Validation in China of a non-invasive salivary pepsin biomarker containing two unique human pepsin monoclonal antibodies to diagnose gastroesophageal reflux disease

Diagnostic value associated with the combination of saliva pepsin and microorganisms in functional heartburn and gastroesophageal reflux disease

Heartburn is a common symptom shared by both gastroesophageal reflux disease (GERD) and functional heartburn (FHB), which can make it challenging to differentiate between the two conditions. However, examining oral manifestations of GERD can be a cost-effective and readily available method to aid in this differentiation process. It may serve as a valuable tool in distinguishing GERD from FHB.

Clinical relevance of salivary pepsin detection in diagnosing gastroesophageal reflux disease subtypes

Background

Gastroesophageal reflux disease (GERD) is heterogeneous with a varied symptom spectrum and reflux profiles. Its definite diagnosis often requires invasive tools including endoscopy or reflux monitoring. The aim of this study was to investigate the clinical relevance of salivary pepsin detection as a non-invasive screening tool to diagnose GERD of different subtypes.

Methods

A total of 77 patients with suspected GERD symptoms and 12 asymptomatic controls were analysed. All participants performed symptom evaluation, upper endoscopy, esophageal manometry, and 24-hour multichannel intraluminal impedance-dual pH probe monitoring. Saliva was self-collected across three different time points: at early fasting, postprandially, and at symptom occurrence. Salivary pepsin levels were measured via Peptest. The optimal threshold of salivary pepsin for diagnosing distal or proximal reflux was determined according to a receiver-operating characteristic curve.

Results

The average salivary pepsin concentration of suspected GERD patients was significantly higher than that of controls (100.63 [68.46, 141.38] vs 67.90 [31.60, 115.06] ng/mL, P = 0.044), although no difference was found among patients with different symptom spectrums. The distal reflux group had a higher average pepsin concentration than non-reflux patients (170.54 [106.31, 262.76] vs 91.13 [63.35, 127.63] ng/mL, P = 0.043), while no difference was observed between the distal reflux group and the proximal reflux group. The optimal cut-off value of salivary pepsin concentration for diagnosing pathological distal reflux was 157.10 ng/mL, which was higher than that for diagnosing pathological proximal reflux (122.65 ng/mL). The salivary pepsin concentration was significantly correlated with distal and proximal reflux parameters.

Conclusions

Salivary pepsin measurement can help in identifying true GERD with pathological distal reflux or proximal reflux, regardless of different symptom spectrums. A higher threshold should be applied for diagnosing distal reflux than for proximal reflux.

The clinical application value of salivary pepsin in the diagnosis of gastroesophageal reflux diseases

BACKGROUND

Peptest is a noninvasive and convenient diagnostic kit for gastroesophageal reflux disease (GERD). We aimed to explore the application value of Peptest in the diagnosis of GERD.

METHODS

Patients suspected of GERD all completed 24 h pH-impedance monitoring (24 h MII-pH) and then took proton pump inhibitor (PPI) 2 weeks. The postprandial, post-symptom and random salivary samples were taken. Receiver operating characteristic analysis was used to identify the best cutoff value of Peptest, to differentiate GERD patients from non-GERD patients and the optimal sampling time of Peptest was analyzed. Reflux characteristics and esophageal motility between Peptest (+) group and Peptest (-) group were compared in negative 24 h MII-pH patients. Peptest concentration were compared among non-reflux, distal reflux, and proximal reflux groups according to 24 h MII-pH curve.

RESULTS

The area under the curve of post-symptom Peptest was highest in three time points and the diagnostic specificity was 81.0% and sensitivity was 53.3% with the diagnostic value of 86 ng/mL. Compared with negative Peptest group, distal mean nocturnal baseline impedance was significantly lower, gastroesophageal junction contractile integral was substantially lower in positive Peptest group in negative 24 h MII-pH patients. The concentration of post-symptom and postprandial Peptest increased gradually in the non-reflux, distal reflux, and proximal reflux groups.

CONCLUSIONS & INFERENCES

Peptest has a relatively low diagnostic value for GERD. Post-symptom Peptset is the best sampling time with the optimal value of 86 ng/mL and may have auxiliary diagnostic value for negative 24 h MII-pH patients. Peptest may assist 24 h MII-pH in monitoring proximal reflux.

Noninvasive, MultiOmic, and Multicompartmental Biomarkers of Reflux Disease: A Systematic Review

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disorder that may complicate conditions such as obstructive airway disease. Our group has identified predictive biomarkers of GERD in particulate exposed first responders with obstructive airway disease. In addition, GERD diagnosis and treatment is costly and invasive. In light of these clinical concerns, we aimed to systematically review studies identifying noninvasive, multiOmic, and multicompartmental biomarkers of GERD.

METHODS

A systematic review of PubMed and Embase was performed using keywords focusing on reflux disease and biomarkers and registered with PROSPERO. We included original human studies in English, articles focusing on noninvasive biomarkers of GERD published after December 31, 2009. GERD subtypes (non-erosive reflux disease and erosive esophagitis) and related conditions (Barrett's Esophagus [BE] and Esophageal Adenocarcinoma). Predictive measures were synthesized and risk of bias assessed (Newcastle-Ottawa Scale).

RESULTS

Initial search identified n = 238 studies andn 13 articles remained after applying inclusion/exclusion criteria. Salivary pepsin was the most studied biomarker with significant sensitivity and specificity for GERD. Serum assessment showed elevated levels of Tumor Necrosis Factor-alpha in both GERD and Barrett's. Exhaled breath volatile sulfur compounds and acetic acid were associated with GERD. Oral Microbiome: Models with Lautropia, Streptococcus, and Bacteroidetes showed the greatest discrimination between BE and controls vs Lautropia; ROCAUC 0.94 (95% confidence interval; 0.85-1.00).

CONCLUSION

Prior studies identified significant multiOmic, multicompartmental noninvasive biomarker risks for GERD and BE. However, studies have a high risk of bias and the reliability and accuracy of the biomarkers identified are greatly limited, which further highlights the need to discover and validate clinically relevant noninvasive biomarkers of GERD.

Salivary biomarkers and esophageal disorders

Saliva is a complex physiologic fluid that contains an abundance of biological analytes, or biomarkers. Recent research has shown that these biomarkers may be able to convey the physiologic health of a person. Work has been done linking derangements in these salivary biomarkers to a wide variety of pathologic disorders ranging from oncologic diseases to atopic conditions. The specific area of interest for this review paper is esophageal disorders. Particularly because the diagnosis and management of esophageal disorders often includes invasive testing such as esophagogastroduodenoscopy, prolonged pH monitoring, and biopsy. The aim of this review will be to explore salivary biomarkers (pepsin, bile, epidermal growth factor, and micro-RNA) that are being studied as they relate specifically to esophageal disorders. Finally, it will explore the benefits of salivary testing and identify areas of possible future research.

Gastroesophageal reflux disease and salivary pepsin in patients with heterotopic gastric mucosa in the upper esophagus

BACKGROUND

Heterotopic gastric mucosa in the upper esophagus (HGMUE) is reported to be related to gastroesophageal reflux disease (GERD). This study investigated the prevalence of GERD and the use of salivary pepsin to diagnose gastroesophageal reflux, especially proximal reflux, in HGMUE patients.

METHODS

One hundred and fifty-three HGMUE patients and 50 healthy volunteers were studied. All subjects took a reflux symptom index questionnaire (RSI); underwent endoscopy, barium esophagogram, high-resolution manometry (HRM), and 24-hour multichannel intraluminal impedance-pH-metry (MII-pH); and salivary pepsin test.

RESULTS

Ninety-five (62.1%) HGMUE patients but no control subjects were diagnosed with GERD. The salivary pepsin concentration, RSI score, DeMeester score, acid exposure time (AET), total reflux episodes, proximal acidic reflux episodes, and proximal weakly acidic reflux episodes were significantly higher in the HGMUE group than in the control group (P < 0.05). The salivary pepsin test showed a sensitivity of 85.9% and specificity of 56.9% for diagnosing GERD using the optimal cut-off value of 75 ng/mL. One hundred and seven (69.9%) and 46 (30.1%) HGMUE patients were categorized as pepsin (+) and pepsin (-), respectively when 75 ng/mL was used as a cut-off value. Male sex, RSI, AET, and proximal acid reflux episodes were positive predictive factors for the occurrence of pepsin (+) in HGMUE patients.

CONCLUSIONS

GERD, especially GERD with proximal acid reflux and related symptoms, was common in HGMUE patients. The salivary pepsin test could be an additional useful test for testing reflux in HGMUE patients, but it will not replace the MII-pH.

A urine and serum metabolomics study of gastroesophageal reflux disease in TCM syndrome differentiation using UPLC-Q-TOF/MS

Gastroesophageal reflux disease (GERD) is a common, chronic and complex upper gastrointestinal disease. In Traditional Chinese medicine (TCM) theory, GERD is classified into two main types: stagnant heat of liver and stomach (SHLS) and deficient cold of spleen and stomach (DCSS). The discovery and evaluation of potential biomarkers for different syndrome types of GERD may contribute to comprehend specific molecular mechanism and identify new targets for diagnosis and appropriate management. In our study, 60 subjects including 40 GERD patients (20 SHLS and 20 DCSS) and 20 healthy controls were recruited, and the serum and urine metabolic profiles from untargeted liquid chromatography coupled to mass spectrometry (LC-MS) metabolomics approach were obtained. Finally 38 biomarkers associated with disease were identified and 9 metabolic pathways were enriched. The most enriched pathways were amino acid metabolism, steroid hormone biosynthesis, glycerophospholipid metabolism, sphingolipid metabolism and TCA cycle. According to the area under curve (AUC) value, we propose a cohort of three metabolites from urine and serum samples as promising biomarkers for TCM syndrome differentiation of GERD, which are prolylhydroxyproline, glycitein-4'-O-glucuronide, capsianoside I in urine and neuAcalpha2-3Galbeta-Cer (d18:1/16:0), sphinganine, arachidonic acid in serum. The cumulative AUC value of merged biomarkers in urine and serum was 0.979 (95%CI 0.927-1) and 0.842 (95%CI 0.704-0.980), respectively. The results indicated that LC-MS based metabolomic profiling method might be an effective and promising tool on further pathogenesis discovering of GERD. The findings provided new strategy for the diagnosis of GERD TCM syndrome differentiation in clinic.

Salivary peptest for laryngopharyngeal reflux and gastroesophageal reflux disease: A systemic review and meta-analysis

BACKGROUND

A rapid lateral flow test (Peptest) to detect pepsin in saliva/sputum has been considered as a valuable method for diagnosing laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD). The aim of this meta-analysis is to analyze the utility of Peptest for diagnosis of LPR and GERD.

METHODS

PubMed, EMBASE, and the Cochran Library (from January 1980 to 26 January 2020) were searched for pepsin in saliva for LPR/GERD diagnosis. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve data were summarized to examine the accuracy.

RESULTS

A total of 16 articles that included 2401 patients and 897 controls were analyzed. The pooled sensitivity and specificity for the diagnosis of GERD/LPR with Peptest were 62% (95% confidence interval [CI] 49%-73%) and 74% (95% CI 50%-90%), respectively. The summarized diagnostic odds ratio and area under the curve were 5.0 (95% CI 2-19) and 0.70 (95% CI 0.66-0.74), respectively.

CONCLUSION

Peptest shows moderate diagnostic value for LPR and GERD. More studies with standard protocols should be done to verify its usefulness.

The Role of Salivary Pepsin in the Diagnosis of Gastroesophageal Reflux Disease (GERD) Evaluated Using High-Resolution Manometry and 24-Hour Multichannel Intraluminal Impedance-pH Monitoring

BACKGROUND The Lyon Consensus classification confirms or rules out gastroesophageal reflux disease (GERD). The refractory symptoms of patients with GERD taking proton pump inhibitors (PPIs) are challenging in clinical practice. Salivary pepsin concentration was proposed as a diagnostic biomarker for GERD. We aimed to determine the diagnostic value of salivary pepsin concentration for patients with conclusive GERD, based on the Lyon classification, and the correlation of salivary pepsin concentration with parameters of high-resolution manometry and 24-h multichannel intraluminal impedance-pH in patients with PPI-refractory symptoms. MATERIAL AND METHODS Saliva samples obtained from 130 patients who were suspicious for GERD and had PPI-refractory symptoms were used for pepsin determination using the enzyme-linked immunosorbent assay. All patients underwent upper gastrointestinal endoscopy, high-resolution manometry, 24-h multichannel intraluminal impedance, and pH recording and were classified as conclusive GERD, inconclusive GERD, and evidence against GERD groups according to Lyon classification. RESULTS Salivary pepsin concentration was 8.2 ng/mL (3.8-17.8 ng/mL), 4.0 ng/mL (2.3-6.1 ng/mL), and 2.4 ng/mL (2.2-3.1 ng/mL) in conclusive GERD, inconclusive GERD, and evidence against GERD groups, respectively (P<0.001), and had a negative correlation with distal mean nocturnal baseline impedance and positive correlations with acid exposure time, total number of reflux events, and esophagogastric junction type. The area under the ROC curve of salivary pepsin for conclusive GERD was 0.76 (0.68-0.84), with a sensitivity of 76.36% and a specificity of 63.41% for conclusive GERD diagnosis at a cut-off value of 4.21 ng/mL. CONCLUSIONS Salivary pepsin test had moderate diagnostic value for conclusive GERD by Lyon classification in patients with PPI-refractory symptoms.