Symptom severity and oesophageal chemosensitivity to acid in older and young patients with gastro-oesophageal reflux

Mucosal integrity and acid sensitivity predict proton pump inhibitor response in patients with heartburn and normal acid exposure

BACKGROUND

Patients with typical reflux symptoms and normal acid exposure time (AET) are classified as either reflux hypersensitivity (RH) or functional heartburn (FH), some of whom respond to proton pump inhibitors (PPIs). We determined if esophageal psychophysiological parameters predict PPI response in symptomatic RH and FH patients.

METHODS

We prospectively recruited adults with heartburn diagnosed with RH or FH on 24-h impedance-pH monitoring off PPI. Mucosal integrity was evaluated using mean nocturnal baseline impedance (MNBI). Symptom response required ≥50 % reduction in global symptom severity. Infusion of hydrochloric acid (0.1 N) into the mid-esophagus evaluated acid sensitivity, using time to initial typical symptom perception (lag time) and intensity rating. Factors influencing PPI response were identified using logistic regression.

RESULTS

Of 102 study participants (age 21-64 years, 69.6 % women, 54 RH, 48 FH), 37.3 % demonstrated PPI response (RH: 44.4 %, FH: 29.2 %, p = NS). On multivariable logistic regression, lower MNBI correlated with PPI response in both RH and FH, shorter lag time also correlated in RH. The optimal MNBI threshold for predicting PPI response was 2500 ohms.

CONCLUSIONS

Lower MNBI indicating mucosal acid damage, and esophageal acid sensitivity prompting early symptom reporting are physiomarkers of PPIs response in RH and FH patients.

Ziverel for PPI-refractory reflux symptoms: efficacy and mechanisms of action in humans

OBJECTIVES

It is thought that esophageal hypersensitivity in combination with an impaired mucosal barrier function contributes to PPI-resistant reflux symptoms. Ziverel, a bioadhesive agent that coats the esophageal wall, was shown to have a positive effect on reflux symptoms. However, the mechanisms of action are unclear. We aimed to assess the effect of Ziverel on esophageal sensitivity to acid and mucosal barrier function.

METHODS

We performed a double-blind randomized placebo-controlled crossover trial in PPI-refractory patients with reflux symptoms. Patients were assigned (1:1) to 14 days of Ziverel followed by 14 days of placebo or opposite treatment order. The effect was evaluated using acid perfusion tests, an upper endoscopy with electrical tissue impedance spectroscopy (ETIS) and esophageal biopsies. The primary outcome was the esophageal sensitivity based on perfusion sensitivity score. Secondary outcomes included mucosal barrier function and reflux symptoms and correlations between the different outcomes.

RESULTS

Perfusion sensitivity score was not significantly different during treatment with Ziverel (106 (73-115)) and placebo (102 (67-110)) (p = 0.508) along with total RDQ score (2.6 (1.9-3.3) vs 2.8 (1.6-3.5) p = 0.456). ETIS showed comparable values during treatment with Ziverel (13514 (8846-19734)Ω·m) and placebo (13217 (9127-24942)Ω·m (p = 0.650)). Comparing Ziverel and placebo no difference was seen in transepithelial electrical resistance (TEER) 203 (163-267) Ω.cm2 vs 205 (176-240) Ω.cm2 (p = 0.445) and fluorescein flux 775 (17-6964) nmol/cm2/h vs 187 (4-12209) nmol/cm2/h (p = 0.638).

CONCLUSION

Ziverel did not show a benefit on acid sensitivity, reflux symptoms or esophageal mucosal integrity compared to placebo in PPI-refractory patients with reflux symptoms.Trial registration: Netherlands Trial Register number: NL7670.

The Effect of STW5 (Iberogast) on Reflux Symptoms in Patients With Concurrent Dyspeptic Symptoms: A Double-blind Randomized Placebo-controlled Crossover Trial

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.

Elucidating the Link: Chronic Obstructive Pulmonary Disease and the Complex Interplay of Gastroesophageal Reflux Disease and Reflux-Related Complications

Background and Objective: Presenting chronic obstructive pulmonary disease (COPD) patients frequently report concurrent symptoms of gastroesophageal reflux disease (GERD). Few studies have shown a correlation between GERD and COPD. We aimed to examine the correlation between GERD and COPD as well as secondary related reflux complications, such as esophageal stricture, esophageal cancer, and Barrett's esophagus. Methods: This population-based analysis included 7,159,694 patients. Patients diagnosed with GERD with and without COPD were compared to those without GERD. The enrollment of COPD included centrilobular and panlobular emphysema and chronic bronchitis. Risk factors of COPD or GERD were used for adjustment. Bivariate analyses were performed using the chi-squared test or Fisher exact test (2-tailed) for categorical variables as appropriate to assess the differences in the groups. Results: Our results showed that COPD patients had a significantly higher incidence of GERD compared to those without COPD (27.8% vs. 14.1%, p < 0.01). After adjustment of demographics and risk factors, COPD patients had a 1.407 times higher risk of developing non-erosive esophagitis (p < 0.01), 1.165 higher risk of erosive esophagitis (p < 0.01), 1.399 times higher risk of esophageal stricture (p < 0.01), 1.354 times higher risk of Barrett's esophagus without dysplasia (p < 0.01), 1.327 times higher risk of Barrett's esophagus with dysplasia, as well as 1.235 times higher risk of esophageal cancer than those without COPD. Conclusions: Based on the evidence from this study, there are sufficient data to provide convincing evidence of an association between COPD and GERD and its secondary reflux-related complications.

Esophageal secondary peristalsis following acid infusion and chemical clearance correlate with mucosal integrity and acid sensitivity in GERD patients

Background

Acid sensitivity can be altered in patients with gastroesophageal reflux disease (GERD). Secondary peristalsis helps clear gastro-esophageal refluxate and residual ingested food bolus.

Objectives

The aim of this study was to investigate the associations among acid sensitivity, esophageal mucosal integrity, chemical clearance, and secondary peristalsis before and after esophageal acid infusion.

Design

This was an investigator-initiated, prospective, cross-sectional study.

Methods

Adult reflux patients underwent high resolution manometry and 24 h impedance-pH monitoring off acid suppression to identify GERD phenotypes, including non-erosive reflux disease (NERD), reflux hypersensitivity (RH), and functional heartburn (FH). Secondary peristalsis was assessed using five rapid 20 mL air injections into the esophagus before and after infusion of hydrochloric acid (0.1 N) into the mid-esophagus. Conventional acid infusion parameters recorded included lag time, intensity rating, and sensitivity score. Chemical clearance was evaluated using the post-reflux swallow-induced peristaltic wave (PSPW), and mucosal integrity was assessed by the mean nocturnal baseline impedance (MNBI) derived from impedance-pH monitoring.

Results

A total of 88 patients (age 21-64 years, 62.5% women) completed the study including 12 patients with NERD, 45 with RH, and 31 with FH. There was no significant difference in acid infusion parameters between patients with NERD, RH, and FH. Upon acid infusion, patients who exhibited successful secondary peristalsis had longer lag time, higher MNBI, and shorter bolus contact time than those without secondary peristalsis. Meanwhile, patients with intact PSPW demonstrated significantly higher intensity ratings in response to acid perfusion and higher MNBI than those with impaired PSPW. The lag time correlated positively with MNBI (r = 0.285; p = 0.007).

Conclusion

In conclusion, the protective effect of esophageal secondary peristalsis and chemical clearance on esophageal mucosal integrity was demonstrated. Concerning acid sensitivity, longer lag time in patients with intact secondary peristalsis may be attributed to better esophageal mucosal integrity, while stronger intensity ratings may have a greater tendency to induce PSPW and protect esophageal mucosal integrity.

Features of the Parameters of 24-Hours pH-Impedance and High-Resolution Esophageal Manometry in Patients with Barrett's Esophagus on Proton Pump Inhibitors

Аim: to identify predictors of insufficient effectiveness of proton pump inhibitors based on the evaluation of the results of 24-hour pH-impedance and high-resolution esophageal manometry in patients with Barrett's esophagus.

Materials and methods. 52 patients with histologically confirmed Barrett's esophagus who are on therapy with proton pump inhibitors were examined. All patients underwent daily pH-impedance and high-resolution esophageal manometry.

Results. According to daily pH-impedance, group 1 consisted of 37 patients who responded satisfactorily to antisecretory therapy, group 2 of 15 patients who demonstrated insufficient response to acid-suppressive therapy, 11 of whom had no clinical manifestations. The total number of reflux averaged 55 in group 1 and 106 in group 2. The average number of acid reflux in group 1 was 5.68, in group 2 — 48.5. The average number of non-acid reflux prevailed in patients of group 2 and averaged 58, in group 1 the indicator averaged 47. Evaluation of the results of high-resolution esophageal manometry showed that violations of the structure and function of the esophago-gastric junction were detected in 21 patients out of 52. Disorders of the motility of the thoracic esophagus were detected in 31 patients out of 52. When comparing the frequency of motor disorders from the thoracic esophagus in groups 1 and 2, no significant differences were obtained. However, significantly more frequent registration of violations of the structure and/or function of the esophago-gastric junction was found in the group with unsatisfactory effectiveness of proton pump inhibitors.

Conclusion. In a number of patients with Barrett's esophagus, there is an insufficient effect of acid-suppressive therapy and at the same time an asymptomatic course of the disease, which may increase the risk of its progression. Predictors of insufficiently successful treatment of patients with Barrett's esophagus may be both insufficient pharmacological effect of proton pump inhibitors themselves, and motility disorders that cause the presence of non-acid reflux, decreased esophageal clearance, which in turn may cause the patient's symptoms to persist and adversely affect the condition of the esophageal mucosa.

Features of the Parameters of 24-Hours pH-Impedance and High-Resolution Esophageal Manometry in Patients with Barrett's Esophagus on Proton Pump Inhibitors

Аim: to identify predictors of insufficient effectiveness of proton pump inhibitors based on the evaluation of the results of 24-hour pH-impedance and high-resolution esophageal manometry in patients with Barrett's esophagus.

Materials and methods. 52 patients with histologically confirmed Barrett's esophagus who are on therapy with proton pump inhibitors were examined. All patients underwent daily pH-impedance and high-resolution esophageal manometry.

Results. According to daily pH-impedance, group 1 consisted of 37 patients who responded satisfactorily to antisecretory therapy, group 2 of 15 patients who demonstrated insufficient response to acid-suppressive therapy, 11 of whom had no clinical manifestations. The total number of reflux averaged 55 in group 1 and 106 in group 2. The average number of acid reflux in group 1 was 5.68, in group 2 — 48.5. The average number of non-acid reflux prevailed in patients of group 2 and averaged 58, in group 1 the indicator averaged 47. Evaluation of the results of high-resolution esophageal manometry showed that violations of the structure and function of the esophago-gastric junction were detected in 21 patients out of 52. Disorders of the motility of the thoracic esophagus were detected in 31 patients out of 52. When comparing the frequency of motor disorders from the thoracic esophagus in groups 1 and 2, no significant differences were obtained. However, significantly more frequent registration of violations of the structure and/or function of the esophago-gastric junction was found in the group with unsatisfactory effectiveness of proton pump inhibitors.

Conclusion. In a number of patients with Barrett's esophagus, there is an insufficient effect of acid-suppressive therapy and at the same time an asymptomatic course of the disease, which may increase the risk of its progression. Predictors of insufficiently successful treatment of patients with Barrett's esophagus may be both insufficient pharmacological effect of proton pump inhibitors themselves, and motility disorders that cause the presence of non-acid reflux, decreased esophageal clearance, which in turn may cause the patient's symptoms to persist and adversely affect the condition of the esophageal mucosa.

Aging Combined with High Waist-to-Hip Ratio Is Associated with a Higher Risk of Gastro-Esophageal Reflux Disease

Background and Objective: To assess whether the combination of high waist-to-hip ratio (WHR) and elderly age is associated with higher risk of GERD. Material and Methods: A total of 16,996 subjects aged ≥20 years who received esophagogastroduodenoscopy (EGD) between January 2010 and December 2019. We evaluated the risk of GERD in different age groups and WHR groups in unadjusted analysis and multivariate logistic regression models for predictors of GERD. Results: There was a trend towards more participants with both age ≥65 years and WHR ≥ 1 (n = 129) (n = 66, 51%) than participants with age < 65 and WHR < 0.9 (n = 10,422) (n = 2814, 27%) presenting with GERD. Participants who had both age ≥ 65 years and high WHR ≥ 1 had the highest risk of any type of GERD (adjusted OR, 2.07; 95% CI, 1.44−2.96, p value < 0.05) based on multivariate logistic regression analysis. Conclusions: The combination of having a high WHR and being elderly was associated with a higher risk of GERD, and preventing central obesity in the elderly population reduced the risk of GERD and the requirement for medical resources.

The effect of a patient informative leaflet on chronic use of proton pump inhibitors in a primary care center: a randomized control trial

BACKGROUND

Chronic non-medically indicated PPIs are highly prescribed worldwide. The long-term side effects of PPI must be wisely considered during an extended prescription duration. Our study purpose is to assess the impact of providing patients and physicians with educational guides on the rates of reducing or eliminating PPIs.

DESIGN AND METHODS

A controlled study targeting adult patients with chronic PPI use was conducted in a family medicine center in Beirut. Block randomization was employed. Patients (n = 140) were equally divided into an intervention group consisting of a patient-oriented informative and motivational leaflet and a control group having the same follow-up without having the leaflet. All participants filled a questionnaire. All participants received a short phone call in 2 and 6 months. An e-mail clarifying the objective of this study was sent to all physicians and supplemented with a PPI deprescribing algorithm.

RESULTS

At the 6-month follow-up, the rate of participants who talked to treating physicians about their PPI therapy was higher in the intervention group (p-value<0.0001), and the rate of participants who stepped down or off PPI was higher in the intervention group (p-value<0.0001). In participants who stepped down or off PPI, the reported breakthrough symptoms decreased over time (moderate: 24.2%, mild: 35.5%, and nil: 40.3% at 2-month follow-up; and moderate: 0%, mild: 55.4% and nil: 44.6% at 6-month follow-up; p-value<0.0001).

CONCLUSION

A low-intensity, low-cost, and easily replicable intervention encouraged a significant number of long-term users of PPIs to reduce or stop these medications without causing significant breakthrough symptoms.

Endoscopic Findings of Gastro-Esophageal Reflux Disease in Elderly and Younger Age Groups

Objective: To determine and compare the clinical features and endoscopic findings of gastro-esophageal reflux disease (GERD) in elderly and younger age groups. Materials and Methods: The clinical and endoscopic features were evaluated for all patients with GERD between January 2017 and September 2020. The criteria for inclusion were being aged over 65 and under 50 years and having an upper gastrointestinal endoscopy with reflux symptoms resistant to ppi theraphy. The exclusion criteria included prior surgery, age under 18 years, and pregnancy. The diagnosis of GERD was made according to the patients' symptoms. The SPSS 11.0 for Windows pocket program was used for statistical analysis. Results: Two hundred eighty-six patients aged over 65 years and 261 patients aged below 50 years were enrolled in this study. The mean age of the older group was 68.2 ± 4.5 years and the mean age of the young group was 38 ± 7.2 years. The male/female ratio was 5/3 and 2/1 in the young and older groups, respectively. The older patients had less severe and rare typical symptoms than the young patients. However, significantly more serious endoscopic findings were noted in the older patients compared with the younger patients. Conclusion: The older and young patients with GERD were predominantly male and typical reflux problems were less common in older patients with GERD. Older patients had more important endoscopic findings such as hernia, esophagitis, and cancer.

Asymptomatic Barrett’s Oesophagus-Complicated Gastroesophageal Reflux Disease at Ineffective Antisecretory Therapy

Aim. A clinical description of gastroesophageal reflux disease (GERD) complicated by Barrett’s oesophagus (BO) at inadequate antisecretory therapy and the assessment of functional tests in control of conservative treatment.

Key points. A 63-yo patient with no complaints in a proton pump inhibitor (PPI) therapy was admitted for a follow-up examination for BO-complicated GERD using oesophagogastroduodenoscopy (OGDS) with biopsy, high-resolution oesophageal manometry and 24-h pH-impedance. Endoscopy revealed signs of BO (long segment C1M3), erosive reflux oesophagitis (grade B in Los Angeles classification). Non-contractile oesophagus in manometry. Antisecretory therapy was stated ineffective and subject to correction in 24-h pH-impedance.

Conclusion. Asymptomatic BO-complicated GERD patients comprise a special cohort. The main challenge to prevent progression into oesophageal adenocarcinoma is an adequate personalised patient management leveraging the modern diagnostic techniques, control of antisecretory treatment and its correction a situ.

Reflux symptoms and oesophageal acidification in treated achalasia patients are often not reflux related

OBJECTIVE

After treatment, achalasia patients often develop reflux symptoms. Aim of this case-control study was to investigate mechanisms underlying reflux symptoms in treated achalasia patients by analysing oesophageal function, acidification patterns and symptom perception.

DESIGN

Forty treated achalasia patients (mean age 52.9 years; 27 (68%) men) were included, 20 patients with reflux symptoms (RS+; Gastro-Oesophageal Reflux Disease Questionnaire (GORDQ) ≥8) and 20 without reflux symptoms (RS-: GORDQ <8). Patients underwent measurements of oesophagogastric junction distensibility, high-resolution manometry, timed barium oesophagogram, 24 hours pH-impedance monitoring off acid-suppression and oesophageal perception for acid perfusion and distension. Presence of oesophagitis was assessed endoscopically.

RESULTS

Total acid exposure time during 24 hours pH-impedance was not significantly different between patients with (RS+) and without (RS-) reflux symptoms. In RS+ patients, acid fermentation was higher than in RS- patients (RS+: mean 6.6% (95% CI 2.96% to 10.2%) vs RS-: 1.8% (95% CI -0.45% to 4.1%, p=0.03) as well as acid reflux with delayed clearance (RS+: 6% (95% CI 0.94% to 11%) vs RS-: 3.4% (95% CI -0.34% to 7.18%), p=0.051). Reflux symptoms were not related to acid in both groups, reflected by a low Symptom Index. RS+ patients were highly hypersensitive to acid, with a much shorter time to heartburn perception (RS+: 4 (2-6) vs RS-:30 (14-30) min, p<0.001) and a much higher symptom intensity (RS+: 7 (4.8-9) vs RS-: 0.5 (0-4.5) Visual Analogue Scale, p<0.001) during acid perfusion. They also had a lower threshold for mechanical stimulation.

CONCLUSION

Reflux symptoms in treated achalasia are rarely caused by gastro-oesophageal reflux and most instances of oesophageal acidification are not reflux related. Instead, achalasia patients with post-treatment reflux symptoms demonstrate oesophageal hypersensitivity to chemical and mechanical stimuli, which may determine symptom generation.

Gastroesophageal Reflux Disease and Barrett Esophagus in the Elderly

As our population continues to age, the early diagnosis and optimal management of patients with gastroesophageal reflux disease becomes paramount. Maintaining a low threshold for evaluating atypical symptoms in this population is key to improving outcomes. Should patients develop complications including severe esophagitis, peptic stricture, or Barrett esophagus, then a discussion of medical, endoscopic, and surgical treatments that accounts for patient's comorbidities and survival is important. Advances in screening, surveillance, and endoscopic treatment of Barrett esophagus have allowed us to dispel concerns of futility and treat a larger subset of the at-risk population.

Esophageal Function Abnormalities in Patients With Barrett's Esophagus

Various esophageal functional abnormalities have been described in patients with Barrett's esophagus (BE). A significantly higher esophageal acid exposure especially in the supine position has been documented in BE, as compared with the other gastroesophageal reflux disease phenotypes. In addition, weakly acidic reflux and duodenogastroesophageal reflux are more common in BE patients. The presence of Barrett's mucosa reduces esophageal mucosal impedance, occasionally to a level that prevents detection of reflux episodes. Reduced amplitude contractions and lower esophageal sphincter basal pressure are more common in BE patients as compared with the other gastroesophageal reflux disease groups. Ineffective esophageal motility is the most commonly defined motor disorder in BE. Reduced chemoreceptor and mechanoreceptor sensitivity to acid and balloon distention, respectively, have been suggested to explain lack or significantly less reports of reflux-related symptoms by BE patients.

Esophageal acid sensitivity in patients with gastroesophageal reflux disease: Does esophageal hypomotility matter?

BACKGROUND/AIM

Esophageal acid sensitivity plays a role in symptomatic manifestation of gastroesophageal reflux disease (GERD). Esophageal hypomotility is common in patients with GERD. We aimed to determine whether esophageal acid sensitivity may differ between patients with and without esophageal hypomotility.

METHODS

We prospectively enrolled 41 consecutive patients (10 females, mean age 53 years, range 32-79) with typical reflux symptoms and 10 healthy subjects (5 females, mean age 45 years, range 28-56) for esophageal acid sensitivity and motility tests. Demographics, body mass index (BMI), and reflux symptoms using a validated questionnaire (GERDQ) were recorded. All subjects underwent infusion of 0.1 N hydrochloric acid in the esophagus at a rate of 10 mL/min for 10 minutes. The parameters for esophageal acid infusion included lag time, intensity rating, and acid sensitivity score.

RESULTS

Esophageal motility diagnosis included 24 patients with normal motility and 17 patients with ineffective esophageal motility (IEM). Lag time was similar between the patient groups. No differences between patients with normal motility and IEM were found for any of other acid infusion parameters. There was a positive correlation between lag time and BMI (r = .33, P = .04). GERDQ was negatively correlated to lag time (r = -.73, P < .001).

CONCLUSIONS

Esophageal acid sensitivity was similar in GERD patients with and without hypomotility. Decreased acid sensitivity in individuals with increasing body mass index may play a pathological role in symptomatic modulation of patients with GERD.

Decline in perception of acid regurgitation symptoms from gastroesophageal reflux disease in diabetes mellitus patients

Objectives

To determine if a discrepancy exists between subjective symptoms and the grade of endoscopic gastroesophageal reflux disease (GERD) in diabetes mellitus (DM) patients.

Methods

All 2,884 patients who underwent esophagogastroduodenoscopy completed the modified Gastrointestinal Symptom Rating Scale (GSRS), an interview-based rating scale consisting of 16 items including a question on acid regurgitation. Patients were divided into DM and non-DM groups (1,135 and 1,749 patients, respectively). GERD was diagnosed endoscopically and graded according to the Los Angeles classification. Grade B or more severe GERD was defined as severe endoscopic GERD. The intergroup GSRS score was compared statistically.

Results

In severe endoscopic GERD patients, the prevalence of patients with a positive GSRS score in the acid regurgitation question was statistically lower in DM patients than non-DM patients. Of the 60 non-DM patients with severe endoscopic GERD, 40 patients (67%) had a positive GSRS score for acid regurgitation; however, of the 51 DM patients with severe endoscopic GERD, 23 patients (45%) had a positive GSRS score. Multivariate analysis showed that severe endoscopic GERD (OR: 2.01; 95% CI: 1.21–3.33; p = 0.0066), non-DM (OR: 0.74; 95% CI: 0.54–0.94; p = 0.0157), younger age (OR: 0.98; 95% CI: 0.97–0.99; p = 0.0125), and hiatal hernia (OR: 1.46; 95% CI: 1.12–1.90; p = 0.0042) were associated with acid regurgitation symptoms.

Conclusions

There is a discrepancy between subjective symptoms and endoscopic GERD grade in DM patients. The ability of DM patients to feel acid regurgitation may be decreased.

Implementation of Proton Pump Inhibitor Deprescription Protocol in Geriatric Residents

BACKGROUND

Deprescribing is a recommended intervention to reduce morbidity and mortality caused by polypharmacy in older residents. However, a lack of definite deprescription guidelines and evidence of clinically meaningful outcomes complicates or precludes the practicality of such an approach.

OBJECTIVE

The objective of the present pilot study is to establish and implement a stepwise taper protocol that can potentially minimize overuse of proton pump inhibitors in a safe, effective, and feasible manner in the nursing home.

METHODS

Proton pump inhibitor dosage was reduced by half every 3 weeks until the lowest dose was reached; thereafter, the frequency was changed to every other day for 3 weeks, if tolerated. Subsequently, histamine receptor antagonists replaced proton pump inhibitors and followed the same deprescription regimen until discontinuation. Patient-specific interventions also included reassessment of therapeutic agents and dosage forms for more tolerable alternatives to facilitate deprescription efforts and minimize gastric ulceration or discomfort.

RESULTS

The pilot study enrolled 10 patients (average age 65.6 years, medication burden 16.8 units, and antisecretory duration 37.5 months). Physicians accepted >95% of interventions, and 90% of patients achieved cessation at 12 weeks. Post cessation, none of the patients needed antacid, prokinetic, or antisecretory agents at 4 weeks. Difficulties in order interpretation and transcription among nurses as well as order entry and calculations among pharmacists were noted.

CONCLUSIONS

The present pilot study added to the growing body of evidence that gradual deprescription of antisecretory medications is feasible. Nonetheless, the pilot design precludes any conclusions about safety and efficacy of the intervention.

Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site: Quality Improvement Project

BACKGROUND

Increased prescribing of proton pump inhibitors (PPIs) in the past few decades can be attributed mainly to long-term use of this type of therapy. Recent evidence indicates signals of harm associated with long-term use of PPIs, such as increased risk of Clostridium difficile infection, recurrence of C. difficile infection, and fracture. A few studies have assessed the effectiveness of step-down management of patients receiving long-term PPI therapy in ambulatory care settings. However, it is unknown whether PPIs can be discontinued in older people without return of gastrointestinal symptoms.

OBJECTIVES

To determine the proportion of residents receiving long-term PPI therapy who were able to discontinue the drug without experiencing gastrointestinal symptoms warranting recommencement of the PPI or initiation of a histamine-2 receptor antagonist.

METHODS

The records of residents who had been taking a PPI for longer than 6 months at a single residential care site were audited by one pharmacist to determine the PPI indication. For residents who fit the criteria for discontinuation (no indication for long-term PPI therapy, not currently experiencing gastrointestinal symptoms, no previous trial of PPI discontinuation without success, and no anxiety when medications are discontinued), the pharmacist faxed a recommendation to discontinue PPI therapy without tapering to the physicians' offices. For cases in which the recommendation was accepted, 3 pharmacists followed the residents weekly for 8 weeks to assess whether gastrointestinal symptoms returned.

RESULTS

The pharmacist identified 28 residents who fit the criteria, and the recommendation to discontinue therapy was accepted for 27. At 8 weeks after the intervention, 19 (70%) of these residents were still asymptomatic and did not require re-initiation of medications to manage their gastrointestinal symptoms.

CONCLUSIONS

These results support discontinuation of long-term PPI therapy for older people who fit the criteria for discontinuation. The study provided limited evidence to support the use of tapering. However, tapering can be used to identify the lowest effective dose and may increase patient comfort with deprescribing. Further research is needed to determine the effects of and best approaches to PPI discontinuation in older populations.

Mucosal integrity and sensitivity to acid in the proximal esophagus in patients with gastroesophageal reflux disease

Acid reflux episodes that extend to the proximal esophagus are more likely to be perceived. This suggests that the proximal esophagus is more sensitive to acid than the distal esophagus, which could be caused by impaired mucosal integrity in the proximal esophagus. Our aim was to explore sensitivity to acid and mucosal integrity in different segments of the esophagus. We used a prospective observational study, including 12 patients with gastroesophageal reflux disease (GERD). After stopping acid secretion-inhibiting medication, two procedures were performed: an acid perfusion test and an upper endoscopy with electrical tissue impedance spectroscopy and esophageal biopsies. Proximal and distal sensitivity to acid and tissue impedance were measured in vivo, and mucosal permeability and epithelial intercellular spaces at different esophageal levels were measured in vitro. Mean lag time to heartburn perception was much shorter after proximal acid perfusion (0.8 min) than after distal acid perfusion (3.9 min) (P = 0.02). Median in vivo tissue impedance was significantly lower in the distal esophagus (4,563 Ω·m) compared with the proximal esophagus (8,170 Ω·m) (P = 0.002). Transepithelial permeability, as measured by the median fluorescein flux was significantly higher in the distal (2,051 nmol·cm(-2)·h(-1)) than in the proximal segment (368 nmol·cm(-2)·h(-1)) (P = 0.033). Intercellular space ratio and maximum heartburn intensity were not significantly different between the proximal and distal esophagus. In GERD patients off acid secretion-inhibiting medication, acid exposure in the proximal segment of the esophagus provokes symptoms earlier than acid exposure in the distal esophagus, whereas mucosal integrity is impaired more in the distal esophagus. These findings indicate that the enhanced sensitivity to proximal reflux episodes is not explained by increased mucosal permeability.

The impact of laparoscopic Nissen fundoplication on the long-term quality of life in patients with gastroesophageal reflux disease

Laparoscopic Nissen fundoplication is now the most common surgical procedure for treatment of gastroesophageal reflux disease (GERD), offering promising long-term outcomes. Outcomes for 46 patients with GERD who underwent Nissen fundoplication during the last 5 years (November 2007-June 2012) were prospectively studied using a structured questionnaire that evaluated clinical symptom scores for heartburn, dysphagia, and satisfaction with clinical outcomes. Postoperative care of the patients including analgesia, median hospital stay, overall cost, and complications was also studied. Clinical follow-up data for 2 years after surgery were available for all 46 patients. Forty-two patients (91.3%) were satisfied with their quality of life and only eight patients (17.4%) continued to receive antacids after surgery. Dysphagia to solid and liquid occasionally appeared in 26.1% (N = 12) and 17.4% (N = 8) of patients, respectively. Laparoscopic Nissen fundoplication was an effective long-term treatment for GERD. The operation resulted in a significant reduction of symptoms and minimized the use of antacid drugs with a high degree of patient satisfaction. Although some patients may have returned to antacid treatment at late follow-up or continued to complain of mild discomfort, they were overall pleased with the outcome.

Symptom Prevalence, Symptom Severity, and Health-Related Quality of Life Among Young, Middle, and Older Adults With Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a chronic, life threatening illness that affects primarily women. The purpose of this study was to describe the prevalence of PAH symptoms and to determine whether there are differences in symptom severity and HRQOL in PAH symptoms among young, middle, and older adults with PAH. A cross sectional design was utilized. For all the age groups, shortness of breath (SOB) on exertion and fatigue were the two most prevalent symptoms. SOB on exertion had the highest symptom severity scores followed by fatigue for all groups. Symptom severity was significantly different among the groups for palpitations, abdominal swelling and nausea. For components of HRQOL, physical functioning worsened with age. All groups had diminished general health, role physical and vitality levels. There are some differences in symptom prevalence, symptom severity and HRQOL among young, middle and older adults. Awareness of these differences is important for healthcare providers to know and assess overtime. Palliative care should be an integral part of caring for patients with PAH.

Hypersensitivity to acid is associated with impaired esophageal mucosal integrity in patients with gastroesophageal reflux disease with and without esophagitis

Increased esophageal sensitivity and impaired mucosal integrity have both been described in patients with gastroesophageal reflux disease, but the relationship between hypersensitivity and mucosal integrity is unclear. The aim of the present study was to investigate acid sensitivity in patients with erosive and nonerosive reflux disease and control subjects to determine the relation with functional esophageal mucosal integrity changes as well as to investigate cellular mechanisms of impaired mucosal integrity in these patients. In this prospective experimental study, 12 patients with nonerosive reflux disease, 12 patients with esophagitis grade A or B, and 11 healthy control subjects underwent an acid perfusion test and upper endoscopy. Mucosal integrity was measured during endoscopy by electrical tissue impedance spectroscopy and biopsy specimens were analyzed in Ussing chambers for transepithelial electrical resistance, transepithelial permeability and gene expression of tight junction proteins and filaggrin. Patients with nonerosive reflux disease and esophagitis were more sensitive to acid perfusion compared with control subjects, having a shorter time to perception of heartburn and higher perceived intensity of heartburn. In reflux patients, enhanced acid sensitivity was associated with impairment of in vivo and vitro esophageal mucosal integrity. Mucosal integrity was significantly impaired in patients with esophagitis, displaying higher transepithelial permeability and lower extracellular impedance. Although no significant differences in the expression of tight junction proteins were found in biopsies among patient groups, mucosal integrity parameters in reflux patients correlated negatively with the expression of filaggrin. In conclusion, sensitivity to acid is enhanced in patients with gastroesophageal reflux disease, irrespective of the presence of erosions, and is associated with impaired esophageal mucosal integrity. Mucosal integrity of the esophagus is associated with the expression of filaggrin.

Reflux features in elderly patients with gastroesophageal reflux disease

AIM: To analyze the features of reflux in elderly patients with gastroesophageal reflux disease (GERD).

METHODS: We randomly selected 28 elderly outpatients (55-85 years old) treated at Beijing Shijitan Hospital from January 2011 to March 2013. There were 12 patients (eight males vs four females) with reflux symptom and 16 controls (ten males vs six females) without reflux symptom. Endoscopy, esophageal manometry and 24-h pH-Z monitoring were conducted in all subjects.

RESULTS: The mean age of patients in the reflux (R) and non-reflux (NR) groups was 67.92 ± 19.88 years old and 64.94 years ± 17.38 years old, respectively (P > 0.05). Mean length of low esophagus sphincter (LES) was 3.14 cm ± 1.46 cm in the R group and 3.13 cm ± 0.84 cm in the NR group (P = 0.983). Upright reflux times in the R group were more than that in the NR (10.85 ± 12.89 vs 0.75 ± 0.889, P = 0.01), while supine reflux times were alike (10.28 ± 22.35 vs 0.36 ± 0.58, P = 0.024). Proximal esophageal acid regurgitation times and weak acid regurgitation times were different between the two groups (P = 0.012, 0.036), while non-acid regurgitation times did not (P = 0.18). Distal esophageal acid regurgitation times, weak acid regurgitation times and non-acid regurgitation times did not differ between the two groups (P = 0.072, 0.197, 0.067). Alimentary bolus in both upright and supine positions was similar between the two groups.

CONCLUSION: Upright reflux times are more in elderly patients with gastroesophageal reflux disease than in controls, although supine reflux times are not different. Proximal esophageal acid regurgitation times and weak acid regurgitation times are more in elderly patients with gastroesophageal reflux disease than in controls.

Symptoms and endoscopic features at barrett's esophagus diagnosis: implications for neoplastic progression risk

OBJECTIVES

Risk stratification of Barrett's esophagus (BE) patients based on clinical and endoscopic features may help to optimize surveillance practice for esophageal adenocarcinoma (EAC) development. The aim of this study was to investigate patient symptoms and endoscopic features at index endoscopy and risk of neoplastic progression in a large population-based cohort of BE patients.

METHODS

A retrospective review of hospital records relating to incident BE diagnosis was conducted in a subset of patients with specialized intestinal metaplasia from the Northern Ireland BE register. Patients were matched to the Northern Ireland Cancer Registry to identify progressors to EAC or esophageal high-grade dysplasia (HGD). Cox proportional hazards models were applied to evaluate the association between endoscopic features, symptoms, and neoplastic progression risk.

RESULTS

During 27,997 person-years of follow-up, 128 of 3,148 BE patients progressed to develop HGD/EAC. Ulceration within the Barrett's segment, but not elsewhere in the esophagus, was associated with an increased risk of progression (hazard ratio (HR) 1.72; 95% confidence interval (CI): 1.08-2.76). Long-segment BE carried a significant sevenfold increased risk of progression compared with short-segment BE; none of the latter group developed EAC during the study period. Conversely, the absence of reflux symptoms was associated with an increased risk of cancer progression (HR 1.61; 95% CI: 1.05-2.46).

CONCLUSIONS

BE patients presenting with a long-segment BE or Barrett's ulcer have an increased risk of progressing to HGD/EAC and should be considered for more intense surveillance. The absence of reflux symptoms at BE diagnosis is not associated with a reduced risk of malignant progression, and may carry an increased risk of progression.

Gastroesophageal reflux disease and the elderly

Gastroesophageal reflux disease is a common disorder in all patients but a particular problem in the elderly, for whom the disease often presents with advanced mucosal damage and other complications. Symptoms are also not as reliable an indication of disease severity in older patients. Likewise, therapy is more difficult because of potential side effects and drug interactions.

Is the advanced age a contraindication to GERD laparoscopic surgery? Results of a long term follow-up

Background

In this prospective non randomized observational cohort study we have evaluated the influence of age on outcome of laparoscopic total fundoplication for GERD.

Methods

Six hundred and twenty consecutive patients underwent total laparoscopic fundoplication for GERD. Five hundred and twenty-four patients were younger than 65 years (YG), and 96 patients were 65 years or older (EG). The following parameters were considered in the preoperative and postoperative evaluation: presence, duration, and severity of GERD symptoms, presence of a hiatal hernia, manometric and 24 hour pH-monitoring data, duration of operation, incidence of complications and length of hospital stay.

Results

Elderly patients more often had atypical symptoms of GERD and at manometric evaluation had a higher rate of impaired esophageal peristalsis in comparison with younger patients. The duration of the operation was similar between the two groups. The incidence of intraoperative and postoperative complications was low and the difference was not statistically significant between the two groups. An excellent outcome was observed in 93.0% of young patients and in 88.9% of elderly patients (p = NS).

Conclusions

Laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients, warranting low morbidity and mortality rates and a significant improvement of symptoms comparable to younger patients.

Acid sensitization of esophageal mucosal afferents: implication for symptom perception in patients across the gastroesophageal reflux disease spectrum

BACKGROUND

Sensitization of esophageal chemoreceptors, either directly by intermittent acid exposure or indirectly through esophagitis-associated inflammatory mediators, is likely to be the mechanism underlying the perception of heartburn.

AIMS

To compare basal esophageal sensitivity with electrical stimulation and acid, and to compare the degree of acid-induced sensitization in controls and in patient groups across the entire spectrum of gastroesophageal reflux disease: erosive oesophagitis (EO), nonerosive reflux disease (NERD), and functional heartburn (FH).

METHODS

Esophageal sensory and pain thresholds to electrical stimulation were measured before, 30, and 60 minutes after an intraesophageal infusion of saline or HCl. Patients received a 30-minute infusion of 0.15 M HCl and controls were randomized to receive either HCl (n = 11) or saline (n = 10). After electrical sensory threshold testing, participants received another 30-minute infusion of HCl to determine whether sensitivity to acid is increased by prior acid exposure

RESULTS

All patient groups had higher basal sensory thresholds than healthy controls (controls, 13 ± 1.4 mA; FH, 20 ± 5.1 mA; NERD, 21 ± 5.1 mA; EO, 23 ± 5.4 mA; P < 0.05). Acute esophageal acid exposure reduced sensory thresholds to electrical stimulation in FH and NERD patients (P < 0.05). The level of acid sensitivity during the first HCl infusion was comparable between all patient groups and controls. The secondary infusion caused increased discomfort in all participants (P < 0.01). This acid-induced sensitization to HCl was significantly elevated in the patient groups ( P < 0.05).

CONCLUSIONS

(1) Esophageal acid infusion sensitizes it to subsequent electrical and chemical stimulation. (2) The acid-related sensitization is greater in gastroesophageal reflux disease than in controls and may influence in part symptom perception in this population. (3) Acid-related sensitization within the gastroesophageal reflux disease population is not dependant on mucosal inflammation.

Characteristics of esophageal motility and esophageal acid exposure in elderly patients with gastroesophageal reflux disease

AIM: To investigate the characteristics of esophageal motility and esophageal acid exposure in elderly patients with gastroesophageal reflux disease (GERD).

METHODS: Twenty-five elderly patients and fourteen non-elderly patients with typical GERD symptoms were recruited and divided into a reflux esophagitis group and a non-erosive reflux esophagitis group. All patients underwent high-resolution manometry and 24 h pH monitoring.

RESULTS: The lower esophageal sphincter pressure (LESP) was significantly lower in elderly GERD patients than in non-elderly GERD patients (9.81 mmHg ± 5.78 mmHg vs 13.79 mmHg ± 4.40 mmHg, P < 0.05), especially in the elderly RE group. The speed of esophageal peristalsis transmission was slower (62.99 cm/s ± 21.10 cm/s vs 64.69 cm/s ± 14.03 cm/s, P < 0.01) and the peristalsis wave duration time was longer (3.74 s ± 1.32 s vs 2.94 s ± 0.66 s, P < 0.05) in elderly GERD patients than in non-elderly GERD patients. The supine time (pH < 4) (9.10% ± 12.99% vs 1.92% ± 2.56%) and DeMeester score in elderly patients were higher than those in non-elderly patients (45.43 mmHg-cm-s ± 50.63 mmHg-cm-s vs 16.06 mmHg-cm-s ± 23.66 mmHg-cm-s). There were no significant differences in other parameters between the two groups.

CONCLUSION: Compared with non-elderly patients, esophageal anti-reflux defense mechanism is weakened, the function of esophageal peristalsis declines and the degree of acid exposure aggravates in elderly GERD patients.

Effect of age and correlation between esophageal visceral chemosensitivity and mechanosensitivity in healthy Japanese subjects

BACKGROUND

The aim of this study was to examine the impact of age on esophageal sensation, and to determine whether esophageal mechanosensitivity and chemosensitivity are correlated in healthy Japanese subjects.

METHODS

To evaluate chemosensitivity, a catheter was inserted and placed 10 cm above the upper border of the lower esophageal sphincter (LES), which was determined with an esophageal manometric catheter. After saline had been infused into the esophagus at a rate of 10 mL/min for 2 min, 0.1 N hydrochloric acid, instead of saline-without the subjects' knowledge-was infused for 10 min at the same rate. The acid perfusion sensitivity score (APSS) was assessed. To evaluate mechanosensitivity, a barostat test was performed, with a balloon being placed 10 cm above the upper border of the LES. The initial perception threshold (IPT), pain threshold (PT), and maximal pain were quantified.

RESULTS

The APSS was significantly inversely correlated with age. IPT, PT, and mean maximal pain were significantly correlated with age. Body mass index, drinking, and smoking habits were not correlated with the esophageal perception threshold. The correlation of chemosensitivity and mechanosensitivity was also assessed, and the APSS was inversely correlated with IPT, PT, and maximal pain.

CONCLUSIONS

The thresholds of esophageal visceral chemosensitivity and mechanosensitivity in same individuals were significantly correlated and both of these thresholds were inversely correlated with age.

Comparisons of symptoms reported by elderly and non-elderly patients with GERD

BACKGROUND

The characteristics of symptoms reported by elderly patients with gastroesophageal reflux disease (GERD) have not been fully investigated. We performed this study to clarify these characteristics in elderly patients with GERD.

METHODS

The study subjects were 340 Japanese patients with symptoms of heartburn and/or acid regurgitation. All patients were investigated by upper gastrointestinal endoscopy, and were asked about the presence of atypical GERD symptoms, such as an epigastric burning sensation, epigastralgia, epigastric discomfort, and abdominal fullness, as well as the time of day when bothersome symptoms occurred.

RESULTS

Of the 340 patients, 161 were elderly (≥65 years old) and 179 were non-elderly (age <65 years). There were 158 patients without esophageal mucosal breaks, 147 with low-grade reflux esophagitis (RE; Los Angeles classification grade A or B), and 35 with high-grade reflux esophagitis (LA grade C or D). Elderly patients with RE reported typical reflux symptoms at the same frequency as the non-elderly patients, whereas elderly patients without mucosal breaks reported typical symptoms more frequently than the non-elderly patients without mucosal breaks. Both elderly and non-elderly patients with different types of GERD reported that their symptoms occurred most frequently during the postprandial period.

CONCLUSION

Elderly patients with GERD tend to show typical GERD symptoms frequently at the typical post-prandial time points in a day, irrespective of the presence of esophageal mucosal breaks.

Differences in cerebral response to esophageal acid stimuli and psychological anticipation in GERD subtypes--an fMRI study

Background

To evaluate whether there are differences in the cerebral response to intraesophageal acid and psychological anticipation stimuli among subtypes of gastroesophageal reflux disease (GERD).

Methods

Thirty nine patients with GERD and 11 healthy controls were enrolled in this study after gastroscopy and 24 hr pH monitoring. GERD subjects were divided into four subgroups: RE (reflux esophagitis), NERD+ (non-erosive reflux disease with excessive acid reflux), NERD-SI+ (normal acid exposure and positive symptom index) and NERD-SI+ (normal acid exposure and negative symptom index, but responded to proton pump inhibitor trial). Cerebral responses to intraesophageal acid and psychological anticipation were evaluated with fMRI.

Results

During intraesophageal acid stimulation, the prefrontal cortex (PFC) region was significantly activated in all subgroups of GERD; the insular cortex (IC) region was also activated in RE, NERD+ and NERD-SI- groups; the anterior cingulated cortex (ACC) region was activated only in RE and NERD-SI- groups. The RE subgroup had the shortest peak time in the PFC region after acid was infused, and presented the greatest change in fMRI signals in the PFC and ACC region (P = 0.008 and P = 0.001, respectively). During psychological anticipation, the PFC was significantly activated in both the control and GERD groups. Activation of the IC region was found in the RE, NERD-SI+ and NERD-SI- subgroups. The ACC was activated only in the NERD-SI+ and NERD-SI- subgroups. In the PFC region, the NERD-SI- subgroup had the shortest onset time (P = 0.008) and peak time (P < 0.001). Compared with actual acid infusion, ACC in RE and IC in NERD+ were deactivated while additional areas including the IC and ACC were activated in the NERD-SI+ group; and in NERD-SI- group, onset-time and peak time in the PFC and IC areas were obviously shorter in induced anticipation than in actual acid infusion.

Conclusions

The four subgroups of GERD patients and controls showed distinctly different activation patterns and we therefore conclude GERD patients have different patterns of visceral perception and psychological anticipation. Psychological factors play a more important role in NERD-SI+ and NERD-SI- groups than in RE and NERD+ groups.

Non-erosive reflux disease (NERD), symptomatic and asymptomatic erosive reflux disease (ERD): from hypersensitive to hyposensitive esophagus

AIMS

To compare the esophageal sensitivity to acid and saline in patients with symptomatic and asymptomatic erosive reflux disease (ERD), non-erosive reflux disease (NERD) and controls, and to assess the response to proton-pump inhibitors in patients with symptomatic ERD and NERD.

METHODOLOGY

Patients with GERD and a control group of healthy asymptomatic volunteers were recruited. All subjects underwent esophagogastroduodenoscopy and the acid-saline perfusion test. Symptomatic ERD and NERD patients were given rabeprazole 20 mg twice daily for 2 weeks and their response to treatment assessed.

RESULTS

A total of 105 subjects were recruited: ERD=37 (symptomatic=24, asymptomatic=13), NERD=34 and controls=34. During saline perfusion, only the NERD group recorded a significantly higher sensitivity score compared to controls (2.74±7.28 vs. 0) (p=0.035). During acid perfusion, symptomatic ERD (15.42±13.42) and NERD (16.71±15.04) had significantly higher scores versus controls and asymptomatic ERD patients (both p<0.001). The mean %∆ reflux symptom score following treatment was significantly higher in symptomatic ERD patients compared to NERD patients (89.08±21.67 vs. 58.53±32.54; p<0.001).

CONCLUSIONS

Patients with NERD were a generally hypersensitive group while asymptomatic ERD patients represent a hyposensitive group of patients which merits further study.

Gastroesophageal reflux disease: Important considerations for the older patients

Gastroesophageal reflux disease (GERD) is the most common upper gastrointestinal disorder seen in the elderly. The worldwide incidence of GERD is increasing as the incidence of Helicobacter pylori is decreasing. Although elderly patients with GERD have fewer symptoms, their disease is more often severe. They have more esophageal and extraesophageal complications that may be potentially life threatening. Esophageal complications include erosive esophagitis, esophageal stricture, Barrett's esophagus and adenocarcinoma of the esophagus. Extraesophageal complications include atypical chest pain that can simulate angina pectoris; ear, nose, and throat manifestations such as globus sensation, laryngitis, and dental problems; pulmonary problems such as chronic cough, asthma, and pulmonary aspiration. A more aggressive approach may be warranted in the elderly patient, because of the higher incidence of severe complications. Although the evaluation and management of GERD are generally the same in elderly patients as for all adults, there are specific issues of causation, evaluation and treatment that must be considered when dealing with the elderly.

Altered sensorimotor responses to esophageal acidification in older adults with GERD

OBJECTIVE

This study aimed to compare the effect of intraluminal acidification on esophageal sensory perception and motor activity between older and younger patients with gastroesophageal reflux disease (GERD).

MATERIAL AND METHODS

All 40 subjects had saline and hydrochloric acid infused into the mid-esophagus. The esophageal perception to acid infusion was documented including lag time, intensity rating, and sensitivity score. Esophageal body motility was recorded.

RESULTS

The younger group had a shorter lag time to initial heartburn perception (p = 0.01) and a greater sensory intensity rating (p = 0.001). The acid infusion sensitivity score was lower in the older patients (p = 0.001). Age positively correlated to lag time to initial symptom perception (r = 0.44, p = 0.005), but negatively correlated to sensory intensity (r = -0.40, p = 0.01) and acid infusion sensitivity score (r = -0.39, p = 0.01). When compared with saline infusion, acid infusion induced a significant increase in the deglutition frequency in younger patients (0.51 vs. 0.67, p = 0.005), but not in older patients (0.59 vs. 0.65, p = 0.67).

CONCLUSIONS

Age-related decrease in sensorimotor response to esophageal acidification may be an important element in the pathogenesis and clinical presentation of GERD in older adults.

Review: treatment of gastroesophageal reflux disease in the elderly

The prevalence of gastroesophageal reflux disease (GERD) increases with age; older patients are more likely to develop severe disease. Common symptoms of GERD in the elderly include dysphagia, vomiting, and respiratory problems. Older patients are more likely to require aggressive therapy, and usually their management is compounded by the presence of comorbidities and consumption of various medications. Proton pump inhibitors are the mainstay of GERD treatment in the elderly because of their profound and consistent acid suppressive effect. Overall, proton pump inhibitors seem to be safe for both short- and long-term therapy in elderly patients with GERD. Antireflux surgery may be safe and effective in a subset of elderly patients with GERD.

Review article: sleep-related gastro-oesophageal reflux as a distinct clinical entity

BACKGROUND

Many patients with chronic gastro-oesophageal reflux disease (GERD) have frequent nighttime heartburn as well as sleep-related gastro-oesophageal reflux (GOR). Sleep-related GOR has been shown to play an important role in the development of oesophagitis and other complications of GOR.

AIM

To present a conceptual argument that nighttime heartburn and associated sleep-related GOR should be recognized as a distinct clinical entity deserving special attention with regard to the diagnosis and treatment of GERD.

METHODS

The data presented come from surveys of GERD patients as well as from physiological studies to include studies monitoring oesophageal pH and spontaneous reflux events during polysomnographically (PSG) monitored sleep.

RESULTS

Evidence is presented to show that nighttime heartburn is prevalent and its occurrence separates patients from those who have heartburn most exclusively in the daytime. The evidence presented also supports the notion that nighttime heartburn sufferers have a more complicated disease and they have a greater risk of developing oesophagitis and other respiratory complications. The data also show that responses to acid mucosal contact are quite different during sleep compared to responses measured during the waking state.

CONCLUSIONS

Nighttime heartburn and GOR represent a distinct clinical entity which deserves specific attention in the diagnosis and optimal treatment of GERD.

Impact of gender and age on the long-term outcome of laparoscopic fundoplication

BACKGROUND

It has been suggested that gender and age could be factors that influence the likelihood of success following antireflux surgery, and our anecdotal impression has been that the outcome following Nissen fundoplication in older women is often disappointing. If correct, characterization of the extent of any differences in outcome might help patient selection and, hence, surgical outcomes. Therefore, in this study we investigated the impact of gender and age on longer-term clinical outcomes following laparoscopic fundoplication.

METHODS

Perioperative and follow-up data from patients undergoing laparoscopic fundoplication in our departments have been collected prospectively and stored in a database. From the database, patients who had undergone either an anterior 180 degrees partial or 360 degrees total laparoscopic fundoplication for gastroesophageal reflux and completed 5 years clinical follow-up were identified. Patients were classified according to gender and age, and outcome data were analyzed to determine differences. Analog scales of 0-10 were used to determine symptoms of heartburn and dysphagia and overall satisfaction.

RESULTS

Seven hundred three patients were studied (58% males). Females were less satisfied with the outcome (score = 7.8 +/- 2.8 vs. 8.4 +/- 2.5, P = 0.0036), and had higher scores for heartburn (2.0 +/- 2.7 vs. 1.2 +/- 2.2; P = 0.0001) and dysphagia for solid food (2.7 +/- 2.9 vs. 2.0 +/- 2.5, P = 0.0049) compared to males. Revisional procedures were undertaken more frequently in females (15.5% vs. 8.4%, P = 0.0038). Age had no impact on any clinical outcome.

CONCLUSIONS

While the outcome for laparoscopic fundoplication is not influenced by age, the outcome for women is poorer than in males.

Correlation between oesophageal acid exposure and dyspeptic symptoms in patients with nonerosive reflux disease

BACKGROUND & AIMS

Oesophageal acidification induces dyspeptic symptoms in healthy individuals. This study aimed to evaluate the correlation between oesophageal acid exposure and dyspeptic symptoms in patients with nonerosive reflux disease.

METHODS

A total of 68 patients with dominant symptoms of heartburn, negative upper gastrointestinal endoscopy and concomitant dyspeptic symptoms participated in the study. The severity of dyspepsia and reflux-related symptoms was evaluated, and 24-h gastro-oesophageal pH-monitoring study was performed in all patients at baseline and after 4 weeks of therapy with esomeprazole 40 mg.

RESULTS

Oesophageal basal acid exposure was pathological in 43 patients and normal in 25 patients, with a similar prevalence and severity of individual dyspeptic symptoms in the two groups. A significant correlation between reflux and dyspepsia scores was observed in the subgroup of patients with normal, but not in those with abnormal pHmetry (r=0.4, P=0.04 and r=0.2 P=0.07, respectively). After esomeprazole, a reduction in severity of dyspepsia (>or=50% with respect to baseline) was observed, independent of improvement of reflux-associated symptoms. Improvement in dyspepsia was, however, similar in patients with normal and abnormal basal acid exposure (14/25 vs. 33/43, respectively, P=NS).

CONCLUSION

Dyspeptic symptoms coexist in a subset of nonerosive reflux disease patients, but prevalence and severity of the symptoms seems to be independent of oesophageal acid exposure.