Pathophysiological characteristics of patients with non-erosive reflux disease differ from those of patients with functional heartburn

Esophageal motor abnormalities in gastroesophageal reflux disorders

Gastroesophageal reflux disease (GERD), a prevalent condition with multifactorial pathogenesis, involves esophageal motor dysmotility as a key contributing factor to its development. When suspected GERD patients have an inadequate response to proton-pump inhibitor (PPI) therapy and normal upper endoscopy results, high-resolution manometry (HRM) is utilized to rule out alternative diagnosis such as achalasia spectrum disorders, rumination, or supragastric belching. At present, HRM continues to provide supportive evidence for diagnosing GERD and determining the appropriate treatment. This review focuses on the existing understanding of the connection between esophageal motor findings and the pathogenesis of GERD, along with the significance of esophageal HRM in managing GERD patients. The International GERD Consensus Working Group introduced a three-step method, assessing the esophagogastric junction (EGJ), esophageal body motility, and contraction reserve with multiple rapid swallow (MRS) maneuvers. Crucial HRM abnormalities in GERD include frequent transient lower esophageal sphincter relaxations, disrupted EGJ, and esophageal body hypomotility. Emerging HRM metrics like EGJ-contractile integral and innovative provocative maneuver like straight leg raise have the potential to enhance our understanding of factors contributing to GERD, thereby increasing the value of HRM performed in patients who experience symptoms suspected of GERD.

Recent insights on functional heartburn and reflux hypersensitivity

PURPOSE OF REVIEW

Rome IV experts have proposed that gastroesophageal reflux disease (GERD) should be diagnosed only in patients with abnormal esophageal acid exposure, and that reflux hypersensitivity (RH) and functional heartburn (FH) both should be considered functional conditions separate from GERD. Although past and recent evidence support that FH can be completely distinguished from GERD, the concept that RH is not GERD is highly questionable. This review attempts to provide current data on these issues.

RECENT FINDINGS

Many recent investigations have provided new data on the different pathophysiological features characterizing RH and FH. Major differences have emerged from analyses of impedance-pH monitoring studies using the novel impedance metrics of baseline impedance (an index of mucosal integrity) and the rate of postreflux swallow-induced peristaltic waves (a reflection of the integrity of esophageal chemical clearance).

SUMMARY

The better ability to interpret impedance-pH tracings together with earlier data on the different prevalence of microscopic esophagitis in RH and FH patients, and recent studies documenting poor therapeutic efficacy of pain modulators and good results of antireflux surgery for RH support recategorization of RH within the GERD world. Further research is needed to correctly phenotype patients who have heartburn without mucosal breaks, and to guide their effective management.

Untangling Nonerosive Reflux Disease From Functional Heartburn

Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have nonerosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common phenotype of gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. A diagnosis of NERD requires endoscopy and reflux testing, whereas a diagnosis of functional heartburn also requires esophageal manometry. NERD is treated most commonly with medical, endoscopic, and surgical antireflux approaches, whereas functional heartburn as well as NERD can be treated with neuromodulators, psychological intervention, and complementary medicine options.

Evaluation of symptomatic reflux esophagitis in proton pump inhibitor users

The aim of the present study was to evaluate symptomatic reflux esophagitis (RE) in proton pump inhibitor (PPI) users. The present study conducted a hospital-based, retrospective cross-sectional study of consecutive RE cases in PPI users at Juntendo University Hospital recruited between 2008 and 2016. Eligible patients were PPI users with a complete patient profile, who completed the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) questionnaire, and who underwent upper gastrointestinal endoscopy for the examination of RE, hiatal hernia (HH) and endoscopic gastric mucosal atrophy (EGA). The patients with RE who were administered PPIs were divided into two groups: Those with symptomatic RE (FSSG≥8) and those with non-symptomatic RE (FSSG<8). The present study investigated the risk factors for symptomatic RE among the patients with RE patients who were administered PPIs. Of the 13,052 cases who underwent patient profiling, the FSSG questionnaire and upper gastrointestinal endoscopy, a total of 2,444 PPI users were eligible. Of the PPI users, 206 cases (8.4%) had RE. Among the 206 patients with RE, 115 (55.8%) had symptomatic RE. The profile of the symptomatic and non-symptomatic RE groups were as follows: A total of 45 females (39.1%) vs. 32 females (35.2%; non-significant); mean ± standard deviation age, 54.8±13.5 vs. 62.9±11.1 years (P<0.01); mean body mass index, 23.5±3.3 vs. 23.2±3.8 (non-significant); severe RE, 12 (10.4%) vs. 2 (2.2%; P<0.05); HH, 70 (60.9%) vs. 40 (44.0%; P<0.05); and mean score of EGA, 1.2±1.8 vs. 1.8±2.1 (P<0.05). Multivariate analysis revealed that a younger age [odds ratio (OR)=0.94; 95% confidence interval (CI): 0.92-0.97, P<0.01] and HH(+) (OR=2.37; 95% CI: 1.30-4.34, P<0.01) were associated with symptomatic RE among patients with RE who were administered PPIs. In conclusion, a younger age and HH were associated with symptomatic RE in patients with RE who were administered PPIs.

Esophageal Motor Disorders Are a Strong and Independant Associated Factor of Barrett's Esophagus

Background/Aims

Esophageal motor disorder (EMD) has been shown to be associated with gastroesophageal reflux disease (GERD). However, the association of EMD with a Barrett's esophagus (BE) is controversial. Our objective was to evaluate whether the presence of EMD was an independent factor associated with BE.

Methods

A retrospective case-control study was conducted in GERD patients who all had oeso-gastroduodenal endoscopy and high-resolution esophageal manometry. The clinical data collected was known or potential risk factors for BE: male gender, smoking and alcohol consumption, age, body mass index, presence of hiatal hernia, frequency, and age of GERD. EMD were classified according to the Chicago classification into: ineffective motor syndrome, fragmented peristalsis and absence of peristalsis, lower esophageal sphincter hypotonia.

Results

Two hundred and one patients (101 in the GERD + BE group and 100 in the GERD without BE) were included. In univariate analysis, male gender, alcohol consumption, presence of hiatal hernia, and EMD appeared to be associated with the presence of BE. In a multivariate analysis, 3 independent factors were identified: the presence of EMD (odds ratio [OR], 3.99; 95% confidence interval [CI], 1.71-9.28; P = 0.001), the presence of hiatal hernia (OR, 5.60; 95% CI, 2.45-12.76; P ＜ 0.001), Helicobacter pylori infection (OR, 0.08; 95% CI, 0.01-0.84; P = 0.035).

Conclusions

The presence of EMD (particularly ineffective motor syndrome and lower esophageal sphincter hypotonia) is a strong independent associated factor of BE. Searching systematically for an EMD in patients suffering from GERD could be a new strategy to organize the endoscopic follow-up.

High-resolution manometry is superior to endoscopy and radiology in assessing and grading sliding hiatal hernia: A comparison with surgical in vivo evaluation

Background

Hiatal hernia is diagnosed by barium-swallow esophagogram or esophagogastroduodenoscopy, with possible suboptimal results. High-resolution manometry clearly identifies crural diaphragm and lower esophageal sphincter.

Objectives

To assess the diagnostic accuracy of high-resolution manometry in detecting hiatal hernia compared to esophagogram and esophagogastroduodenoscopy, using as reference the surgical in vivo measurement.

Methods

Patients were studied with esophagogram, esophagogastroduodenoscopy, high-resolution manometry and in vivo evaluation of the esophago-gastric junction. Esophago-gastric junction was classified as type I (no separation between crural diaphragm and lower esophageal sphincter); type II (≥1, ≤ 2 cm separation); type III (>2 cm). During in vivo measurement, distance between the esophago-gastric junction and crural diaphragm proximal border was recorded.

Results

Surgery identified 53 hiatal hernias in 100 patients. Forty-seven percent were classified as type I esophago-gastric junction, 35% type II and 18% type III. Referenced to in vivo evaluation, high-resolution manometry showed superior diagnostic sensitivity and specificity (94.3% and 91.5%, respectively) to esophagogram and esophagogastroduodenoscopy, with 92.6% predictive value of a positive test and 93.5% predictive value of a negative test. The kappa value for high-resolution manometry and in vivo evaluation was 0.85. High-resolution manometry showed optimal sensitivity and specificity in detecting types I, II and III esophago-gastric junction.

Conclusions

High-resolution manometry enables an accurate diagnosis of hiatal hernia and a better classification than endoscopy and radiology, reaching optimal agreement with in vivo assessment.

The Rome IV versus Rome III criteria for heartburn diagnosis: A comparative study

BACKGROUND

The phenotypes of heartburn patients are heterogeneous.

OBJECTIVE

The objective of this study was to investigate the proportion of heartburn phenotypes in a Chinese population and to compare the Rome IV and III criteria for heartburn diagnosis.

METHODS

A retrospective study was performed among heartburn patients referred for upper endoscopy and esophageal function tests in a tertiary hospital. Their symptoms fulfilled Rome IV and III criteria.

RESULTS

A total of 233 patients were included. Fifty-nine patients (25%) were diagnosed with esophagitis, 96 (41%) with non-erosive reflux disease (NERD) and 78 (34%) with functional heartburn (FH) based on Rome III criteria. Approximately 70% of the Rome III NERD patients were changed based on Rome IV criteria, with 36 patients (15%) diagnosed with reflux hypersensitivity (RH) and 32 patients (14%) who didn't fulfill the criteria considered unclassified. The FH and RH patients showed higher esophagogastric junction-contractile integral (EGJ-CI) and less hiatal hernia than did Rome IV NERD patients. The unclassified had more hiatal hernias than the FH and RH (p < 0.05). The EGJ-CI was similar between Rome III NERD and FH cases.

CONCLUSION

The Rome IV criteria were stricter for heartburn diagnosis and superior in distinguishing NERD from functional disorders on motility patterns than Rome III.

Esophageal Impedance Monitoring: Clinical Pearls and Pitfalls

The development of intraluminal esophageal impedance monitoring has improved our ability to detect and measure gastroesophageal reflux without dependence on acid content. This ability to detect previously unrecognized weak or nonacid reflux episodes has had important clinical implications in the diagnosis and management of gastroesophageal reflux disease (GERD). In addition, with the ability to assess bolus transit within the esophageal lumen, impedance monitoring has enhanced the recognition and characterization of esophageal motility disorders in patients with nonobstructive dysphagia. The assessment of the intraluminal movement of gas and liquid has also been proven to be of diagnostic value in conditions such as rumination syndrome and excessive belching. Further, alternative applications of impedance monitoring, such as the measurement of mucosal impedance, have provided novel insights into assessing esophageal mucosal integrity changes as a consequence of inflammatory change. Future applications for esophageal impedance monitoring also hold promise in esophageal conditions other than GERD. However, despite all of the clinical benefits afforded by esophageal impedance monitoring, important clinical and technical shortcomings limit its diagnostic value and must be considered when interpreting study results. Overinterpretation of studies or application of impedance monitoring in patients can have deleterious clinical implications. This review will highlight the clinical benefits and limitations of esophageal impedance monitoring and provide clinical pearls and pitfalls associated with this technology.

Diagnosis and Management of Functional Heartburn

Heartburn is among the most common gastrointestinal symptoms presenting to both generalist physicians and gastroenterologists. Heartburn that does not respond to traditional acid suppression is a diagnostic and therapeutic dilemma. In the era of high utilization of proton pump inhibitors, a substantial proportion of patients presenting to the gastroenterologist with chronic symptoms of heartburn do not have a reflux-mediated disease. Subjects without objective evidence of reflux as a cause of their symptoms have "functional heartburn". The diagnostic role of endoscopy, reflux and motility testing in functional heartburn (FH) patients is discussed. Lifestyle modifications, pharmacological interventions, and alternative therapies for FH are also presented. Recognition of patients with FH allows earlier assignment of these patients to different treatment algorithms, which may allow greater likelihood of success of treatment, diminished resource utilization and improved quality of life. Further data on this large and understudied group of patients is necessary to allow improvement in treatment algorithms and a more evidence-based approach to care of these patients.

Dysmotility and reflux disease

PURPOSE OF REVIEW

In the last decade, with the advent of new oesophageal testing [i.e. 24-h impedance-pH monitoring, combined impedance-manometry, high-resolution manometry (HRM)], relevant progress in understanding the mechanisms contributing to the development of gastro-oesophageal reflux disease (GORD) has been made, allowing a better management of patients with this disorder. The aim of our review is to report the state-of-the-art about oesophageal motor disorders in patients with reflux disease and to stimulate new research in this field.

RECENT FINDINGS

Hypotensive lower oesophageal sphincter (LOS), transient LOS relaxations, impairment of oesophagogastric junction including hiatal hernia, oesophageal bolus transit abnormalities and presence of ineffective oesophageal motility have been strongly implicated in GORD development. In particular, the majority of recent studies carried out with HRM and impedance-pH testing reported that these motor abnormalities are increasingly prevalent with increasing severity of GORD, from nonerosive reflux disease and erosive oesophagitis to Barrett's oesophagus.

SUMMARY

Defining and characterizing oesophageal dysmotility in patients with reflux disease is of maximum importance in order to properly diagnose these patients and to treat them with the best management of care. New studies are needed in order to better understand the physiomechanic basis of oesophageal dysmotility in GORD patients.

Esophageal motility abnormalities in gastroesophageal reflux disease

Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophageal motility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from non-erosive reflux disease to erosive reflux disease and Barrett’s esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.

The value of early wireless esophageal pH monitoring in diagnosing functional heartburn in refractory gastroesophageal reflux disease

BACKGROUND AND AIMS

It is difficult to differentiate functional heartburn from proton pump inhibitor (PPI) failure. The aims of this study were to assess the role of early wireless esophageal pH monitoring in patients referred with gastroesophageal reflux disease (GERD) and to identify differences in the clinical spectrum among GERD subtypes.

METHODS

We enrolled consecutive referred patients with suspected GERD. After endoscopy on the first visit, all underwent wireless esophageal pH monitoring when off the PPI.

RESULTS

Two hundred thirty patients were enrolled. These patients were classified into a reflux esophagitis group (20, 8.7 %) and a normal endoscopic findings group (210, 91.3 %). Among the 210 patients in the normal endoscopic findings group, 63 (27.4 %) were diagnosed with pathological reflux, 35 (15.2 %) with hypersensitive esophagus, 87 (37.8 %) with normal acid exposure with negative symptom association, and 25 (10.9 %) with test failure. These groups did not differ in age, body mass index, smoking habit, alcohol consumption, symptom severity, quality of life, presence of atypical symptoms, overlap with irritable bowel syndrome, and the frequency of somatization, depression, and anxiety. PPI responses were evaluated in 135 patients. Fifty patients (37.0 %) were not responsive to the 4-week treatment; 26 (19.3 %) were diagnosed with refractory non-erosive gastroesophageal disease, and 24 (17.8 %) with functional heartburn. The demographics and clinical and psychological characteristics did not differ between the two groups.

CONCLUSIONS

Demographic characteristics and symptom patterns alone cannot differentiate functional heartburn from various subtypes of GERD. Wireless esophageal pH monitoring should be considered for the initial evaluation of GERD in the tertiary referral setting.

Esophageal chemical clearance is impaired in gastro-esophageal reflux disease--a 24-h impedance-pH monitoring assessment

BACKGROUND

Impedance-pH monitoring allows assessment of retrograde and antegrade intra-esophageal movement of fluids and gas. Reflux is followed by volume clearance and chemical clearance, elicited by secondary and swallow-induced peristalsis, respectively. We aimed to assess whether chemical clearance is impaired in gastro-esophageal reflux disease (GERD).

METHODS

Blinded retrospective review of impedance-pH tracings from patients with erosive reflux disease (ERD) and non-erosive reflux disease (NERD), and from proton pump inhibitor (PPI)-refractory patients before and after laparoscopic fundoplication. The number of refluxes followed within 30 s by swallow-induced peristaltic waves was divided by the number of total refluxes to obtain a parameter representing chemical clearance namely the postreflux swallow-induced peristaltic wave (PSPW) index.

KEY RESULTS

The PSPW index was significantly lower in 31 ERD (15%) and in 44 NERD (33%) off-PPI patients than in 30 controls (75%), as well as in 18 ERD (16%) and in 48 NERD (31%) on-PPI patients than in 26 on-PPI functional heartburn (FH) cases (67%) (P < 0.05 for all comparisons). In 29 PPI-refractory patients, the median PSPW index was unaltered by otherwise effective antireflux surgery (20% postoperatively, 21% preoperatively). The overall sensitivity, specificity, positive, and negative predictive values of the PSPW index in identifying GERD patients were 97%, 89%, 96%, and 93%.

CONCLUSIONS & INFERENCES

Impairment of chemical clearance is a primary pathophysiological mechanism specific to GERD: it is unaffected by medical/surgical therapy, is not found in FH, and is more pronounced in ERD than in NERD. Using the PSPW index could improve the diagnostic efficacy of impedance-pH monitoring.

The effects of increasing body mass index on heartburn severity, frequency and response to treatment with dexlansoprazole or lansoprazole

BACKGROUND

Higher body mass index (BMI) is a recognised risk factor for gastro-oesophageal reflux disease (GERD). Data regarding the impact of BMI on proton pump inhibitor (PPI) therapy are conflicting.

AIM

To assess the impact of BMI on baseline heartburn symptom severity and frequency and response to PPI therapy in patients with non-erosive GERD (NERD) or erosive oesophagitis (EO).

METHODS

In post hoc analyses of phase 3 trial data, 621 NERD and 2692 EO patients were stratified by BMI (<25, 25 to <30 and ≥30 kg/m(2) ). NERD patients received either dexlansoprazole MR 30 mg or placebo daily for 4 weeks. EO patients received either dexlansoprazole MR 60 mg or lansoprazole 30 mg for 8 weeks. Symptom frequency and severity were assessed at baseline and subsequently by daily diary.

RESULTS

In both the NERD and EO cohorts, baseline heartburn severity increased with increasing BMI. The impact of PPI therapy on the reduction in heartburn symptom frequency and severity in both NERD and EO patients was similar across BMI categories. EO healing rates in patients treated with dexlansoprazole but not lansoprazole were higher in obese patients compared with those with a BMI <30 kg/m(2) . Differences between the PPIs were small.

CONCLUSIONS

The PPIs evaluated in this study reduced the frequency and severity of 24-h heartburn regardless of baseline BMI. In addition, because patients with higher BMI have more severe symptoms at baseline, they may experience greater therapeutic gain with dexlansoprazole (NERD and erosive oesophagitis) and possibly lansoprazole (erosive oesophagitis) treatment.

Pathogenesis of proton-pump inhibitor-refractory non-erosive reflux disease according to multichannel intraluminal impedance-pH monitoring

BACKGROUND AND AIM

Proton-pump inhibitor (PPI) therapy is the first-line treatment for gastroesophageal reflux disease; however, there are some reports of PPI failure in cases of non-erosive reflux disease (NERD). Among the pathogenic factors associated with PPI-refractory NERD, reflux other than acid reflux can not be detected by conventional pH monitoring. The purpose of this study was to clarify the usefulness of multichannel intraluminal impedance-pH (MII-pH) monitoring for PPI-refractory NERD patients and examine the pathogenesis.

METHODS

We used MII-pH monitoring to examine 29 PPI-refractory NERD patients on PPI treatment. Reflux parameters, symptom index (SI: positive if ≥ 50%), and proximal migration were analyzed. The acidity of the reflux was divided into acid (nadir pH ≤ 4) and non-acid (nadir pH > 4). Subjects were classified into reflux-related disease (abnormal reflux parameters or positive SI) and non-reflux-related disease (normal reflux parameters and negative SI).

RESULTS

Of the 29 subjects, 21 were diagnosed with reflux-related disease, including 6 with acid reflux type and 15 with non-acid reflux type, and 8 were diagnosed with non-reflux-related disease. Of the total 1816 liquid reflux episodes, 834 showed proximal migration, which was more common in symptomatic reflux than in asymptomatic reflux.

CONCLUSIONS

MII-pH monitoring could distinguish reflux-related disease (especially non-acid type) from PPI-refractory NERD. Proximal migration was associated with symptomatic reflux in PPI-refractory NERD patients.

The added value of quantitative analysis of on-therapy impedance-pH parameters in distinguishing refractory non-erosive reflux disease from functional heartburn

BACKGROUND

By analysis of symptom-reflux association, endoscopy-negative refractory heartburn can be related to acid/non-acid refluxes with impedance-pH monitoring. Unfortunately, patients frequently do not report symptoms during the test. We aimed to assess the contribution of quantitative analysis of impedance-pH parameters added to symptom-reflux association in evaluating patients with endoscopy-negative heartburn refractory to high-dose proton pump inhibitor therapy.

METHODS

The symptom association probability (SAP), the symptom index (SI), the esophageal acid exposure time and the number of distal and proximal refluxes were assessed at on-therapy impedance-pH monitoring. Relationships with hiatal hernia and manometric findings were also evaluated.

KEY RESULTS

Eighty patients were prospectively studied. Refractory heartburn was more frequently related to reflux by a positive SAP/SI and/or abnormal impedance-pH parameters (52/80 cases) (65%) than by a positive SAP/SI only (38/80 cases) (47%) (P = 0.038). In patients with refractory non-erosive reflux disease (NERD) defined by a positive SAP/SI and/or abnormal impedance-pH parameters, the prevalence of hiatal hernia was significantly higher (56%vs 21%, P = 0.007) and the mean lower esophageal sphincter tone was significantly lower (18.7 vs 25.8 mmHg, P = 0.005) than in those (35%) with reflux-unrelated, i.e., functional heartburn (FH). On the contrary, no significant difference was observed subdividing patients according to a positive SAP/SI only.

CONCLUSIONS & INFERENCES

Quantitative analysis of impedance-pH parameters added to symptom-reflux association allows a subdivision of refractory-heartburn patients into refractory NERD and FH which is substantiated by pathophysiological findings and which restricts the diagnosis of FH to one third of cases.

Conventional versus robot-assisted laparoscopic Nissen fundoplication: a comparison of postoperative acid reflux parameters

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is a technically demanding surgical procedure designed to cure gastroesophageal reflux disease (GERD). It represents an alternative to life-long medical therapy and the only recommended treatment modality to overcome refractoriness to proton pump inhibitor (PPI) therapy. The recent development of robotic systems prompted evaluation of their use in antireflux surgery. Between 1997 and 2000, in a PPI-responsive series we found postoperative normalization of esophageal acid exposure time (EAET) in most but not all cases. Between 2007 and 2009, in a PPI-refractory series we found postoperative normalization of EAET in all cases. We decided to analyze retrospectively our prospectively collected data to evaluate whether differences other than the conventional or robot-assisted technique could justify postoperative differences in acid reflux parameters.

METHODS

Baseline demographic, endoscopic, and manometric parameters were compared between the two series of patients, as well as postoperative manometric and acid reflux parameters.

RESULTS

There were no significant differences in the baseline demographic, endoscopic, and manometric characteristics between the two groups of patients. The median lower esophageal sphincter tone increased significantly, and the median EAET decreased significantly after conventional as well as after robot-assisted LNF. The median postoperative EAET was significantly lower in the robot-assisted (0.2%) than in the conventional LNF group (1%; P = 0.001). Abnormal EAET values were found in 6 of 44 (14%) and in 0 of 44 cases after conventional and robot-assisted LNF, respectively (P = 0.026).

CONCLUSIONS

Robot-assisted LNF provided a significant gain in postoperative acid reflux parameters compared with the conventional technique. In a challenging clinical setting, such as PPI-refractoriness, in which the efficacy of endoscopic or pharmacological treatment modalities is only moderate, even a small therapeutic gain can be clinically relevant. In centers where robot-assisted LNF is available, it should be preferred to conventional LNF in PPI-refractory GERD.

Oesophageal motility and bolus transit abnormalities increase in parallel with the severity of gastro-oesophageal reflux disease

BACKGROUND

Limited data are available regarding the frequency of oesophageal motility and bolus transit abnormalities in subgroups of patients with gastro-oesophageal reflux disease (GERD).

AIM

To assess oesophageal motility and bolus transit in endoscopically defined GERD subgroups.

METHODS

Patients (N=755) with typical reflux symptoms underwent upper endoscopy, conventional or impedance oesophageal manometry and/or impedance-pH testing. They were divided into: erosive oesophagitis (EO; N=340), Barrett Oesophagus (BO; N=106), non-erosive reflux disease (NERD; endoscopy-, abnormal pH and/or SAP/SI+; N=239) and functional heartburn (FH; endoscopy-, normal pH and SAP/SI-; N=70). Manometric patterns and bolus transit were defined according to previously published criteria.

RESULTS

Increasing GERD severity was associated with decreased lower oesophageal sphincter resting pressure (P< 0.05) and distal oesophageal amplitude (P<0.01), higher prevalence of hiatal hernia (P<0.01) and increased prevalence of ineffective oesophageal motility (P<0.01). Patients with EO and BO had a significantly lower percentage of complete bolus transit compared with NERD and FH (P<0.01). Overall, abnormal bolus transit (ABT) for liquid swallows was found in 12% of FH, 20% of NERD, 54% of EO and 56% of BO (P<0.01). Combined impedance-manometry showed abnormal oesophageal function in 4% of FH, 4% of NERD, 22% of EO and 21% of BO patients with normal oesophageal manometry.

CONCLUSIONS

Oesophageal motility abnormalities increase in parallel with the severity of GERD from NERD to EO and BO. Bolus transit abnormalities in severe reflux disease underscore the importance of impaired oesophageal function in the development of mucosal injury.

Concomitant irritable bowel syndrome is associated with failure of step-down on-demand proton pump inhibitor treatment in patients with gastro-esophageal reflux disease

BACKGROUND

The predictors for treatment failure of on-demand proton pump inhibitor (PPI) therapy in gastro-esophageal reflux disease (GERD) patients are unclear. We studied the efficacy and predictors for treatment failure of step-down on-demand PPI therapy in patients with non-erosive reflux disease (NERD) and those with low grade erosive esophagitis.

METHODS

Consecutive symptomatic GERD patients who had positive esophageal pH studies and complete symptom resolution with initial treatment of esomeprazole were given step-down on-demand esomeprazole for 26 weeks. Patients with esophagitis of Los Angeles (LA) grade C or above and recent use of PPI were excluded. Treatment failure was defined as an inadequate relief of reflux symptoms using global symptom assessment. Potential predictors of treatment failure were determined using multivariate analysis.

KEY RESULTS

One hundred and sixty three NERD and 102 esophagitis patients were studied. The 26-week probability of treatment failure was 36.2% (95% CI: 23.9-46.5%) in NERD group and 20.1% (95% CI: 10.9-28.3%) in esophagitis group, respectively (P = 0.021). Irritable bowel syndrome (adjusted HR: 2.1, 95% CI: 1.5-3.8, P = 0.01), in addition to daily reflux symptom (adjusted hazard ratio: 2.7, 95% CI: 1.9-4.2, P = 0.001) and concomitant dyspepsia (adjusted hazard ratio: 1.7, 95% CI: 1.1-2.8, P = 0.04), were independent predictors for treatment failure.

CONCLUSIONS & INFERENCES

Compared to patients with esophagitis, NERD patients have higher failure rate of on-demand PPI therapy. Concomitant irritable bowel syndrome, in addition to daily reflux symptom and dyspepsia, is associated with the failure of on-demand PPI in these patients.

Mosapride as an adjunct to lansoprazole for symptom relief of reflux oesophagitis

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Reflux oesophagitis is a common clinical disorder associated with significant morbidity. Proton pump inhibitors are the current pharmacotherapy of choice, but not all treated patients achieve symptom relief. Little is known about the efficacy of mosapride, a prokinetic agent which decreases episodes of gastro-oesophageal reflux, as an adjunct to proton pump inhibitors in improving the symptoms of reflux oesophagitis. WHAT THIS STUDY ADDS Mosapride was generally not more effective than placebo as an adjunct therapy to a standard dose of lansoprazole in decreasing the symptom burden of patients with reflux oesophagitis. However, in a subgroup with more severe symptoms, combination therapy with lansoprazole and mosapride was possibly superior to monotherapy with lansoprazole. AIMS To investigate if mosapride, a prokinetic agent, was an effective adjunct to acid suppression in improving the symptoms of reflux oesophagitis. METHODS Patients (n= 96) with reflux oesophagitis were randomly assigned to either mosapride (5 mg three times daily) or placebo for 4 weeks. Symptom severity was assessed by a validated questionnaire at enrolment, 4 and 8 weeks after medication. The primary outcome for the first 4 weeks was decrease in symptom scores. After a 3 day washout period, patients initially allocated to mosapride crossed over to placebo and vice versa for the next 4 weeks. The outcome of the second phase was maintenance of symptom control. All patients received lansoprazole (30 mg once daily) throughout study. RESULTS The decreased symptom score after 4 weeks of treatment with lansoprazole and mosapride (n= 50) was 13.42 +/- 1.16 (mean +/- SEM), similar to that of lansoprazole plus placebo (10.85 +/- 1.03, n= 46), with an insignificant difference of 2.57 (95% CI -0.53, 5.67, P= 0.103). However, a sub-group analysis for patients with pre-treatment scores of >18 points (n= 48) revealed that lansoprazole plus mosapride achieved a greater reduction of symptom score than lansoprazole plus placebo (18.22 +/- 1.91 vs. 12.88 +/- 1.65; mean difference of 5.34, 95% CI 0.28, 10.40, P= 0.039). In the second phase, there was no difference between lansoprazole with mosapride or placebo in maintaining symptom control (39/44 or 86.64% vs. 41/50 or 82%, P= 0.401). Subgroup analysis for those with substantial residual symptoms revealed similar results. CONCLUSION Compared with placebo, mosapride generally does not provide additional benefit to a standard dose of lansoprazole in patients with reflux oesophagitis, except possibly in the subgroup of severely symptomatic patients.

Meta-analysis used to identify factors associated with the effectiveness of proton pump inhibitors against non-erosive reflux disease

BACKGROUND

A lack of published data remains on factors associated with the treatment response to proton pump inhibitors (PPI) in patients with non-erosive reflux disease (NERD).

METHODS

Studies on effectiveness of PPI in patients with NERD were identified using the MEDLINE database and manual searches of the available literature. Twenty publications that comprised a total of 22 study arms were eligible, and meta-analyses of these 22 study arms were carried out.

RESULTS

Overall improvement rate in patients with PPI was 68%. Univariate meta-regression analysis was used to explore the source of heterogeneity, P-value for males was 0.192, and in the presence of Helicobacter pylori (H. pylori) infection was 0.186, indicating that these factors are associated with treatment effectiveness. Thus, as the frequency of male and H. pylori-infected patients increased, the effectiveness of PPI against NERD improved. By multivariate meta-regression analysis, the P-value for male and H. pylori infection decreased further (P = 0.002 and P = 0.003, respectively), indicating little interaction between male sex and H. pylori infection.

CONCLUSION

These results suggest that H. pylori infection and patient sex may be associated with the effectiveness of PPI against patients with NERD. The reasons are still unclear, and further examinations are needed to clarify them.

Functional heartburn: what it is and how to treat it

Functional heartburn is considered one of the most common functional esophageal disorders. The disorder is more common in young women and is associated with other functional bowel disorders and psychological co-morbidity, primarily somatization. The etiology of functional heartburn remains unknown. Most patients, however, demonstrate esophageal hypersensitivity. Functional heartburn has been identified as the main cause for proton pump inhibitor (PPI) failure in patients with heartburn. Treatment is still a challenge, and patients should be started with PPI treatment. In non-responders, escalation of the PPI dose could be attempted and, if unsuccessful, pain modulators should be prescribed.

Functional heartburn vs. non-erosive reflux disease: similarities and differences

BACKGROUND

Bowel symptoms have been associated with non-erosive reflux disease (NERD). However, their role in functional heartburn (FH) has not been established.

AIMS

To characterize bowel symptoms in FH and NERD patients, and investigate their role as predictors of severity of reflux symptoms.

METHODS

A prospective study of patients with normal upper endoscopy undergoing a 24-h oesophageal pH monitoring for the evaluation of reflux symptoms. Patients with oesophageal acid exposure <3.1% and a symptom index <50% were classified as FH (n = 60), while those with oesophageal acid exposure >4% were defined as NERD (n = 160). Symptom severity was scored on validated scales.

RESULTS

In FH, a female predominance was noted (P < 0.001). Reflux symptoms were scored higher in NERD patients (P < 0.001) while bowel symptoms were similarly scored in the two groups. In both groups, severity of reflux symptoms was independently associated with a composite score on the bowel scales (P < 0.001) and was not predicted by oesophageal acid exposure. In FH, reflux symptom severity was inversely related to age (P = 0.03), while in NERD, the opposite was true (P = 0.01).

CONCLUSIONS

In both FH and NERD, bowel symptoms were the strongest predictors of reflux symptoms severity. A female preponderance, and an opposite relationship between reflux symptom severity and age, indicate that FH and NERD may be distinct entities.

Nonerosive reflux disease: a pathophysiologic perspective

Nonerosive reflux disease (NERD) is the most common phenotype of gastroesophageal reflux disease. By definition, patients with NERD have typical reflux symptoms caused by the intraesophageal reflux of gastric contents but have no visible esophageal mucosal injury. This is in contrast to patients with reflux esophagitis, also known as erosive reflux disease, and Barrett's esophagus, who have obvious esophageal mucosal injury on endoscopy. Only 50% of patients with NERD have pathologic esophageal acid contact time (ACT) as detected on 24-hour pH monitoring (ie, NERD-positive). NERD patients with physiologic esophageal ACT and good temporal correlation of symptoms with reflux events (symptom index > 50% or symptom-association probability > 95%) are considered to have esophageal hypersensitivity (ie, NERD-negative). Finally, patients with physiologic esophageal ACT but poor symptom-reflux correlation are now considered to have functional heartburn and not NERD. NERD-positive patients have motor dysfunction and acidic reflux abnormalities that are similar to patients with reflux esophagitis and Barrett's esophagus, whereas NERD-negative patients have minimal abnormalities that are not much different than healthy controls. The histopathologic feature most indicative of NERD is the presence of dilated intercellular spaces within squamous epithelium, an ultrastructural abnormality readily identified on transmission electron microscopy and on light microscopy.

Acid and non-acid reflux patterns in patients with erosive esophagitis and non-erosive reflux disease (NERD): a study using intraluminal impedance monitoring

BACKGROUND

Non-erosive reflux disease (NERD) and erosive esophagitis (EE) are the most common phenotypic presentations of gastroesophageal reflux disease (GERD).

AIM

To assess acid and non-acid reflux patterns in patients with EE and NERD using combined esophageal pH-impedance monitoring.

METHODS

A total of 26 GERD patients off acid-suppressive medication and ten healthy volunteers (HV) underwent upper endoscopy and 24-h pH-impedance monitoring. Analysis of the pH-impedance signals included total reflux time, number of reflux episodes according to gas-liquid composition, and pH (acid, non-acid).

RESULTS

EE was identified in 13 patients and NERD in 13 patients. Pathologic acid reflux was found in 92.3 and 69.2% of patients with EE and NERD, respectively (P = 0.15). When compared to HV, EE patients and NERD patients showed a higher incidence of acid (P = 0.002 and P < 0.001, EE vs. HV and NERD vs. HV, respectively) and non-acid reflux episodes (P = 0.03 and P = 0.001, EE vs. HV and NERD vs. HV, respectively). Mean reflux times, as assessed by both pH-metry and impedance monitoring, and incidence of acid and non-acid reflux episodes were similar in EE and NERD patients. In the supine position, however, EE patients showed a higher incidence of acid (P = 0.048) and liquid reflux episodes (P = 0.07).

CONCLUSION

Whereas EE patients have more acid reflux episodes in the supine position than NERD patients, patients with EE and NERD have similar non-acid reflux patterns. This observation lends support to the notion that non-acid reflux is less damaging to the esophageal mucosa than acid reflux.

Functional heartburn, nonerosive reflux disease, and reflux esophagitis are all distinct conditions—A debate: Pro

Gastroesophageal reflux disease (GERD) traditionally has been approached as a spectrum-continuum, suggesting that patients may progress over time and develop a more severe esophageal mucosal involvement. The spectrum-continuum conceptual model had a profound impact on the research priorities in GERD, as well as on proposed diagnostic algorithms and therapeutic strategies. Natural course studies in GERD are almost always retrospective and commonly afflicted with a plethora of shortcomings. Factors that affect quality of natural course studies in GERD include the following: index endoscopy results are taken at face value; antireflux treatment is consumed until index endoscopy and/or offered during the follow-up phase; pathophysiologic, anatomic, and genetic factors are overlooked; and lack of confirmation of the durability of the new esophageal mucosal finding. Functional heartburn is common and likely to affect a large subset of patients presenting with heartburn. Evidence to support progression of functional heartburn to nonerosive reflux disease (NERD), erosive esophagitis, or Barrett's esophagus is very scarce. The largest population-based or longest-duration natural course studies report that only 10% of patients progress from NERD to erosive esophagitis over time. The other GERD patients remained within their respective phenotypic presentations of GERD.

Acid-related oesophageal sensitivity, not dysmotility, differentiates subgroups of patients with non-erosive reflux disease

BACKGROUND

Patients with non-erosive reflux disease can experience reflux symptoms with similar frequency and severity as those with erosive reflux disease. Oesophageal motility and acid sensitivity are thought to influence symptom occurrence.

AIM

To compare the effect of infused hydrochloric acid on oesophageal physiology in patients with non-erosive reflux disease and erosive reflux disease.

METHODS

Twelve healthy controls and 39 patients with reflux disease [14 erosive reflux disease, 11 non-erosive reflux disease with normal (functional heartburn) and 14 non-erosive reflux disease with excess acid exposure] had hydrochloric acid and saline infused into distal and then proximal oesophagus. Oesophageal contraction amplitude, lower oesophageal sphincter pressure and pain intensity were documented at baseline and during each infusion.

RESULTS

Patients with non-erosive reflux disease had higher pain sensitivity to acid than those with erosive reflux disease and controls. Proximal acid infusion caused greater pain than distal in patients with non-erosive reflux disease. Acid and saline sensitivity were more pronounced in patients with functional heartburn. Lower oesophageal sphincter pressure and oesophageal contraction amplitudes were lower in the erosive reflux disease and non-erosive reflux disease groups, but did not change during infusions.

CONCLUSIONS

Patients with non-erosive reflux disease and, to a lesser extent, patients with erosive reflux disease, are sensitive to acid in the oesophagus, being more sensitive to proximal acid. Hypersensitivity is most marked in functional heartburn patients. This acid sensitivity is not associated with motility change.

Refractory gastrooesophageal reflux disease

The introduction of proton pump inhibitors (PPIs) has facilitated the treatment of gastrooesophageal reflux disease (GORD) enormously; however, treatment of GORD still fails in a small proportion of patients. This small proportion of therapy-resistant patients encompasses a substantial part of the working load of physicians and has become a common clinical problem. A strong variability in acid-suppressive effect of PPI treatment exists depending on compliance, Helicobacter pylori status and genotype. Nocturnal acid breakthrough does not seem to be a major determinant of refractory GORD. Recent data, however, show that PPI-refractory GORD can result from nonacid reflux episodes. It is wise to reconsider the diagnosis of GORD in patients who are PPI-refractory. Most patients in whom a PPI is not effective do not have GORD, instead they suffer from other disorders such as functional dyspepsia. If after a thorough history is taken the suspicion of GORD is still high, the next step would be to perform upper endoscopy and reflux monitoring. In case patients truly have PPI-refractory GORD, therapy can be aimed at oesophageal hypersensitivity or a surgical solution can be sought.

[Prevalence of supraesophageal manifestations in patients with gastroesophageal erosive and non-erosive reflux disease]

BACKGROUND

Respiratory, ear-nose and throat complaints, chest pain and dysphagia can be a part of clinical manifestations of gastroesophageal reflux disease. The first two are named supraesophageal manifestations of gastroesophageal reflux disease. Controversy about the prevalence of these clinical manifestations in patients with non-erosive and erosive gastroesophageal reflux disease exists.

AIMS

Evaluate the prevalence of supraesophageal manifestations in patients with erosive and non-erosive gastroesophageal reflux disease.

METHODS

Files from patients submitted to upper endoscopy, esophageal manometry and pH monitoring for the investigation of gastroesophageal reflux disease (heartburn as the chief complaint) were reviewed and respiratory and ear, nose and throat symptoms were recorded. Patients with erosive disease (grades I to III according to Savary-Miller classification) and with non-erosive disease (normal endoscopy with abnormal pH monitoring were selected. Statistical analysis included the chi-square test.

RESULTS

Two hundred and eighty patients fulfilled the inclusion criteria being 162 with erosive disease (70% with grade I esophagitis) and 118 with non-erosive disease. Overall, 88 patients had ear, nose and throat symptoms (31%), the more frequent were hoarseness and clearing and 42, respiratory manifestations (15%), being cough the more prevalent. In the ear, nose and throat symptoms group, 45 were erosive disease (28%) and 43 non-erosive disease (36.4%). As for the respiratory symptom group, 21 patients (13%) were erosive disease and 21 (18%) were non-erosive disease.

CONCLUSION

There was no difference in the prevalence of supraesophageal manifestations between patients with gastroesophageal erosive and non-erosive reflux disease.

Proton-pump inhibitor therapy in patients with gastro-oesophageal reflux disease: putative mechanisms of failure

Proton-pump inhibitor (PPI) failure in gastro-oesophageal reflux disease (GORD) patients has become the main reason for referral of these patients to gastroenterology specialists. It is estimated that 30% of GORD patients requiring a PPI once daily will experience treatment failure. Patients with non-erosive reflux disease are the most common GORD-related group in which once-daily PPI therapy fails. Various mechanisms have been suggested to underlie PPI failure in GORD patients. The most pertinent include weakly acidic reflux, duodenogastro-oesophageal reflux, visceral hyperalgesia, delayed gastric emptying, psychological co-morbidity and concomitant functional bowel disorders, as well as others. Because of the importance of PPI failure as a target for future drug development, further understanding of the most relevant underlying mechanisms is needed.

Efficacy in intra-oesophageal acid suppression may decrease after 2-year continuous treatment with proton pump inhibitors

BACKGROUND

Long-term intra-oesophageal acid suppression with proton pump inhibitors represents a management option for Barrett's oesophagus and severe reflux oesophagitis, but its stability over time has not been adequately assessed.

AIM

Our aim was to evaluate prospectively the efficacy of proton pump inhibitors in suppressing intra-oesophageal acidity after 2-year continuous treatment.

METHODS

Forty-five patients with Barrett's oesophagus or severe reflux oesophagitis on a proton pump inhibitor regimen (once or twice daily) that normalised the total percentage acid exposure time were re-evaluated by means of 24-h oesophageal pH-monitoring after 2-year of continuous unmodified treatment.

RESULTS

A significant rise in the total percentage acid exposure time was observed at 2-year follow-up (P=0.029), owing to an increased value in 27 (60%) cases (9 on a twice daily regimen), higher than normal in 10 of them (22% of the whole group) (3 on a twice daily regimen). In 18 patients (40%) the total percentage acid exposure time was stable or decreased. Heartburn remained efficiently suppressed in all patients.

CONCLUSIONS

The efficacy of proton pump inhibitors in suppressing intra-oesophageal acidity during continuous treatment may decrease over time, up to abnormal levels of oesophageal acid exposure in a minority of cases. This may occur without heartburn recurrence and with both once and twice daily regimens.

GABRA6 genetic polymorphism is associated with the risk of functional heartburn in Chinese

BACKGROUND AND AIM

Polymorphisms of GABA(A)alpha6 (GABRA6)-1521 and IL-1beta-511 have been linked with susceptibility to stress and gastric acid secretion. The aim of this study was to assess psychiatric profiles and GABRA6 and IL-1beta genotypes in functional heartburn, an important esophageal reflux condition.

METHODS

Psychological symptoms were assessed with a Brief Symptom Rating Scale and personality traits with a short-form Maudsley Personality Inventory. DNA from 452 healthy controls, 80 controls with neurosis, and 122 patients with functional heartburn was genotyped with PCR-RFLP technique.

RESULTS

Symptom-scale parameters (except hostility) were significantly higher in patients with functional heartburn than in healthy controls; their neuroticism scores were also higher, but extroversion scores were lower. Distribution of GABRA6 genotypes in patients with functional heartburn showed more heterozygotes than among healthy controls and neurotic subjects, but distributions of IL-1beta genotypes were similar. Multiple logistic regression analysis showed GABRA6 heterozygosity was significantly associated with functional heartburn (odds ratio, 2.37; 95% confidence interval, 1.36-4.12; P < 0.01) even after adjustment for age, sex, Helicobacter pylori infection, General Symptom Index, and score of neuroticism.

CONCLUSIONS

Chinese patients with certain psychiatric characteristics and GABRA6 heterozygosity are probably predisposed to functional heartburn, providing insight into this condition's psychopathology and genetics.

Therapeutic effects of laparoscopic fundoplication for nonerosive gastroesophageal reflux disease

PURPOSE

Surgical treatments for nonerosive gastroesophageal reflux disease (NERD) have not been investigated sufficiently. We examined the results of laparoscopic fundoplication for patients with NERD.

METHODS

We performed laparoscopic fundoplication for NERD in 22 patients. The severity of esophageal hiatal hernia, morphology of the cardiac orifice, and results of 24-hour continuous esophageal and gastric pH were evaluated. We used a four-point scale for the improvement rating of postoperative symptoms.

RESULTS

There were 20 patients (91%) with a sliding hiatal hernia, and 21 patients (95%) with a loose cardiac orifice. Seven patients had acid reflux with 4.0% or higher esophageal fraction of time pH below 4. The surgical techniques used were Nissen fundoplication in 10 patients and Toupet fundoplication in 12 patients. Improvement of postoperative heartburn was rated as excellent in 16 patients, good in 5, and fair in 1. The overall efficacy rating was 95%, and discontinuation of proton pump inhibitor (PPI) was possible in 21 patients.

CONCLUSION

Our results of performing laparoscopic fundoplication in patients with NERD were excellent. Even if abnormal acid reflux cannot be confirmed preoperatively, sufficient therapeutic efficacy can be expected for patients with esophageal hiatal hernia or a loose cardiac orifice.

Primary and secondary esophageal contractions in patients with gastroesophageal reflux disease

We studied the primary and secondary esophageal peristalsis in 36 patients with heartburn and acid regurgitation and in 14 asymptomatic volunteers. Primary peristalsis was elicited by ten swallows of a 5-mL bolus of water and secondary peristalsis was elicited by intra-esophageal infusion of 5, 10, and 15 mL water, 0.1 N hydrochloric acid and air. Esophageal contractions were measured by an 8-lumen manometric catheter assembly incorporating a 6-cm sleeve device. Contractions were registered at 3, 9, and 15 cm from the upper margin of the sleeve and the infusion was done through a side hole located at 12 cm. Twenty patients had normal endoscopic esophageal examination, 10 with normal (group I) and 10 with abnormal pH-metric examination (group II), and 16 had esophagitis (group III). The amplitude of contractions after swallows was lower (97.8 +/- 10.0 mmHg) in the distal esophagus of group III patients than in controls (142.3 +/- 14.0 mmHg). Patients of group III had fewer secondary contractions (water: 25% of infusion) than patients of the other groups and controls (67% of infusion). Patients of group III also had a lower amplitude of secondary peristalsis in the distal esophagus (water: 70.1 +/- 9.6 mmHg) than controls (129.2 +/- 18.2 mmHg). We conclude that patients with esophagitis have an impairment of primary and secondary peristalsis in the distal esophagus.

Predictors of treatment response in patients with non-erosive reflux disease

BACKGROUND

Up to 40% of patients with non-erosive reflux disease (NERD) fail to respond to proton pump inhibitor therapy.

AIM

To determine useful prognostic factors for response to and suppression in NERD.

METHODS

A pooled analysis from three multicentre, double-blind trials of patients with a normal endoscopy and heartburn for 4 days or more during the 7 days prior to the start of each treatment. Patients received omeprazole 20 mg, esomeprazole 20 mg or esomeprazole 40 mg/day for 4 weeks. Complete resolution of heartburn was defined as no heartburn during the last week.

RESULTS

Of 2458 patients included, complete heartburn resolution was achieved in 63% at the end of 4 weeks treatment. Response on days 5-7 provided an 85% probability of complete resolution of heartburn at 4 weeks; the probability of complete heartburn resolution at 4 weeks in those with moderate to severe symptoms on days 5-7 was 22%. Sensitivity and specificity of no heartburn on days 5-7 was 55% and 83% respectively. Patient demographics, duration of symptoms, medications used, other symptoms and body mass index were not predictors.

CONCLUSION

Assessment of heartburn resolution during the first week of therapy was the best predictor of treatment success at 4 weeks in non-erosive reflux disease, but was suboptimal as a test.

Normal values of 24-h ambulatory intraluminal impedance combined with pH-metry in subjects eating a Mediterranean diet

BACKGROUND AND AIMS

Multichannel intraluminal impedance combined with pH-metry is a novel technique for studying gastro-oesophageal reflux. As refluxes are particularly frequent after meals, we carried out this study in order to assess the impact of a Mediterranean diet on normal values of impedancemetry.

METHODS

Twenty-five Italian healthy subjects (13 men, median age 29 years, range 22-67 years) without reflux symptoms were recruited for this study. They underwent oesophageal 24-h impedance + pH-metry. A Mediterranean diet was given to all subjects on the day of examination and its total energy intake was 9668.5 kJ (2300 kcal).

RESULTS

A total of 1518 refluxes were recorded during 24 h with more upright than recumbent episodes (median 15 versus 0; p<0.01). The median total acid exposure time was 0.5% (range 0-4.2%). Acid and weakly acidic refluxes were equally reported (49% versus 51%). Weakly acidic episodes were more frequent than acid ones during 1-h postprandial periods (68% versus 32%; p<0.0001). Liquid-only and mixed refluxes reached the proximal oesophagus (15 cm above lower oesophageal sphincter) in 42.6% of cases. Median acid clearing time was longer than median bolus clearing time (28 s versus 12 s; p<0.01).

CONCLUSIONS

This study provides normal values of pH-impedancemetry in Italian people eating a Mediterranean diet and are suitable for comparative pathophysiological investigations on reflux patients who have dietary habits similar to those of our country.

Functional heartburn

Functional heartburn (FH) is a common disorder that accounts for 30% to 50% of the patients with nonerosive reflux disease. FH is composed from a heterogeneous group of patients. They primarily include the hypersensitive and the nonacid sensitive esophagus. The mechanisms responsible for pain, clinical characteristics, and the optimal therapeutic approach of FH remain to be fully elucidated. Symptom response rate to potent antireflux treatment is significantly lower in FH patients as compared with any other gastroesophageal reflux disease (GERD) group, suggesting that in proton pump inhibitor (PPI) non-responders mechanisms other than acid reflux are likely the cause of symptoms. Patients with FH should be approached therapeutically as patients with GERD and should initially receive antireflux medications. Due to the need for profound acid suppression in this group of patients, PPIs should be considered relatively early in their care. Failure to respond to standard dosage of PPI is common and will require doubling the dose. If patients continue to report heartburn symptoms while receiving PPI twice daily, adding or switching to pain modulators/visceral analgesics is an appropriate therapeutic approach. Data about the usage of other therapeutic modalities in FH such as antireflux surgery, endoscopic treatment for GERD, and psychotherapy are still unavailable. Emerging treatment will likely include novel pain modulators and more effective antireflux medications.

HCV liver infection and liver steatosis: evidence for indirect mechanisms in genotype 3?

BACKGROUND

Hepatitis C virus (HCV) infection is associated with the appearance of liver steatosis.

AIM

To search for a correlation between the number of HCV infected hepatocytes and the presence, amount and distribution of steatosis.

METHODS

A total of 124 frozen liver biopsies from HCV patients (genotype 3 = 21) were studied. HCV-antigens were detected on frozen liver sections using a four steps immunoperoxidase technique. Steatosis was graded by haematoxilin-eosin counterstaining on a serial section.

RESULTS

Steatosis was detected in 82 of 124 (66.1%) patients without differences between different genotypes. Uric acid, body mass index, gammaGT levels significantly correlated with steatosis in non-3 (P < 0.01, P < 0.05, P < 0.01, respectively) but not in genotype 3 patients. HCV-antigens were detected in 95 of 124 (76.6%) cases. A positive correlation between steatosis and the number of infected hepatocytes was observed only in genotype 3 patients (P = 0.06). In most cases the number of cells with steatosis greatly outnumbered that of HCV infected cells.

CONCLUSION

We confirm a possible role of the virus in the genesis of steatosis in HCV genotype 3 infected patients; however, as steatosis do not appear to be directly related to the presence of HCV-antigens within single hepatocytes, an indirect, possibly cytokine mediated, mechanism might be operative.

Reassessment of the diagnostic value of histology in patients with GERD, using multiple biopsy sites and an appropriate control group

BACKGROUND

Histology is generally considered as a tool of limited value in the diagnosis of gastro-esophageal reflux disease (GERD).

AIM

To reevaluate the diagnostic role of histological alterations in GERD, using multiple biopsy sites and an appropriate control group.

METHODS

We studied 135 patients with typical and atypical symptoms of GERD. They underwent upper GI endoscopy and Los Angeles classification was used for grading cases with mucosal breaks. Biopsies were taken at the Z-line, 2 and 4 cm above it. Microscopic esophagitis was identified by necrosis/erosion, neutrophil/eosinophil intraepithelial infiltration, basal cell hyperplasia, elongation of papillae, dilation of intercellular spaces and a score (range: 0-2) was given for each lesion. Twenty-four-hour esophageal pH monitoring was performed in each patient. Twenty subjects without reflux symptoms, and with normal endoscopy and pH testing were considered as controls.

RESULTS

Histological alterations were found in 100 of 119 GERD patients (84%) and in 3 of 20 controls (15%) with a significant difference (p < 0.00001). Histology was abnormal in 96% of patients with erosive esophagitis and in 76% of patients with nonerosive reflux disease (NERD). The sum of scores of microscopic lesions found in all biopsy sites ranged from 0 to 22 and we identified a cut-off value (score 2) that distinguished efficiently controls from GERD patients.

CONCLUSIONS

In contrast with previous reports on the marginal role of histology in patients with GERD, our study shows that this technique can be a useful diagnostic tool, particularly in patients with NERD, when biopsies are taken at two sites including Z-line and 2 cm above it.

Recent developments in the pathophysiology and therapy of gastroesophageal reflux disease and nonerosive reflux disease

PURPOSE OF REVIEW

Gastroesophageal reflux disease is a very common disorder. Proton pump inhibitors are the highly successful mainstay of medical gastroesophageal reflux disease treatment. However, some limitations of proton pump inhibitor therapy continue to drive studies that aim at better understanding and managing manifestations of gastroesophageal reflux disease. This review summarizes recent progress in our understanding of the pathophysiology and treatment of gastroesophageal reflux disease.

RECENT FINDINGS

Recent studies have demonstrated a potential role of increased gastric acid secretion in gastroesophageal reflux disease, a factor largely neglected during the last decade. Failure to respond adequately to proton pump inhibitor therapy has been attributed to diagnostic inaccuracy, to nocturnal acid breakthrough, to ongoing non-acid reflux and to esophageal hypersensitivity. The relevance of nocturnal acid breakthrough has been recently challenged. Transient lower esophageal sphincter relaxations are a major mechanism of gastroesophageal reflux disease; inhibition of transient lower esophageal sphincter relaxations is a potentially important therapeutic target. Recent studies have focused on GABA receptor stimulation using baclofen or sodium valproate. The role of esophageal body peristalsis in the clearance of reflux events has been questioned. Endoscopic antireflux therapies aim at perendoscopic reinforcement of the antireflux barrier as a novel therapeutic approach to gastroesophageal reflux disease. At present, long-term and controlled data are scarce. Recent observations have challenged the long-term efficacy of surgical antireflux therapy.

SUMMARY

Increased understanding of the pathophysiology of gastroesophageal reflux disease may lead to new or improved treatments. Major advances have been made in the role of gastric acid secretion, the control of transient lower esophageal sphincter relaxations and mechanisms underlying esophageal hypersensitivity. Recent studies have highlighted some shortcomings of proton pump inhibitor therapy and of antireflux surgery. Novel approaches are treatments aimed at decreasing transient lower esophageal sphincter relaxations and endoscopic antireflux procedures. Large-scale controlled studies are lacking for both treatments.