Gastroesophageal reflux disease: beyond mucosal injury

Diagnosis and management of food allergy-associated gastroesophageal reflux disease in young children-EAACI position paper

Gastro-oesophageal reflux (GOR) and food allergy (FA) are common conditions, especially during the first 12 months of life. When GOR leads to troublesome symptoms, that affect the daily functioning of the infant and family, it is referred to as GOR disease (GORD). The role of food allergens as a cause of GORD remains controversial. This European Academy of Allergy and Clinical Immunology (EAACI) position paper aims to review the evidence for FA-associated GORD in young children and translate this into clinical practice that guides healthcare professionals through the diagnosis of suspected FA-associated GORD and medical and dietary management. The task force (TF) on non-IgE mediated allergy consists of EAACI experts in paediatric gastroenterology, allergy, dietetics and psychology from Europe, United Kingdom, United States, Turkey and Brazil. Six clinical questions were formulated, amended and approved by the TF to guide this publication. A systematic literature search using PubMed, Cochrane and EMBASE databases (until June 2021) using predefined inclusion criteria based on the 6 questions was used. The TF also gained access to the database from the European Society of Paediatric Gastroenterology and Hepatology working group, who published guidelines on GORD and ensured that all publications used within that position paper were included. For each of the 6 questions, practice points were formulated, followed by a modified Delphi method consisting of anonymous web-based voting that was repeated with modified practice points where required, until at least 80% consensus for each practice point was achieved. This TF position paper shares the process, the discussion and consensus on all practice points on FA-associated GORD.

Pre-procedural proton pump inhibition is associated with fewer peri-oesophageal lesions after cryoballoon pulmonary vein isolation

Pulmonary vein isolation (PVI) using cryoenergy is safe and efficient for treatment of atrial fibrillation (AF). Pre-existing upper gastrointestinal (GI) pathologies have been shown to increase the risk for AF. Therefore, this study aimed at assessing incidental pathologies of the upper GI tract in patients scheduled for PVI and to analyse the impact of patients’ characteristics on PVI safety outcome. In 71 AF patients, who participated in the MADE-PVI trial, oesophagogastroduodenoscopy and endosonography were prospectively performed directly before and the day after PVI to assess pre-existing upper GI pathologies and post-interventional occurrence of PVI-associated lesions. Subgroup analysis of the MADE-PVI trial identified clinically relevant incidental findings in 53 patients (74.6%) with age > 50 years being a significant risk factor. Pre-existing reflux oesophagitis increased risk for PVI-associated mediastinal oedema, while patients already treated with proton pump inhibitors (PPI) had significantly fewer mediastinal oedema. Our results suggest that AF patients with pre-existing reflux oesophagitis are at higher risk for PVI-associated mediastinal lesions, which is decreased in patients with constant PPI-treatment prior to PVI. Since PVI-associated mediastinal lesions are regarded as surrogate parameter for an increased risk of the fatal complication of an oesophago-atrial fistula, our findings hint at a beneficial effect of pre-interventional prophylactic PPI-treatment to reduce risk for PVI-associated complications.

German Clinical Trials Register (DRKS00016006; date of registration: 17/12/2018).

Correlation between pre-operative endoscopic findings with reflux symptom score for gastro-oesophageal reflux disease in bariatric patients

Introduction:

There is a strong association between gastro-oesophageal reflux disease and morbid obesity.

Methods:

Two hundred and eleven morbidly obese patients operated between September 2007 and June 2017 were retrospectively reviewed. All patients underwent pre-operative upper gastrointestinal endoscopy and assessment by reflux symptomatic score questionnaire.

Results:

Of the total 211 patients, 156 (73.94%) were females; mean body mass index of the cohort was 46.23 ± 3.1 kg/m². There was no evidence of Barrett's oesophagus or malignancy on pre-operative endoscopy. 63.04% of the patients (n = 133) in the study cohort had normal endoscopy. Pre-operative evaluation by reflux symptom score (RSS) questionnaire revealed no evidence of gastro-oesophageal reflux disease in 61.13% of patients (n = 129). The total number of patients with symptoms was 82 (38.86%). They were further divided into two categories based on severity of symptoms, namely, mild + moderate 60 (73.17%) and severe + very severe 22 (26.83%). From the cohort of symptomatic patients, the sub-cohort of 60 mild + moderate symptomatic patients had equal number of patients with normal 30 (50%) and abnormal endoscopy 30 (50%). In the sub-cohort of patients with severe + very severe symptoms (n = 22; 26.83%), endoscopy was abnormal in 6 (27.7%) patients. Whereas, out of 129 (61.13%) asymptomatic patients, one-third (n = 42) had abnormal endoscopy. The weighted kappa score was used between pre-operative endoscopic findings and RSS was statistically not significant (k - 0.0986).

Conclusion:

Pre-operative endoscopy is a must in all bariatric patients as significant percentage of asymptomatic patients can have abnormal endoscopy and vice versa.

Association between Reflux Esophagitis Incidence and Palmar Hyperhidrosis

The autonomic dysfunction in palmar hyperhidrosis (PH) includes not only sympathetic overactivity but also parasympathetic impairment. A decrease of parasympathetic tone has been noted in gastroesophageal reflux disease of neonates and adults. Patients with reflux esophagitis have a defective anti-reflux barrier. The association between reflux esophagitis and PH is deliberated in this article. The National Health Insurance Database in Taiwan was used. At first-time visits, PH patients were identified by the International Classification of Disease, 9th Revision, Clinical Modification disease code of 780.8 without endoscopic thoracic sympathectomy. Patients were matched by age and gender as control groups. The reflux esophagitis incidence was assessed using disease codes 530.11, 530.81, and 530.85. The factors related to reflux esophagitis were established by the Cox proportional regression model. The risk of reflux esophagitis in PH patients had a hazard ratio of 3.457 (95% confidence interval: 3.043-3.928) after adjustment of the other factors. We confirmed the association between reflux esophagitis and PH. Health care providers must be alerted to this relationship and other risk factors of reflux esophagitis to support suitable treatments to improve the quality of life of patients.

Gastroesophageal reflux disease and atrial fibrillation: Insight from autonomic cardiogastric neural interaction

BACKGROUND

The relationship between gastroesophageal reflux disease (GERD) and atrial fibrillation (AF) has been previously reported. However, the detailed mechanism remains unknown. In this study, we investigated the effects of acid reflux on the intrinsic cardiac autonomic nervous system, atrial/ventricular electrophysiology, and AF inducibility.

METHODS

Eighteen rabbits were randomized into three groups: acid reflux (group 1, n = 6), control (group 2, n = 6), and acid reflux with periesophageal vagal blockade (group 3, n = 6). Atrial and ventricular effective refractory periods (ERPs) and AF inducibility were checked at baseline and then hourly until 5 hours after the experiment.

RESULTS

Three hours after the experiment, atrial ERP prolongation was noted in groups 2 and 3 (P < .05), whereas shortening of the atrial ERPs was observed in group 1, compared with the baseline. However, no changes were observed in ventricular ERPs in the three groups. The AF inducibility was higher in group 1 than in groups 2 and 3. Pathological examination showed clear esophageal mucosal breaks in groups 1 and 3.

CONCLUSIONS

In this study, we found that the antimuscarinic blockade prevents GERD induced changes to atrial electrophysiology and susceptibility to AF-making it highly likely that autonomic activity is important in mediating this effect.

Lack of correlation between gastroesophageal reflux disease symptoms and esophageal lesions after sleeve gastrectomy

BACKGROUND

The postoperative development or worsening of gastroesophageal reflux disease (GERD) represents the major drawback of laparoscopic sleeve gastrectomy (SG). A GERD diagnosis is often based only on symptoms and proton pump inhibitors (PPI) intake, while objective tests like esophagogastroduodenoscopy and pH measurements are performed less frequently.

OBJECTIVES

To evaluate the association between reflux symptoms and GERD-related esophageal lesions.

SETTINGS

University hospital, Rome, Italy.

METHODS

A comprehensive clinical control entailing GERD symptoms, PPI intake, and esophagogastroduodenoscopy was proposed to all patients who underwent SG between June 2007 and February 2011, irrespective of the presence of GERD symptoms. One hundred forty-four of 219 patients agreed to take part in the study (follow-up rate: 65.8%).

RESULTS

After a mean follow-up of 66 months, GERD symptoms and PPI intake were recorded in 70.2% and 63.9% of patients, respectively. Mean visual analogue scale score was 2.9 ± 3.3. The overall frequency of erosive esophagitis was 59.8%, while nondysplastic Barrett's esophagus was detected in 13.1%. The frequency of esophageal biliary reflux was 68%. GERD symptoms and visual analogue scale score were not significantly associated with the development of erosive esophagitis and Barrett's esophagus and the severity of the esophageal lesions. Moreover, the frequency of erosive esophagitis and Barrett's esophagus in patients consuming PPI were similar to that of patients without PPI.

CONCLUSION

Symptoms investigation alone is not a reliable tool to diagnose GERD after SG. The use of objective diagnostic tests, such as esophagogastroduodenoscopy, should be carefully considered in the postoperative follow-up schedule of SG patients.

Food allergy and the gut

Food allergy develops as a consequence of a failure in oral tolerance, which is a default immune response by the gut-associated lymphoid tissues to ingested antigens that is modified by the gut microbiota. Food allergy is classified on the basis of the involvement of IgE antibodies in allergic pathophysiology, either as classic IgE, mixed pathophysiology or non-IgE-mediated food allergy. Gastrointestinal manifestations of food allergy include emesis, nausea, diarrhoea, abdominal pain, dysphagia, food impaction, protein-losing enteropathy and failure to thrive. Childhood food allergy has a generally favourable prognosis, whereas natural history in adults is not as well known. Elimination of the offending foods from the diet is the current standard of care; however, future therapies focus on gradual reintroduction of foods via oral, sublingual or epicutaneous food immunotherapy. Vaccines, modified hypoallergenic foods and modification of the gut microbiota represent additional approaches to treatment of food allergy.

Non-IgE-mediated gastrointestinal food allergies in children

Non-IgE-mediated gastrointestinal food allergic disorders (non-IgE-GI-FA) including food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE), and food protein-induced allergic proctocolitis (FPIAP) are relatively uncommon in infants and young children, but are likely under-diagnosed. Non-IgE-GI-FA have a favorable prognosis, with majority resolving by age 3-5 years. Diagnosis relies on the recognition of symptoms pattern in FPIAP and FPIES and biopsy in FPE. Further studies are needed for a better understanding of the pathomechanism, which will lead eventually to the development of diagnostic tests and treatments. Limited evidence supports the role of food allergens in subsets of constipation, gastroesophageal reflux disease, irritable bowel syndrome, and colic. The immunologic pathomechanism is not fully understood and empiric prolonged avoidance of food allergens should be limited to minimize nutrient deficiency and feeding disorders/food aversions in infants.

Atrial fibrillation and gastroesophageal reflux disease: the cardiogastric interaction

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and mortality. Multiple conditions like hypertension, heart failure, diabetes, sleep apnoea, and obesity play a role for the initiation and perpetuation of AF. Recently, a potential association between gastroesophageal reflux disease (GERD) and AF development has been proposed due to the close anatomic vicinity of the oesophagus and the left atrium. As an understanding of the association between acid reflux disease and AF may be important in the global multimodal treatment strategy to further improve outcomes in a subset of patients with AF, we discuss potential atrial arrhythmogenic mechanisms in patients with GERD, such as gastric and subsequent systemic inflammation, impaired autonomic stimulation, mechanical irritation due to anatomical proximity of the left atrium and the oesophagus, as well as common comorbidities like obesity and sleep-disordered breathing. Data on GERD and oesophageal lesions after AF-ablation procedures will be reviewed. Treatment of GERD to avoid AF or to reduce AF burden might represent a future treatment perspective but needs to be scrutinized in prospective trials.

Esophageal acid stimulation alters insular cortex functional connectivity in gastroesophageal reflux disease

BACKGROUND

The insula plays a significant role in the interoceptive processing of visceral stimuli. We have previously shown that gastroesophageal reflux disease (GERD) patients have increased insular cortex activity during esophageal stimulation, suggesting a sensitized esophago-cortical neuraxis. However, information regarding the functional connectivity (FC) of the insula during visceral stimulation is lacking. The primary aim of this study was to investigate the FC of insular subregions during esophageal acid stimulation.

METHODS

Functional imaging data were obtained from 12 GERD patients and 14 healthy subjects during four steady state conditions: (i) presence of transnasal esophageal catheter (pre-infusion); (ii) neutral solution; (iii) acid infusion; (iv) presence of transnasal esophageal catheter following infusions (post-infusion). The insula was parcellated into six regions of interest. FC maps between each insular ROI and interoceptive regions were created. Differences in FC between GERD patients and healthy subjects were determined across the 4 study conditions.

KEY RESULTS

All GERD patients experienced heartburn during and after esophageal acidification. Significant differences between GERD patients and healthy subjects were seen in: (i) insula-thalamic FC (neutral solution infusion, acid infusion, post-infusion); (ii) insula-amygdala FC (acid infusion, post-infusion); (iii) insula-hippocampus and insula-cingulate FC (post-infusion).

CONCLUSIONS & INFERENCES

Esophageal stimulation in GERD patients revealed significant insular cortex FC differences with regions involved in viscerosensation and interoception. The results of our study provide further evidence that the insula, located at the transition of afferent physiologic information to human feelings, is essential for both visceral homeostasis and the experience of heartburn in GERD patients.

Hiatal Hernia Is Associated With an Increased Prevalence of Atrial Fibrillation in Young Patients

Purpose: Hiatal hernia (HH) causes protrusion of the stomach into the chest cavity, directly impinging on the left atrium and possibly increasing predisposition to atrial arrhythmogenesis. However, such association has not been fully explored. The objective was to determine if an association between HH and atrial fibrillation (AF) exists and whether there are age- and sex-related differences. Methods: Adult patients diagnosed with HH from 1976 to 2006 at Mayo Clinic Rochester, Minnesota, were evaluated for AF. The number of patients with AF and HH was compared to age- and sex-matched patients with AF reported in the general population. Long-term outcomes were compared to corresponding county and state populations. Results: During the 30-year period, 111,429 patients were diagnosed with HH (mean age 61.4 ± 13.8 years, 47.9% male) and 7,865 patients (7.1%) also had a diagnosis of AF (mean age 73.1 ± 10.5 years; 55% male). In younger patients (<55 years), the occurrence of AF was 17.5-fold higher in men with HH and 19-fold higher in women with HH compared to the frequency of AF reported in the general population. Incidence of heart failure for patients with AF and HH was worse compared to the overall county population, but better than for those with AF. Similarly, mortality was worse in patients with AF and HH compared to the overall state population, but better than for those with AF in the county. Conclusion: Hiatal hernia appears to be associated with increased frequency of AF in both men and women of all age groups, but particularly in young patients. Further studies are needed to investigate this possible association and underlying mechanism.

Esophageal motor disorders: how to bridge the gap between advanced diagnostic tools and paucity of therapeutic modalities?

High-resolution manometry has added significantly to our current understanding of esophageal motor function by providing improved detail and a data analysis paradigm that is more akin to an imaging format. Esophageal pressure topography provides a seamless dynamic representation of the pressure profile through the entire esophagus and thus, is able to eliminate movement artifact and also assess intrabolus pressure patterns as a surrogate for bolus transit mechanics. This has led to improved identification of anatomic landmarks and measurement of important physiological parameters (esophagogastric junction relaxation, distal latency, and contractile integrity). This research has bridged the gap into clinical practice by defining physiologically relevant phenotypes that may have prognostic significance and improve treatment decisions in achalasia, spasm, and hypercontractile disorders. However, more work is needed in determining the etiology of symptom generation in the context of normal or trivial motor dysfunction. This research will require new techniques to assess visceral hypersensitivity and alterations in central modulation of pain and discomfort.

Gastrointestinal side effects of prescription medications in the older adult

Gastrointestinal (GI) symptoms resulting from either prescription medications or over-the-counter drugs are frequently encountered in geriatric practice but often mistaken for symptoms of an organic disease leading to multiple diagnostic studies. The morbidity, mortality, and medical costs associated with drug toxicity, even when restricted to the GI tract, are probably underestimated. The consequences of drug toxicity are quite variable and range from a symptom of mild discomfort (eg, drug-induced diarrhea) at one end of the spectrum, to fatal GI hemorrhage or perforation. Better awareness of the possibility of drug-induced GI tract pathology by primary care physicians improves the recognition of these adverse effects, and ultimately, improves patient care. This review focuses on the most common and well-described drug-related side effects of the GI tract.

Long-term risk of atrial fibrillation with symptomatic gastroesophageal reflux disease and esophagitis

The mechanisms underlying the triggers and maintenance of atrial fibrillation (AF) are not fully understood. One potential unproved mechanism is that gastroesophageal reflux disease (GERD), in which acid reflux induces local and systemic inflammation, may increase triggered activity in the myocardium and pulmonary veins and increase AF risk. A self-report questionnaire was mailed to a random sample of 5,288 residents of Olmsted County, Minnesota, aged 25 to 74 years to assess the presence and frequency of GERD from 1988 to 1994. The long-term risk for AF over a period of 11.4 +/- 5.0 years was determined through review of clinical evaluations and the electrocardiographic database in those without previous AF. The average age was 53 +/- 17 years, and 2,571 subjects (49%) were man. Of these patients, 741 developed AF (cumulative probability of AF at 18 years 20%, 95% confidence interval [CI] 17% to 22%). Age (hazard ratio [HR] 1.09, 95% CI 1.08 to 1.10, p <0.001), male gender (HR 1.81, 95% CI 1.53 to 2.14, p <0.001), hypertension (HR 1.36, 95% CI 1.14 to 1.61, p = 0.0006), and heart failure (HR 1.74, 95% CI 1.16 to 2.60, p = 0.007) were independently associated with the risk of AF. The presence of any GERD was not associated with risk for AF (HR 0.81, 95% CI 0.68 to 0.96, p = 0.014) after adjustment for other risk factors. The frequency of GERD did not significantly affect the risk for AF, although patients with more frequent GERD had a slightly higher AF risk. Esophagitis increased the risk for AF (HR 1.94, 95% CI 1.35 to 2.78, p <0.001), but the association did not persist when accounting for other risk factors (p = 0.72). In conclusion, in this large population-based study of patients surveyed for GERD, no association was found with the presence or frequency of symptoms and AF. Patients with esophagitis were more likely to develop AF, although this association requires further study.

Allergic gastrointestinal motility disorders in infancy and early childhood

Gastro-oesophageal reflux disease, constipation and colic are among the most common disorders in infancy and early childhood. In at least a subset of infants with these functional disorders, improvement after dietary elimination of specific food proteins has been demonstrated. Gastrointestinal food allergy should therefore be considered in the differential diagnosis of infants presenting with persistent regurgitation, constipation or irritable behaviour, particularly if conventional treatment has not been beneficial. The diagnosis of food protein-induced gastrointestinal motility disorders is hampered by the absence of specific clinical features or useful laboratory markers. Gastrointestinal biopsies before commencing a hypoallergenic diet may provide the most important diagnostic clues. Early recognition is essential for the optimal management of these patients to prevent nutritional sequelae or aversive feeding behaviours. Treatment relies on hypoallergenic formulae, as well as maternal elimination diets in breast-fed infants. Further research is required to better define the pathological mechanisms and diagnostic markers of paediatric allergic gastrointestinal motility disorders. The following article will present three instructive cases followed by discussion of the clinical presentation, diagnosis, treatment and natural history of food allergic motility disorders in infancy and early childhood.