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Marchetti L, Rogers BD, Hengehold T, Sifrim D, Gyawali CP. Saliva Production and Esophageal Motility Influence Esophageal Acid Clearance Related to Post-reflux Swallow-Induced Peristaltic Wave. Dig Dis Sci 2024; 69:1714-1721. [PMID: 38528208 DOI: 10.1007/s10620-024-08315-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/23/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The post-reflux swallow-induced peristaltic wave (PSPW) brings salivary bicarbonate to neutralize residual distal esophageal mucosal acidification. AIMS To determine if reduced saliva production and esophageal body hypomotility would compromise PSPW-induced pH recovery in the distal esophagus. METHODS In this multicenter retrospective cross-sectional study, patients with confirmed Sjogren's syndrome and scleroderma/mixed connective tissue disease (MCTD) who underwent high resolution manometry (HRM) and ambulatory pH-impedance monitoring off antisecretory therapy were retrospectively identified. Patients without these disorders undergoing HRM and pH-impedance monitoring for GERD symptoms were identified from the same time-period. Acid exposure time, numbers of reflux episodes and PSPW, pH recovery with PSPW, and HRM metrics were extracted. Univariate comparisons and multivariable analysis were performed to determine predictors of pH recovery with PSPW. RESULTS Among Sjogren's syndrome (n = 34), scleroderma/MCTD (n = 14), and comparison patients with reflux symptoms (n = 96), the scleroderma/MCTD group had significantly higher AET, higher prevalence of hypomotility, lower detected reflux episodes, and very low numbers of PSPW (p ≤ 0.004 compared to other groups). There was no difference in pH-impedance metrics between Sjogren's syndrome, and comparison patients (p ≥ 0.481). Proportions with complete pH recovery with PSPW was lower in Sjogren's patients compared to comparison reflux patients (p = 0.009), predominantly in subsets with hypomotility (p < 0.001). On multivariable analysis, diagnosis of Sjogren's syndrome, scleroderma/MCTD or neither (p = 0.014) and esophageal hypomotility (p = 0.024) independently predicted lack of complete pH recovery with PSPW, while higher total reflux episodes trended (p = 0.051). CONCLUSIONS Saliva production and motor function are both important in PSPW related pH recovery.
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Affiliation(s)
- Lorenzo Marchetti
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Rome, Italy
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave.,, Campus Box 8124, Saint Louis, MO, 63110, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
| | - Tricia Hengehold
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave.,, Campus Box 8124, Saint Louis, MO, 63110, USA
- Division of Gastroenterology, Ohio State University, Columbus, OH, USA
| | - Daniel Sifrim
- Wingate Institute, Queen Mary University of London, London, UK
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave.,, Campus Box 8124, Saint Louis, MO, 63110, USA.
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Marshall-Webb M, Myers JC, Watson DI, Bright T, Omari TI, Thompson SK. Mucosal impedance as a diagnostic tool for gastroesophageal reflux disease: an update for clinicians. Dis Esophagus 2024:doae037. [PMID: 38670809 DOI: 10.1093/dote/doae037] [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: 11/24/2023] [Revised: 03/27/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024]
Abstract
Mucosal impedance is a marker of esophageal mucosal integrity and a novel technique for assessing esophageal function and pathology. This article highlights its development and clinical application for gastroesophageal reflux disease (GERD), Barrett's esophagus, and eosinophilic esophagitis. A narrative review of key publications describing the development and use of mucosal impedance in clinical practice was conducted. A low mean nocturnal baseline impedance (MNBI) has been shown to be an independent predictor of response to anti-reflux therapy. MNBI predicts medication-responsive heartburn better than distal esophageal acid exposure time. Patients with equivocal evidence of GERD using conventional methods, with a low MNBI, had an improvement in symptoms following the initiation of PPI therapy compared to those with a normal MNBI. A similar trend was seen in a post fundoplication cohort. Strong clinical utility for the use of mucosal impedance in assessing eosinophilic esophagitis has been repeatedly demonstrated; however, there is minimal direction for application in Barrett's esophagus. The authors conclude that mucosal impedance has potential clinical utility for the assessment and diagnosis of GERD, particularly when conventional investigations have yielded equivocal results.
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Affiliation(s)
- Matthew Marshall-Webb
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Jennifer C Myers
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - David I Watson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Tim Bright
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Taher I Omari
- Human Physiology and Centre for Neuroscience, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Sarah K Thompson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Argüero J, Sifrim D. Pathophysiology of gastro-oesophageal reflux disease: implications for diagnosis and management. Nat Rev Gastroenterol Hepatol 2024; 21:282-293. [PMID: 38177402 DOI: 10.1038/s41575-023-00883-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/06/2024]
Abstract
Gastro-oesophageal reflux disease (GERD) is a common gastrointestinal disorder in which retrograde flow of gastric content into the oesophagus causes uncomfortable symptoms and/or complications. It has a multifactorial and partially understood pathophysiology. GERD starts in the stomach, where the refluxate material is produced. Following the trajectory of reflux, the failure of the antireflux barrier, primarily the lower oesophageal sphincter and the crural diaphragm, enables the refluxate to reach the oesophageal lumen, triggering oesophageal or extra-oesophageal symptoms. Reflux clearance mechanisms such as primary and secondary peristalsis and the arrival of bicarbonate-rich saliva are critical to prevent mucosal damage. Alterations of the oesophageal mucosal integrity, such as macroscopic oesophagitis or microscopic changes, determine the perception of symptoms. The intensity of the symptoms is affected by peripheral and central neural and psychological mechanisms. In this Review, we describe an updated understanding of the complex and multifactorial pathophysiology of GERD. It is now recognized that different GERD phenotypes have different degrees of reflux, severity of mucosal integrity damage and type, and severity of symptoms. These variations are probably due to the occurrence of a predominant pathophysiological mechanism in each patient. We also describe the main pathophysiological mechanisms of GERD and their implications for personalized diagnosis and management.
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Affiliation(s)
- Julieta Argüero
- Neurogastroenterology section of Gastroenterology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK.
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Krause AJ, Greytak M, Kessler M, Yadlapati R. Pilot study evaluating salivary bile acids as a diagnostic biomarker of laryngopharyngeal reflux. Dis Esophagus 2024:doae021. [PMID: 38525936 DOI: 10.1093/dote/doae021] [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: 12/06/2023] [Revised: 02/16/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024]
Abstract
Bile acids in refluxate contribute to esophageal and laryngeal symptoms and are quantifiable. The aim of this study was to compare salivary bile acid concentrations across healthy controls and symptomatic patients (esophageal or laryngeal) with or without objective gastroesophageal reflux disease (GERD). This prospective study enrolled adults into three groups: esophageal symptoms (heartburn, regurgitation, chest pain); laryngeal symptoms (cough, throat clearing, sore throat, dysphonia); and controls. Symptomatic patients primarily underwent prolonged wireless reflux monitoring off acid suppression and were categorized as symptomatic no GERD (acid exposure time <4%) or esophageal/laryngeal symptoms with GERD (acid exposure time ≥4%). Controls did not undergo reflux monitoring nor upper endoscopy. Saliva samples were provided for bile acid analysis via ultraperformance liquid chromatography tandem mass spectrometry. Thirty-five participants were enrolled (mean age 47.4 years [SD 18.9], 16 [46%] male), including 10 controls and 25 symptomatic: 9 no GERD, 5 esophageal symptoms + GERD, and 11 laryngeal symptoms + GERD. Total salivary bile acids were highest in the laryngeal symptoms + GERD group (24.2 nM [SD 24.7]) compared to other groups (controls: 5.8 [6.0], P = 0.03; symptomatic no GERD: 3.1 [4.4]; P < 0.01; esophageal symptoms + GERD: 7.1 [7.1], P = 0.10). Bile acids were elevated in 45% (5/11) of the laryngeal symptoms + GERD group compared to 0% of the other three groups (P < 0.01). Salivary bile acids were higher among patients with laryngeal symptoms and objective GERD versus other groups. Salivary bile acids are a quantifiable biomarker with diagnostic potential for laryngopharyngeal reflux.
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Affiliation(s)
- Amanda J Krause
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
| | - Madeline Greytak
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
| | - Marco Kessler
- Clinical Development Department, Ironwood Pharmaceuticals, Boston, MA, USA
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
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Krause AJ, Yadlapati R. Review article: Diagnosis and management of laryngopharyngeal reflux. Aliment Pharmacol Ther 2024; 59:616-631. [PMID: 38192086 PMCID: PMC10997336 DOI: 10.1111/apt.17858] [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: 10/17/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Laryngopharyngeal reflux has classically referred to gastroesophageal reflux leading to chronic laryngeal symptoms such as throat clearing, dysphonia, cough, globus sensation, sore throat or mucus in the throat. Current lack of clear diagnostic criteria significantly impairs practitioners' ability to identify and manage laryngopharyngeal reflux. AIMS To discuss current evidence-based diagnostic and management strategies in patients with laryngopharyngeal reflux. METHODS We selected studies primarily based on current guidelines for gastroesophageal reflux disease and laryngopharyngeal reflux, and through PubMed searches. RESULTS We assess the current diagnostic modalities that can be used to determine if laryngopharyngeal reflux is the cause of a patient's laryngeal symptoms, as well as review some of the common treatments that have been used for these patients. In addition, we note that the lack of a clear diagnostic gold-standard, as well as specific diagnostic criteria, significantly limit clinicians' ability to determine adequate therapies for these patients. Finally, we identify areas of future research that are needed to better manage these patients. CONCLUSIONS Patients with chronic laryngeal symptoms are complex due to the heterogenous nature of symptom pathology, inconsistent definitions and variable response to therapies. Further outcomes data are critically needed to help elucidate ideal diagnostic workup and therapeutic management for these challenging patients.
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Affiliation(s)
- Amanda J Krause
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
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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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7
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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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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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Dasarathy D, Vaezi M, Patel D. Optimizing ambulatory reflux monitoring: current findings and future directions. Expert Rev Gastroenterol Hepatol 2024; 18:13-24. [PMID: 38145413 DOI: 10.1080/17474124.2023.2297919] [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: 08/29/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is the most common diagnosis seen in outpatient gastroenterology clinics. The diagnosis is made by a variable combination of symptoms, response to acid suppressive therapy, endoscopic evaluation, and pH testing. In this review, we evaluate how to utilize various reflux testing in clinical practice based on current evidence. AREAS COVERED Ambulatory reflux monitoring is a recognized diagnostic tool for clinical decision making in patients with/without established GERD, persistent reflux symptoms, and lack of response to proton pump inhibitor (PPI) therapy. Standard evaluation approaches include 24-hour pH or impedance monitoring via transnasal catheter, prolonged (48 to 96 hour) wireless pH monitoring, and the recently developed mucosal integrity testing. Testing using one of these methods allows for measurement of acid exposure, frequency of reflux, and to phenotype patients to personalize treatment recommendations. EXPERT OPINION The primary goal of future studies should be to simplify ambulatory reflux monitoring, reduce diagnostic latency, improve patient tolerance, and to obtain clinical outcomes-based studies. The current paradigm of reflux testing is vastly complex with multiple modalities and shifting cutoffs of pH abnormality that lead to high economic burden on the society.
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Affiliation(s)
- Dhweeja Dasarathy
- School of Medicine, and Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Vaezi
- School of Medicine, and Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dhyanesh Patel
- School of Medicine, and Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
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Valdovinos Díaz MA, Amieva-Balmori M, Carmona-Sánchez R, Coss-Adame E, Gómez-Escudero O, González-Martínez M, Huerta-Iga F, Morel-Cerda E, Remes-Troche JM, Tamayo-de la Cuesta JL, Torres-Villalobos G, Valdovinos-García LR, Vázquez-Elizondo G, Villar-Chávez AS, Arenas-Martínez JA. Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:121-143. [PMID: 38580493 DOI: 10.1016/j.rgmxen.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/06/2023] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment. AIM The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD. METHODS The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires. RESULTS Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient. CONCLUSIONS An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.
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Affiliation(s)
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Intestinal, Instituto de Investigaciones Médico-Biológicas de la Universidad Veracruzana, Veracruz, Mexico
| | - R Carmona-Sánchez
- Servicio de Gastroenterología, Práctica privada, San Luis Potosí, Mexico
| | - E Coss-Adame
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia y Motilidad Gastrointestinal, Endoneurogastro, Hospital Ángeles Puebla, Puebla, Mexico
| | - M González-Martínez
- Departamento de Endoscopia, Hospital de Especialidades del CMN Siglo XXI IMSS, Mexico City, Mexico
| | - F Huerta-Iga
- Servicio de Gastroenterología, Hospital Ángeles Torreón, Torreón, Mexico
| | - E Morel-Cerda
- Departamento de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Intestinal, Instituto de Investigaciones Médico-Biológicas de la Universidad Veracruzana, Veracruz, Mexico
| | - J L Tamayo-de la Cuesta
- Servicio de Gastroenterología y Endoscopia Gastrointestinal, Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | - G Torres-Villalobos
- Cirugía Experimental, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - G Vázquez-Elizondo
- Servicio de Gastroenterología, Centro de Enfermedades Digestivas ONCARE, Monterrey, Mexico
| | - A S Villar-Chávez
- Servicio de Gastroenterología, Hospital Ángeles Acoxpa, Mexico City, Mexico
| | - J A Arenas-Martínez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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11
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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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12
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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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13
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Mari A, Marabotto E, Ribolsi M, Zingone F, Barberio B, Savarino V, Savarino EV. Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future. Expert Rev Clin Pharmacol 2023; 16:913-923. [PMID: 37632213 DOI: 10.1080/17512433.2023.2252327] [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: 07/09/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 08/27/2023]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) have revolutionized the management of acid-related disorders, representing today the mainstay treatment of these conditions. However, despite their large range of indications and usefulness, the remarkable expansion of their use in the last two decades cannot be explained by the increasing prevalence of acid-related diseases only. An inappropriate prescription for clinical conditions in which the pathogenetic role of acid has not been documented has been described, with the natural consequence of increasing the costs and the potential risk of iatrogenic harm due to adverse events and complications recently emerged. AREAS COVERED In this review, we summarize current indications of PPIs administration, potential adverse events associated with their chronic utilization, and misuse of PPIs. Moreover, we describe existing and possible initiatives for improving the use of PPIs, and some proposals for the future. EXPERT OPINION PPI deprescribing is the preferred and most effective approach to reduce the use of PPIs, rather than adopting sharp discontinuation, probably due to fewer withdrawal symptoms. Nonetheless, large knowledge gaps still exist in clinical practice regarding the optimal approach of PPI deprescribing in various clinical scenarios. Further prospective well-designed international studies are eagerly warranted to improve our perspectives on controlling global PPI inappropriate use.
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Affiliation(s)
- Amir Mari
- Gastroenterology Unit, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar Ilan University, Nazareth, Israel
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Mentore Ribolsi
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Rome, Italy
| | - Fabiana Zingone
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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14
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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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15
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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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16
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Frazzoni M, Frazzoni L, Ribolsi M, Russo S, Conigliaro R, De Bortoli N, Savarino E. On-therapy impedance-pH monitoring can efficiently characterize PPI-refractory GERD and support treatment escalation. Neurogastroenterol Motil 2023; 35:e14547. [PMID: 36780512 DOI: 10.1111/nmo.14547] [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: 11/09/2022] [Revised: 01/10/2023] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND On-therapy impedance-pH monitoring is recommended in patients with documented GERD and PPI-refractory heartburn in order to establish whether the unremitting symptom is reflux-related or not. AIMS To define on-PPI cut-offs of impedance-pH metrics allowing proper interpretation of on-therapy impedance-pH monitoring. METHODS Blinded expert review of impedance-pH tracings performed during double-dosage PPI, prospectively collected from 150 GERD patients with PPI-refractory heartburn and 45 GERD patients with PPI-responsive heartburn but persisting extra-esophageal symptoms. Acid exposure time (AET), number of total refluxes (TRs), post-reflux swallow-induced peristaltic wave (PSPW) index, and mean nocturnal baseline impedance (MNBI) were assessed. On-PPI cut-offs were defined and evaluated with ROC analysis and the area under curve (AUC). RESULTS All the four impedance-pH metrics significantly differed between PPI-refractory and PPI-responsive heartburn cases. At ROC analysis, AUC was 0.73 for AET, 0.75 for TRs, 0.81 for PSPW index, and 0.71 for MNBI; best cut-offs were ≥1.7% for AET, ≥45 for TRs, ≤36% for PSPW index, and ≤ 1847 Ω for MNBI; AUC of such cut-offs was 0.66, 0.71, 0.73, and 0.68, respectively. Analysis of PSPW index and MNBI added to assessment of AET and TRs significantly increased the yield of on-therapy impedance-pH monitoring in the PPI-refractory cohort (97% vs. 83%, p < 0.0001). Notably, suboptimal acid suppression as shown by AET ≥1.7% was detected in 43% of 150 PPI-refractory cases. CONCLUSIONS We have defined on-PPI cut-offs of impedance-pH metrics by which comprehensive assessment of impedance-pH tracings, including analysis of PSPW index and MNBI can efficiently characterize PPI-refractory GERD and support treatment escalation.
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Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Mentore Ribolsi
- Dipartimento di Medicina e Chirurgia, Digestive Disease, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Salvatore Russo
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Rita Conigliaro
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Nicola De Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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17
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Sawada A, Rogers B, Visaggi P, de Bortoli N, Gyawali CP, Sifrim D. Effect of hiatus hernia on reflux patterns and mucosal integrity in patients with non-erosive reflux disease. Neurogastroenterol Motil 2022; 34:e14412. [PMID: 35593218 DOI: 10.1111/nmo.14412] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hiatus hernia (HH) contributes to development of gastroesophageal reflux disease, Barrett's esophagus and esophageal adenocarcinoma. This study was aimed to investigate the influence of HH on reflux patterns and distal esophageal mucosal integrity in non-erosive reflux disease (NERD). METHODS We retrospectively analyzed PPI-refractory NERD patients referred to three tertiary referral centers who underwent high-resolution manometry and off-PPI 24-h impedance-pH monitoring (with or without bile spectrophotometry). Patients with HH ≥2 cm (HH group, n = 42) or no HH (non-HH group, n = 40) with similar esophageal acid exposure time (AET 6%-12%) were included. KEY RESULTS Age, gender, BMI, esophageal motility, AET, and esophageal clearance were similar between the two groups. The HH group had higher numbers of total reflux episodes (p = 0.015) with similar proportion of acid/non-acid reflux compared with the non-HH group. Mean nocturnal baseline impedance (MNBI) in the distal esophagus was significantly lower in the HH group than the non-HH group at both 5 cm (p = 0.002) and 3 cm (p = 0.015) above the lower esophageal sphincter. Multivariable regression analysis showed that HH, less non-acid reflux and lower post-reflux swallow-induced peristaltic wave index (PSPWI) were independently associated with lower MNBI. Among 31 patients tested with bile spectrophotometry, the HH group had significantly longer bile exposure time than the non-HH group (p = 0.011), and bile reflux inversely and significantly correlated with MNBI (rho = -0.75, p < 0.001). CONCLUSIONS AND INFERENCES Hiatus hernia, less non-acid reflux and lower PSPWI were associated with lower MNBI. HH impairs distal esophageal mucosal integrity, the mechanism of which we speculate to be through excessive bile reflux.
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Affiliation(s)
- Akinari Sawada
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Benjamin Rogers
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA.,Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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18
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Yadlapati R, Gawron AJ, Pandolfino JE. Editorial: wireless pH-monitoring - is it time to put away the pH-impredance catheters: Authors' response. Aliment Pharmacol Ther 2022; 56:1298-1299. [PMID: 36168266 PMCID: PMC10760798 DOI: 10.1111/apt.17218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
LINKED CONTENTThis article is linked to Yadlapati et al papers. To view these articles, visit https://doi.org/10.1111/apt.17180 and https://doi.org/10.1111/apt.17204
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
| | | | - John E. Pandolfino
- Division of Gastroenterology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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19
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Yadlapati R, Gyawali CP, Masihi M, Carlson DA, Kahrilas PJ, Nix BD, Jain A, Triggs JR, Vaezi MF, Kia L, Kaizer A, Pandolfino JE. Optimal Wireless Reflux Monitoring Metrics to Predict Discontinuation of Proton Pump Inhibitor Therapy. Am J Gastroenterol 2022; 117:1573-1582. [PMID: 35973148 PMCID: PMC9532366 DOI: 10.14309/ajg.0000000000001871] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/08/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Ambulatory reflux monitoring performed off proton pump inhibitor (PPI) is the gold standard diagnostic test for nonerosive gastroesophageal reflux disease (GERD). However, the diagnostic metrics and optimal duration of monitoring are not well defined. This study evaluated the performance of multiple metrics across distinct durations of wireless reflux monitoring off PPI against the ability to discontinue PPI therapy in patients with suboptimal PPI response. METHODS This single-arm clinical trial performed over 4 years at 2 centers enrolled adults with troublesome GERD symptoms and inadequate response to > 8 weeks of PPI. Participants underwent 96-hour wireless pH monitoring off PPI. Primary outcome was whether the subject successfully discontinued PPI or resumed PPI within 3 weeks. RESULTS Of 132 participants, 30% discontinued PPI. Among multiple metrics assessed, total acid exposure time (AET) of 4.0% performed best in predicting PPI discontinuation (odds ratio 2.9 [95% confidence interval 1.4, 6.4]; P = 0.006), with other thresholds of AET and DeMeester score performing comparably. AET was significantly higher on day 1 of monitoring compared with other days, and prognostic performance significantly declined when only assessing the first 48 hours of monitoring (area under the curve for 96 hours 0.63 vs area under the curve for 48 hours 0.57; P = 0.01). DISCUSSION This clinical trial highlights the AET threshold of 4.0% as a high-performing prognostic marker of PPI discontinuation. 96 hours of monitoring performed better than 48 hours, in predicting ability to discontinue PPI. These data can inform current diagnostic approaches for patients with GERD symptoms who are unresponsive to PPI therapy.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego School of Medicine, La Jolla, CA, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Melina Masihi
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dustin A Carlson
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Billy Darren Nix
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Anand Jain
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph R. Triggs
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leila Kia
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alexander Kaizer
- University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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20
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Yadlapati R, Gawron AJ, Gyawali CP, Chen J, Clarke J, Fass R, Jain A, Lynch K, Khan A, Katz PO, Katzka DA, Richter J, Schnoll-Sussman F, Spechler SJ, Vaezi MF, Vela M, Pandolfino JE. Clinical role of ambulatory reflux monitoring in PPI non-responders: recommendation statements. Aliment Pharmacol Ther 2022; 56:1274-1283. [PMID: 35971888 PMCID: PMC10443620 DOI: 10.1111/apt.17180] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Optimal ambulatory reflux monitoring methodology in symptomatic reflux patients continues to be debated. AIMS To utilise published literature and expert opinion to develop recommendation statements addressing use of ambulatory reflux monitoring in clinical practice METHODS: The RAND Appropriateness Method (RAM) was utilised among 17 experts with discussion, revision and two rounds of ranking of recommendation statements. Ambulatory reflux monitoring protocol, methodology and thresholds ranked as appropriate by ≥80% of panellists met the criteria for appropriateness. RESULTS Prolonged (96-h recommended) wireless pH monitoring off proton pump inhibitor (PPI) was identified as the appropriate diagnostic tool to assess the need for acid suppression in patients with unproven gastro-oesophageal reflux disease (GERD) and persisting typical reflux symptoms despite once-daily PPI. Acid exposure time (AET) <4.0% on all days of monitoring with negative reflux-symptom association excludes GERD and does not support ongoing PPI treatment. Conversely, AET >6.0% across ≥2 days is conclusive evidence for GERD and supports treatment for GERD, while AET >10% across ≥2 days identifies severe acid burden that supports escalation of anti-reflux treatment. In previously proven GERD, impedance-pH monitoring on PPI is helpful in defining refractory GERD and mechanisms of continued symptoms; the presence of <40 reflux events, AET <2.0% and a negative reflux-symptom association does not support escalation of anti-reflux treatment. In contrast, AET > 4.0% and positive reflux-symptom association support escalation of anti-reflux treatment, including use of invasive therapeutics. CONCLUSIONS Statements meeting appropriateness for average clinical care have been identified when utilising reflux monitoring in patients with typical reflux symptoms and PPI non-response.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
| | - Andrew J. Gawron
- University of Utah, Salt Lake City, Utah, USA
- Salt Lake City VA Medical Center, Salt Lake City, Utah, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joan Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - John Clarke
- Division of Gastroenterology, Stanford University, Palo Alto, California, USA
| | - Ronnie Fass
- Division of Gastroenterology, MetroHealth System, Cleveland, Ohio, USA
| | - Anand Jain
- Division of Gastroenterology, Emory University, Atlanta, Georgia, USA
| | - Kristle Lynch
- Division of Gastroenterology & Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abraham Khan
- Center for Esophageal Health, Division of Gastroenterology & Hepatology, NYU Langone Health, New York City, New York, USA
| | - Philip O. Katz
- Division of Gastroenterology, Weill-Cornell Medical Center, New York City, New York, USA
| | - David A. Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology, Columbia Presbyterian Medical Center, New York City, New York, USA
| | - Joel Richter
- Division of Gastroenterology, University of South Florida, Tampa, Florida, USA
| | - Felice Schnoll-Sussman
- Division of Gastroenterology, Weill-Cornell Medical Center, New York City, New York, USA
| | - Stuart J. Spechler
- Division of Gastroenterology, Baylor Scott & White Health, Dallas, Texas, USA
| | - Michael F. Vaezi
- Division of Gastroenterology, Vanderbilt Medical Center, Nashville, Tennessee, USA
| | - Marcelo Vela
- Division of Gastroenterology, Mayo Clinic, Phoenix, Arizona, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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21
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Ang D, Fox M. Editorial: wireless pH-monitoring-is it time to put away the pH-impedance catheters? Aliment Pharmacol Ther 2022; 56:1296-1297. [PMID: 36168261 DOI: 10.1111/apt.17204] [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: 01/30/2023]
Affiliation(s)
- Daphne Ang
- Department of Gastroenterology, Changi General Hospital, Singapore
| | - Mark Fox
- Center for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Advancements in the use of 24-hour impedance-pH monitoring for GERD diagnosis. Curr Opin Pharmacol 2022; 65:102264. [DOI: 10.1016/j.coph.2022.102264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/01/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022]
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Frazzoni M, Frazzoni L, Ribolsi M, Bortoli ND, Tolone S, Russo S, Conigliaro R, Penagini R, Fuccio L, Zagari RM, Savarino E. Applying Lyon Consensus criteria in the work-up of patients with proton pump inhibitory-refractory heartburn. Aliment Pharmacol Ther 2022; 55:1423-1430. [PMID: 35229321 DOI: 10.1111/apt.16838] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/06/2022] [Accepted: 02/07/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND A hierarchical approach for gastro-oesophageal reflux disease (GERD) diagnosis by impedance-pH monitoring was proposed by the Lyon Consensus, based on acid exposure time (AET) and supportive impedance metrics. AIMS To establish the clinical value of Lyon Consensus criteria in the work-up of patients with proton pump inhibitory (PPI)-refractory heartburn. METHODS Expert review of off-therapy impedance-pH tracings from unproven GERD patients with PPI-refractory heartburn prospectively evaluated at referral centers. Impedance metrics, namely total reflux episodes, postreflux swallow-induced peristaltic wave index, and mean nocturnal baseline impedance, were assessed. Expert review of on-therapy preoperative impedance-pH tracings from a separate cohort of surgically treated erosive/nonerosive GERD cases. RESULTS Off-therapy, normal, inconclusive, and abnormal AET was found in 59%, 17%, and 23% of 317 cases. Supportive evidence of GERD was provided by abnormal impedance metrics in up to 22% and 62% of cases in the normal and inconclusive AET groups, respectively. Adding the cases with inconclusive AET and abnormal impedance metrics to the abnormal AET group, a significant increase in GERD evidence was observed (from 23% to 37% of cases, p < 0.0002). At the on-therapy presurgical evaluation, abnormal/inconclusive AET and supraphysiological values of impedance metrics showed ongoing reflux in 21% and 90% of 96 cases, respectively (p < 0.00001); a relationship between on-therapy ongoing reflux and PPI-refractory heartburn was confirmed by the favorable surgical outcome at 3-year follow-up, 88% of cases being in persistent off-PPI heartburn remission. CONCLUSIONS Impedance-pH monitoring, off- and on-therapy, is of high clinical value in the work-up of patients with PPI-refractory heartburn.
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Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit, Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Modena, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Mentore Ribolsi
- Digestive Disease, Università Campus Bio-Medico di Roma Facoltà Dipartimentale di Medicina e Chirurgia, Roma, Italy
| | - Nicola De Bortoli
- Department of New Technologies and Translational Research in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, Seconda Università degli Studi di Napoli Facoltà di Medicina e Chirurgia, Caserta, Italy
| | - Salvatore Russo
- Digestive Endoscopy Unit, Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Modena, Italy
| | - Rita Conigliaro
- Digestive Endoscopy Unit, Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Modena, Italy
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Rocco Maurizio Zagari
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua School of Medicine and Surgery, Padova, Italy
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Yadlapati R, Gyawali CP, Pandolfino JE. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. Clin Gastroenterol Hepatol 2022; 20:984-994.e1. [PMID: 35123084 PMCID: PMC9838103 DOI: 10.1016/j.cgh.2022.01.025] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/12/2022] [Accepted: 01/20/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS As many as one-half of all patients with suspected gastroesophageal reflux disease (GERD) do not derive benefit from acid suppression. This review outlines a personalized diagnostic and therapeutic approach to GERD symptoms. METHODS The Best Practice Advice statements presented here were developed from expert review of existing literature combined with extensive discussion and expert opinion to provide practical advice. Formal rating of the quality of evidence or strength of recommendations was not the intent of this clinical practice update. BEST PRACTICE ADVICE 1: Clinicians should develop a care plan for investigation of symptoms suggestive of GERD, selection of therapy (with explanation of potential risks and benefits), and long-term management, including possible de-escalation, in a shared-decision making model with the patient. BEST PRACTICE ADVICE 2: Clinicians should provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors, relaxation strategies, and awareness about the brain-gut axis relationship to patients with reflux symptoms. BEST PRACTICE ADVICE 3: Clinicians should emphasize safety of proton pump inhibitors (PPIs) for the treatment of GERD. BEST PRACTICE ADVICE 4: Clinicians should provide patients presenting with troublesome heartburn, regurgitation, and/or non-cardiac chest pain without alarm symptoms a 4- to 8-week trial of single-dose PPI therapy. With inadequate response, dosing can be increased to twice a day or switched to a more effective acid suppressive agent once a day. When there is adequate response, PPI should be tapered to the lowest effective dose. BEST PRACTICE ADVICE 5: If PPI therapy is continued in a patient with unproven GERD, clinicians should evaluate the appropriateness and dosing within 12 months after initiation, and offer endoscopy with prolonged wireless reflux monitoring off PPI therapy to establish appropriateness of long-term PPI therapy. BEST PRACTICE ADVICE 6: If troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy and, in the absence of erosive reflux disease (Los Angeles B or greater) or long-segment (≥3 cm) Barrett's esophagus, perform prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or to rule out GERD. BEST PRACTICE ADVICE 7: Complete endoscopic evaluation of GERD symptoms includes inspection for erosive esophagitis (graded according to the Los Angeles classification when present), diaphragmatic hiatus (Hill grade of flap valve), axial hiatus hernia length, and inspection for Barrett's esophagus (graded according to the Prague classification and biopsied when present). BEST PRACTICE ADVICE 8: Clinicians should perform upfront objective reflux testing off medication (rather than an empiric PPI trial) in patients with isolated extra-esophageal symptoms and suspicion for reflux etiology. BEST PRACTICE ADVICE 9: In symptomatic patients with proven GERD, clinicians should consider ambulatory 24-hour pH-impedance monitoring on PPI as an option to determine the mechanism of persisting esophageal symptoms despite therapy (if adequate expertise exists for interpretation). BEST PRACTICE ADVICE 10: Clinicians should personalize adjunctive pharmacotherapy to the GERD phenotype, in contrast to empiric use of these agents. Adjunctive agents include alginate antacids for breakthrough symptoms, nighttime H2 receptor antagonists for nocturnal symptoms, baclofen for regurgitation or belch predominant symptoms, and prokinetics for coexistent gastroparesis. BEST PRACTICE ADVICE 11: Clinicians should provide pharmacologic neuromodulation, and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies in patients with functional heartburn or reflux disease associated with esophageal hypervigilance reflux hypersensitivity and/or behavioral disorders. BEST PRACTICE ADVICE 12: In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients. BEST PRACTICE ADVICE 13: In patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients, and a salvage option in non-obese patients, whereas sleeve gastrectomy has potential to worsen GERD. BEST PRACTICE ADVICE 14: Candidacy for invasive anti-reflux procedures includes confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla, California
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Visaggi P, Mariani L, Svizzero FB, Tarducci L, Sostilio A, Frazzoni M, Tolone S, Penagini R, Frazzoni L, Ceccarelli L, Savarino V, Bellini M, Gyawali PC, Savarino EV, de Bortoli N. Clinical use of mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index for the diagnosis of gastro-esophageal reflux disease. Esophagus 2022; 19:525-534. [PMID: 35768671 PMCID: PMC9436885 DOI: 10.1007/s10388-022-00933-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/07/2022] [Indexed: 02/03/2023]
Abstract
The clinical diagnosis of gastro-esophageal reflux disease (GERD) is based on the presence of typical esophageal troublesome symptoms. In clinical practice, heartburn relief following a proton pump inhibitor (PPI) trial or endoscopy can confirm a diagnosis of GERD. In cases of diagnostic uncertainty or before anti-reflux interventions, combined impedance-pH monitoring (MII-pH) provides a comprehensive assessment of both physical and chemical properties of the refluxate, allowing to achieve a conclusive diagnosis of GERD. Recently, the Lyon Consensus proposed the use of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPW-I) as novel MII-pH metrics to support the diagnosis of GERD. The calculation of MNBI and PSPW-I currently needs to be performed manually, but artificial intelligence systems for the automated analysis of MII-pH tracings are being developed. Several studies demonstrated the increased diagnostic yield MNBI and PSPW-I for the categorization of patients with GERD at both on- and off-PPI MII-pH monitoring. Accordingly, we performed a narrative review on the clinical use and diagnostic yield of MNBI and PSPW-I when the diagnosis of GERD is uncertain. Based on currently available evidence, we strongly support the evaluation of PSPW-I and MNBI as part of the standard assessment of MII-pH tracings for the evaluation of GERD, especially in patients with endoscopy-negative heartburn.
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Affiliation(s)
- Pierfrancesco Visaggi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Lucia Mariani
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Federica Baiano Svizzero
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Luca Tarducci
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Andrea Sostilio
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, University of Caserta Luigi Vanvitelli, Caserta, Italy
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Linda Ceccarelli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine "DiMI", University of Genoa, Genoa, Italy
| | - Massimo Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Prakash C Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA
| | - Edoardo V Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy.
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