflux disease (GERD), functional dysphagia (FD), and the relationship with esophageal symptoms, esophageal body contraction, and esophagogastric junction (EGJ) metrics. METHODS HRM was performed on 30 EoE, 18 GERD, and 29 FD patients according to the Chicago Classification 3.0. The study data were exported to the online analysis platform Swallow Gateway. The UES was assessed in terms of UES Resting Pressure (UES-RP), UES Basal Pressure (UES-BP), UES Integrated Relaxation Pressure (UES-IRP), UES Relaxation Time (UES-RT), Basal UES Contractile Integral (Basal UES-CI), Post-Deglutitive UES Contractile Integral (Post-Deglutitive UES-CI), and Proximal Contractile Integral (PCI). RESULTS ANOVA analysis showed significantly higher values of Post-Deglutitive UES-CI in EoE patients compared with FD patients (p = 0.001). Basal UES-CI and UES-RP showed significantly higher values in EoE (p = 0.002, p = 0.038) and GERD (p < 0.001, p = 0.001) patients compared with FD patients. Correlations between LES-CI and Post-Deglutitive UES-CI, Basal UES-CI, and UES-RP (p ≤ 0.001, p = 0.027, p = 0.017, respectively), and between LES-BP and Post-Deglutitive UES-CI (p = 0.019), independent of diagnosis, were shown. No correlations have been demonstrated between the UES, EGJ metrics, and esophageal symptoms. CONCLUSIONS Some differences in UES metrics in the three different diseases were found. Further studies are needed to confirm the results of our pilot study and possible applications in clinical practice.
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Affiliation(s)
- Luigi Ruggiero
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Baronissi, Italy; (L.R.); (P.I.); (A.C.); (L.D.L.)
| | - Paola Iovino
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Baronissi, Italy; (L.R.); (P.I.); (A.C.); (L.D.L.)
| | - Domenico Gargano
- Allergy and Clinical Immunology Unit, San Giuseppe Moscati Hospital, 83100 Avellino, Italy;
| | - Angela Caloro
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Baronissi, Italy; (L.R.); (P.I.); (A.C.); (L.D.L.)
| | - Luca De Leo
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Baronissi, Italy; (L.R.); (P.I.); (A.C.); (L.D.L.)
| | - Antonio D’Antonio
- Pathologic Anatomy Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Baronissi, Italy; (A.D.); (A.C.)
| | - Alessandro Caputo
- Pathologic Anatomy Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Baronissi, Italy; (A.D.); (A.C.)
| | - Antonella Santonicola
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Baronissi, Italy; (L.R.); (P.I.); (A.C.); (L.D.L.)
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Helle K, Árok AZ, Ollé G, Antal M, Rosztóczy A. Dental evaluation is helpful in the differentiation of functional heartburn and gastroesophageal reflux disease. World J Gastroenterol 2023; 29:4774-4782. [PMID: 37664156 PMCID: PMC10473917 DOI: 10.3748/wjg.v29.i31.4774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Heartburn is identically the key symptom of both, gastroesophageal reflux disease (GERD) and functional heartburn (FHB), making the differential diagnosis resource-intensive. Oral manifestations of GERD can be easily examined; therefore, their exploration might be a cheap, widely available, and useful tool in the differentiation of GERD and FHB. AIM To evaluate the prevalence of dental erosions (DE) and periodontal diseases (PD) in patients with heartburn and their association with GERD and FHB. METHODS A total of 116 [M/F: 51/65, mean age: 54 (17-80) years] consecutive patients with heartburn were enrolled for detailed esophageal function and orodental examinations. RESULTS Dental disorders were detected in 89% (103/116). Patients with PD + DE had significantly more often pathologic reflux (90.0% vs 27.8%; P < 0.05), higher esophagitis scores (1.8 vs 0.9; P < 0.05), and a significantly different mean impedance curve (P = 0.04) than those without any dental diseases. The opposite approach established that patients with GERD had significantly higher prevalence of DE and PD, especially if both were present (28.9% vs 2.0%; P < 0.01), more severe PD (1.5 vs 1.0; P < 0.01), and longer history of heartburn (15 years vs 9 years; P < 0.01) than those with FHB. CONCLUSION The dental evaluation of patients with heartburn seems to be useful in the differential diagnosis of GERD and FHB. Among the studied parameters, the co-appearance of DE and PD seems to be the best predictor of GERD, whereas the absence of dental disorders was mostly observed in FHB.
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Affiliation(s)
- Krisztina Helle
- Department of Internal Medicine, Division of Gastroenterology, University of Szeged, Szeged 6725, Hungary
| | - Anna Zsófia Árok
- Department of Operative and Esthetic Dentistry, University of Szeged, Szeged 6725, Hungary
| | - Georgina Ollé
- Department of Internal Medicine, Division of Gastroenterology, University of Szeged, Szeged 6725, Hungary
| | - Márk Antal
- Department of Operative and Esthetic Dentistry, University of Szeged, Szeged 6725, Hungary
| | - András Rosztóczy
- Department of Internal Medicine, Division of Gastroenterology, University of Szeged, Szeged 6725, Hungary
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Lowenstein ED, Ruffault PL, Misios A, Osman KL, Li H, Greenberg RS, Thompson R, Song K, Dietrich S, Li X, Vladimirov N, Woehler A, Brunet JF, Zampieri N, Kühn R, Liberles SD, Jia S, Lewin GR, Rajewsky N, Lever TE, Birchmeier C. Prox2 and Runx3 vagal sensory neurons regulate esophageal motility. Neuron 2023; 111:2184-2200.e7. [PMID: 37192624 DOI: 10.1016/j.neuron.2023.04.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/31/2022] [Accepted: 04/24/2023] [Indexed: 05/18/2023]
Abstract
Vagal sensory neurons monitor mechanical and chemical stimuli in the gastrointestinal tract. Major efforts are underway to assign physiological functions to the many distinct subtypes of vagal sensory neurons. Here, we use genetically guided anatomical tracing, optogenetics, and electrophysiology to identify and characterize vagal sensory neuron subtypes expressing Prox2 and Runx3 in mice. We show that three of these neuronal subtypes innervate the esophagus and stomach in regionalized patterns, where they form intraganglionic laminar endings. Electrophysiological analysis revealed that they are low-threshold mechanoreceptors but possess different adaptation properties. Lastly, genetic ablation of Prox2 and Runx3 neurons demonstrated their essential roles for esophageal peristalsis in freely behaving mice. Our work defines the identity and function of the vagal neurons that provide mechanosensory feedback from the esophagus to the brain and could lead to better understanding and treatment of esophageal motility disorders.
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Affiliation(s)
- Elijah D Lowenstein
- Developmental Biology/Signal Transduction, Max Delbrück Center for Molecular Medicine, Berlin, Germany; NeuroCure Cluster of Excellence, CharitéUniversitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pierre-Louis Ruffault
- Developmental Biology/Signal Transduction, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Aristotelis Misios
- Developmental Biology/Signal Transduction, Max Delbrück Center for Molecular Medicine, Berlin, Germany; NeuroCure Cluster of Excellence, CharitéUniversitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Systems Biology of Gene Regulatory Elements, Berlin Institute for Medical Systems Biology, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Kate L Osman
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Huimin Li
- The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Rachel S Greenberg
- Howard Hughes Medical Institute, Department of Cell Biology, Harvard Medical School, Boston, MA 02115, USA
| | - Rebecca Thompson
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Kun Song
- Developmental Biology/Signal Transduction, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Stephan Dietrich
- Development and Function of Neural Circuits, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Xun Li
- Immune Regulation and Cancer, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Nikita Vladimirov
- Systems Biology Imaging, Berlin Institute for Medical Systems Biology, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Andrew Woehler
- Systems Biology Imaging, Berlin Institute for Medical Systems Biology, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Jean-François Brunet
- Institut de Biologie de l'ENS (IBENS), Inserm, CNRS, École normale supérieure, PSL Research University, Paris, France
| | - Niccolò Zampieri
- Development and Function of Neural Circuits, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Ralf Kühn
- Genome Engineering & Disease Models, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Stephen D Liberles
- Howard Hughes Medical Institute, Department of Cell Biology, Harvard Medical School, Boston, MA 02115, USA
| | - Shiqi Jia
- The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Gary R Lewin
- Molecular Physiology of Somatic Sensation, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Nikolaus Rajewsky
- Systems Biology of Gene Regulatory Elements, Berlin Institute for Medical Systems Biology, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Teresa E Lever
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Carmen Birchmeier
- Developmental Biology/Signal Transduction, Max Delbrück Center for Molecular Medicine, Berlin, Germany; NeuroCure Cluster of Excellence, CharitéUniversitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Hoshikawa Y, Momma E, Kawami N, Iwakiri K. Lemborexant Attenuates Regurgitation without Worsening Objective Parameters on Reflux Monitoring in Patients with Gastroesophageal Reflux Disease and Insomnia: A Single-Arm Proof-of-Concept Study. Digestion 2023; 104:438-445. [PMID: 37429270 DOI: 10.1159/000531412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/31/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Esophageal hypersensitivity is associated with gastroesophageal reflux disease (GERD). Since sleep disturbance causes esophageal hypersensitivity, hypnotics may ameliorate GERD. However, zolpidem prolongs esophageal acid clearance. Lemborexant is a new hypnotic with higher efficacy and fewer adverse events than zolpidem. Therefore, the present study investigated the effects of lemborexant on GERD. METHODS Patients with heartburn and/or regurgitation and insomnia who did not take acid suppressants or hypnotics in the last month were recruited. Symptom assessments using GerdQ and reflux monitoring were performed before and after a 28-day treatment with 5 mg lemborexant at bedtime. The primary outcome was a change in the total GerdQ score, excluding the score for insomnia. Secondary outcomes were changes in each GerdQ score and the following parameters on reflux monitoring: the acid exposure time (AET), number of reflux events (RE), acid clearance time (ACT), and post-reflux swallow-induced peristaltic wave (PSPW) index. RESULTS Sixteen patients (age 45.0 [33.3-56.0], 11 females [68.8%]) completed the intervention (1 patient did not tolerate the second reflux monitoring). The total GerdQ score, excluding the score for insomnia, did not significantly change (8.0 [6.0-9.0] before vs. 7.0 [6.3-9.0] after p = 0.16). GerdQ showed the significant attenuation of regurgitation (2.0 [2.0-3.0] vs. 1.0 [0-2.8] p = 0.0054) but not heartburn (2.5 [1.0-3.0] vs. 1.0 [0.3-2.0] p = 0.175). No significant differences were observed in AET, RE, ACT, or PSPW index before and after the intervention. CONCLUSION Lemborexant attenuated regurgitation without the worsening of objective reflux parameters. A randomized placebo-controlled study is warranted in the future.
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Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Eri Momma
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Savarino V, Marabotto E, Zentilin P, De Bortoli N, Visaggi P, Furnari M, Bodini G, Giannini E, Savarino E. How safe are heartburn medications and who should use them? Expert Opin Drug Saf 2023; 22:643-652. [PMID: 37477199 DOI: 10.1080/14740338.2023.2238592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/17/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Heartburn is a frequent symptom occurring in daily clinical practice and is mainly associated with gastroesophageal reflux disease (GERD). However, it can be stimulated by various factors and diseases other than GERD can present with heartburn. Therefore, physicians must be very careful in distinguishing GERD from non-GERD conditions in their patients, particularly when heartburn is refractory to anti-reflux medications. AREAS COVERED The aim of this narrative review was to analyze the medical literature regarding the prevalence of heartburn and the various clinical disorders which can be present with this symptom. The type of medications usually adopted for treating heartburn and their grade of safety have been reviewed using an extensive computerized (Medline/PubMed) search with particular focus on the last 20 years. EXPERT OPINION Many drugs can be used for relieving heartburn in patients with GERD, although PPIs are the pharmacological agents with the greatest efficacy. However, it must be highlighted that many non-GERD conditions may present clinically with this symptom whose intensity does not differ between GERD and functional esophageal disorders, which represent about 50% of all patients with suspected GERD. It is very important to identify these functional conditions because their treatment differs completely from that of GERD.
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Affiliation(s)
- Vincenzo Savarino
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Nicola De Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pierfrancesco Visaggi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Manuele Furnari
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Giorgia Bodini
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Edoardo Giannini
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Ribolsi M, Savarino E. Towards a better diagnosis of gastro esophageal reflux disease. Expert Rev Gastroenterol Hepatol 2023; 17:999-1010. [PMID: 37800858 DOI: 10.1080/17474124.2023.2267435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/03/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION GERD is a common disorder and is characterized by the presence of typical or atypical symptoms. In GERD patients, the presence of mucosal alterations in endoscopy is detected in up to 30% of individuals. The clinical presentation of GERD patients may be complex and their management is challenging, due to the heterogeneous clinical presentation. The present review has been performed searching all relevant articles in this field, over the past years, using PubMed database. AREAS COVERED The diagnosis and management of GERD have been significantly improved in the last years due to the increasing availability of reflux monitoring techniques and the implementation of new procedures in the therapeutic armamentarium. Beside traditional impedance-pH variables, new metrics have been developed, increasing the diagnostic yield of reflux monitoring and better predicting the treatment response. Traditional pharmacological treatments include acid-suppressive-therapy and/or anti-acid. On the other hand, surgical treatment and, more recently, endoscopic procedures represent a promising field in the therapeutic approach. EXPERT OPINION Diagnosis and treatment of GERD still represent a challenging area. However, we believe that an accurate upfront evaluation is, nowadays, necessary in addressing patients with GERD to a more accurate diagnosis as well as to the best treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
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Calabrese F, Poletti V, Auriemma F, Paduano D, Gentile C, Facciorusso A, Franchellucci G, De Marco A, Brandaleone L, Ofosu A, Samanta J, Ramai D, De Luca L, Al-Lehibi A, Zuliani W, Hassan C, Repici A, Mangiavillano B. New Perspectives in Endoscopic Treatment of Gastroesophageal Reflux Disease. Diagnostics (Basel) 2023; 13:2057. [PMID: 37370952 DOI: 10.3390/diagnostics13122057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/05/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Gastroesophageal reflux disease has a high incidence and prevalence in the general population. Clinical manifestations are heterogenous, and so is the response to medical treatment. Proton pump inhibitors are still the most common agents used to control reflux symptoms and for healing esophagitis, but they are not a one-size-fits-all solution for the disease. Patients with persistent troublesome symptoms despite medical therapy, those experiencing some adverse drug reaction, or those unwilling to take lifelong medications deserve valid alternatives. Anti-reflux Nissen fundoplication is an effective option, but the risk of adverse events has limited its spread. In recent years, advancements in therapeutic endoscopy have been made, and three major endoluminal alternatives are now available, including (1) the delivery of radiofrequency energy to the esophago-gastric junction, (2) transoral incisionless fundoplication (TIF), and (3) anti-reflux mucosal interventions (ARMI) based on mucosal resection (ARMS) and mucosal ablation (ARMA) techniques to remodel the cardia. Endoscopic techniques have shown interesting results, but their diffusion is still limited to expert endoscopists in tertiary centers. This review discusses the state of the art in the endoscopic approach to gastroesophageal reflux disease.
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Affiliation(s)
- Federica Calabrese
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Valeria Poletti
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Danilo Paduano
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Carmine Gentile
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, 71100 Foggia, Italy
| | | | - Alessandro De Marco
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
| | - Luca Brandaleone
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
| | - Andrew Ofosu
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Luca De Luca
- Endoscopic Unit, ASST Santi Paolo e Carlo, 20142 Milan, Italy
| | - Abed Al-Lehibi
- King Fahad Medical City, Faculty of Medicine, King Saud Bin Abduaziz University-Health Science, Riyadh 11525, Saudi Arabia
| | - Walter Zuliani
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Cesare Hassan
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
| | - Alessandro Repici
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
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Ribolsi M, Savarino E, Frazzoni M, Cicala M. Prospective validation of reflux monitoring by impedance-pH in predicting PPI response in typical GERD. Dig Liver Dis 2023; 55:721-726. [PMID: 36572569 DOI: 10.1016/j.dld.2022.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 05/29/2023]
Abstract
BACKGROUND The Lyon Consensus proposed a hierarchical approach to GERD diagnosis based on conventional and new impedance-pH metrics, namely acid exposure time (AET), number of reflux episodes, post-reflux swallow-induced peristaltic wave (PSPW) index, and mean nocturnal baseline impedance (MNBI). AIMS To define the value of conventional and new impedance-pH parameters as predictors of response to label-dose PPI in typical GERD. METHODS Consecutive adult patients with typical esophageal symptoms were prospectively studied with impedance-pH monitoring and treated with 8-week label-dose PPI. At the end of the PPI course, symptoms response was assessed. RESULTS Among 255 patients who entered the study, 168 (65.9%) reported symptom remission. At ROC analysis, both MNBI and PSPW index were significantly associated to PPI responsiveness with AUC of 0.783 and 0.801, respectively. Cut-off values of 1747Ω for MNBI and 50% for PSPW index were identified as discriminators between response and non-response to label-dose PPI. At multivariate analysis, MNBI, PSPW index, and AET >6% were efficient predictors of PPI responses (OR 3, 5.4 and 2.3, respectively). Number of reflux episodes did not predict PPI response. CONCLUSIONS The novel MII-pH variables together with pathological are highly predictive of response of the typical GERD syndrome to label-dose PPI.
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Affiliation(s)
- Mentore Ribolsi
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Via Alvaro del Portillo 200 - 00128, Roma, Italy.
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Michele Cicala
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Via Alvaro del Portillo 200 - 00128, Roma, Italy
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ANDERLONI A, SAVARINO E, ZAGARI RM, ARAGONA SE, CIPRANDI G. The practical management of patients with gastroesophageal reflux: an Italian survey. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2023; 182. [DOI: 10.23736/s0393-3660.23.05039-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
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Romańczyk M, Budzyń K, Romańczyk T, Lesińska M, Koziej M, Hartleb M, Waluga M. Heterotopic Gastric Mucosa in the Proximal Esophagus: Prospective Study and Systematic Review on Relationships with Endoscopic Findings and Clinical Data. Dysphagia 2023; 38:629-640. [PMID: 35809096 DOI: 10.1007/s00455-022-10492-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 06/23/2022] [Indexed: 11/26/2022]
Abstract
Cervical inlet patches (CIP) are common endoscopic findings with uncertain pathogenesis and clinical significance. We aimed to perform a systematic review and prospective study of clinical data and endoscopic findings related to CIP. It was a prospective single-center study conducted between 10/01/2017 and 9/01/2018. Forty patients with histopathologically confirmed CIP were compared with 222 individuals in the reference group. The systematic review was executed in accordance with the PRISMA guideline. Alcohol consumption tended to be higher among patients with CIP (3.0 ± 4.6 vs. 1.9 ± 5.0 standard drinks/week CIP patients and reference group, respectively; p < 0.001). Dysphagia was more frequent among patients with CIP (25% vs. 1.4%, CIP patients and reference group, respectively; p < 0.001), and sore throat and hoarseness were less frequent in patients with CIP (17.5% vs. 26.6% CIP patients and reference group, respectively; p < 0.01). In the multivariate regression analysis, the only risk factor of CIP occurrence was dysphagia (OR 21.9, 95%CI 4.9-98.6; p < 0.001). Sore throat and hoarseness were a reverse-risk factor of CIP diagnosis (OR 0.3, 95%CI 0.1-0.93; p = 0.04). Clinical data and coexisting endoscopic findings were not related to CIP. In the presented study, dysphagia was related to CIP occurrence, and sore throat and hoarseness tended to be less frequent among patients with CIP.
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Affiliation(s)
- Marcin Romańczyk
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland
- Chair and Department of Gastroenterology and Hepatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Krzysztof Budzyń
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland.
- Chair and Department of Gastroenterology and Hepatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Tomasz Romańczyk
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland
- Department of Gastroenterology, Wyższa Szkoła Techniczna W Katowicach, Katowice, Poland
| | - Magdalena Lesińska
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland
- Department of Gastroenterology, Wyższa Szkoła Techniczna W Katowicach, Katowice, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Hartleb
- Chair and Department of Gastroenterology and Hepatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Marek Waluga
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland
- Chair and Department of Gastroenterology and Hepatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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Li Y, Wang L, Yang D, Zhang Z, Sun X, Geng X, Lin J, Duan Z. Esophageal chemical clearance and mucosa integrity values in refractory gastroesophageal reflux disease patients with different esophageal dynamics. Scand J Gastroenterol 2023; 58:322-330. [PMID: 36259257 DOI: 10.1080/00365521.2022.2132534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Esophageal post-reflux swallow-induced peristaltic wave index (PSPWI) and mean nocturnal baseline impedance (MNBI), novel impedance-based markers of reflux burden, are associated with esophageal dynamics. We aim to investigate the characteristics of PSPWI and MNBI in Chinese refractory gastroesophageal reflux disease (RGERD) patients with different esophageal dynamic changes. MATERIALS AND METHODS 201 RGERD and 76 functional heartburn patients, undergone off-PPI endoscopy, esophageal manometry and impedance-pH monitoring, were included. Comparisons of conventional and novel impedance-pH metrics were made among different esophageal dynamics groups. Receiver operating-characteristic analyses were utilized to evaluate the diagnostic efficacy of PSPWI and MNBI in differentiating abnormal esophageal dynamics. Correlations were used to investigate their associated factors. RESULTS PSPWI and MNBI of RGERD with esophagogastric junction (EGJ) injury and esophageal dysmotility were lower than EGJ injury alone or normal dynamics (p < 0.05 for both comparisons). PSPWI with esophageal peristalsis abnormality was lower than EGJ injury (p = 0.049), while MNBI showed no statistical difference. PSPWI, MNBI and their combination have auxiliary diagnostic values for esophageal peristalsis [area under the curves (AUCs): 0.683, 0.656, 0.708)] while only their combination for EGJ injury (AUC: 0.610). And they positively correlated with esophageal motility while negatively correlated with ineffective swallows and acid reflux events. CONCLUSIONS PSPWI and MNBI, indicating impairment of esophageal chemical clearance and mucosa integrity, were lower in RGERD patients with multiple esophageal dynamic injuries than single injuries or normal dynamics. Moreover, they provided useful contributing information for potential dynamic injuries if manometry has already been found normal or marginal.
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Affiliation(s)
- Yanqiu Li
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lixia Wang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dong Yang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhifeng Zhang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoyu Sun
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoling Geng
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiarong Lin
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhijun Duan
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Poovipirom N, Ratta-Apha W, Maneerattanaporn M, Geeratragool T, Chuenprapai P, Leelakusolvong S. Treatment outcomes in patients with globus: A randomized control trial of psychoeducation, neuromodulators, and proton pump inhibitors. Neurogastroenterol Motil 2023; 35:e14500. [PMID: 36443929 DOI: 10.1111/nmo.14500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Globus is a persistent or intermittent nonpainful sensation of a lump or foreign body, which markedly affect patient's quality of life. Treatment options for globus are limited and unsatisfying. This study aims to compare the effects of cognitive-behavioral-theory-based psychoeducation (CBT), neuromodulators (NMD), and proton pump inhibitor (PPI) on treatment outcomes in patients with globus. METHODS Eligible patients were randomly received CBT, 0.5 mg flupenthixol and 10 mg melitracen; NMD, or omeprazole 20 mg; PPI, for 4 weeks. The primary endpoint was the reduction in symptom scores; Glasgow Edinburgh Throat Scale (GETS). The secondary endpoints included treatment efficacy on Reflux Symptom Index (RSI), Hospital Anxiety Depression Scale (HADS), and quality of life (QoL) based on a 36-item short-form health survey (SF-36). Treatment compliance and adverse effects were recorded. KEY RESULTS Forty patients were completed study. Baseline characteristics between the groups were comparable. By the end of treatment, both CBT and NMD provided greater reduction in GETS than PPI (CBT vs PPI; 6.46 ± 8.56 vs 0.21 ± 5.42; p = 0.031, NMD vs PPI; 6.92 ± 9.85 vs 0.21 ± 5.42; p = 0.036). The improvement of RSI, HADS, and SF-36 among the groups was similar. Neuromodulators caused more adverse events. CONCLUSIONS & INFERENCES Both CBT and NMD provided equally effective treatment and better than PPI in patients with globus determined by the reduction in GETS. The improvement in RSI, HADS, and QoL of the three groups was not different. Given less of adverse effect than NMD, CBT should be considered as a substantial treatment.
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Affiliation(s)
- Natthanan Poovipirom
- Division of Gastroenterology, Department of Internal Medicine Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Woraphat Ratta-Apha
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Monthira Maneerattanaporn
- Division of Gastroenterology, Department of Internal Medicine Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tanawat Geeratragool
- Division of Gastroenterology, Department of Internal Medicine Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pritsana Chuenprapai
- Division of Gastroenterology, Department of Internal Medicine Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Somchai Leelakusolvong
- Division of Gastroenterology, Department of Internal Medicine Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Atkins M, Burton Murray H, Staller K. Assessment and management of disorders of gut-brain interaction in patients with eating disorders. J Eat Disord 2023; 11:20. [PMID: 36782302 PMCID: PMC9926752 DOI: 10.1186/s40337-022-00731-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/28/2022] [Indexed: 02/15/2023] Open
Abstract
Disorders of gut-brain interaction (DBGI), also known as functional gastrointestinal disorders, are common in individuals with eating disorders, and may precede or perpetuate disordered eating. Understanding the pathophysiology of common gastrointestinal symptoms in DGBI can be important for the care of many patients with eating disorders. In this review, we summarize the literature to date on the complex relationship between DBGI and eating disorders and provide guidance on the assessment and management of the most common symptoms of DBGI by anatomic region: esophageal symptoms (globus and functional dysphagia), gastroduodenal symptoms (functional dyspepsia and nausea), and bowel symptoms (abdominal pain, bloating and constipation).
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Affiliation(s)
- Micaela Atkins
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA. .,Division of Gastroenterology, Center for Neurointestinal Health, Massachusetts General Hospital, 55 Fruit Street, Wang 5, Boston, MA, 02114, USA.
| | - Helen Burton Murray
- Division of Gastroenterology, Center for Neurointestinal Health, Massachusetts General Hospital, 55 Fruit Street, Wang 5, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, 02215, USA
| | - Kyle Staller
- Division of Gastroenterology, Center for Neurointestinal Health, Massachusetts General Hospital, 55 Fruit Street, Wang 5, Boston, MA, 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
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