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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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2
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Xiao YL, Zhou LY, Hou XH, Li YQ, Zou DW, Chen MH. Chinese expert consensus on gastroesophageal reflux disease in 2020. J Dig Dis 2021; 22:376-389. [PMID: 34105263 DOI: 10.1111/1751-2980.13028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Ying Lian Xiao
- Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Li Ya Zhou
- Department of Gastroenterology, Peking University Third Hospital, Beijing, China
| | - Xiao Hua Hou
- Department of Gastroenterology, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yan Qing Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Duo Wu Zou
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Min Hu Chen
- Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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Kikuchi H, Fukuda S, Koike T, Shimodaira Y, Watanabe K, Saito M, Nakagawa K, Hatta W, Masamune A, Iijima K. Association of residual gastric acid secretion with persistent symptoms in gastroesophageal reflux disease patients receiving standard-dose proton pump inhibitor therapy. Esophagus 2021; 18:380-387. [PMID: 32737802 DOI: 10.1007/s10388-020-00765-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/24/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Although a third of gastroesophageal reflux disease (GERD) patients are refractory to proton pump inhibitor (PPI) therapy, the underlying mechanism of the refractoriness remains unclear. We compared the level of gastric acid suppression during PPI treatment between responders and non-responders by directly measuring gastric acid secretion in GERD patients taking PPIs. METHODS Seventy-five consecutive patients receiving standard-dose PPI therapy for GERD were prospectively recruited, irrespective of persistent GERD symptoms. They were asked about their GERD symptoms using a validated questionnaire, and simultaneously underwent both a routine endoscopic examination and a gastric acid secretory testing using an endoscopic gastrin test. Associations between residual gastric acid secretion during PPI treatment and persistent GERD symptoms were analyzed by a logistic regression analysis. RESULTS Overall, 26 of 75 (34.7%) patients were judged to be positive for persistent GERD symptoms. The patients with and without persistent symptoms showed similar gastric acid secretion levels (1.3 [1.3] mEq/10 min vs. 1.4 [2.0] mEq/10 min). Sufficient gastric acid suppression, defined as < 0.6, was not significantly associated with persistent GERD symptoms (odds ratio 1.1, 95% confidence interval 0.40-3.5). CONCLUSIONS This study provided solid evidence to support that the gastric acid suppression level during PPI treatment does not differ between patients with and without persistent GERD symptoms. The insignificant role of residual gastric acid in the persistent GERD symptoms suggests that the use of medications other than those that enhance gastric acid inhibitory effects would be an essential approach for the management of PPI-refractory GERD.
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Affiliation(s)
- H Kikuchi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Sendai, 980-8574, Japan
| | - S Fukuda
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - T Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Sendai, 980-8574, Japan
| | - Y Shimodaira
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - K Watanabe
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - M Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Sendai, 980-8574, Japan
| | - K Nakagawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Sendai, 980-8574, Japan
| | - W Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Sendai, 980-8574, Japan
| | - A Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Sendai, 980-8574, Japan
| | - K Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan.
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Savarino V, Marabotto E, Zentilin P, Demarzo MG, Pellegatta G, Frazzoni M, De Bortoli N, Tolone S, Giannini EG, Savarino E. Esophageal reflux hypersensitivity: Non-GERD or still GERD? Dig Liver Dis 2020; 52:1413-1420. [PMID: 33097427 DOI: 10.1016/j.dld.2020.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 12/11/2022]
Abstract
The most recent iteration of the classifications for functional esophageal disorders, Rome IV, proposed relevant modifications of the previous definitions for Rome III. They specifically considered increased esophageal acid exposure as the marker of gastroesophageal reflux disease (GERD), including the remaining part of non-erosive reflux disease patients with normal acid in the group with functional alterations, considering both reflux hypersensitivity and functional heartburn. However, recent pathophysiological and therapeutic data suggest the need for a return to including reflux hypersensitivity in the GERD spectrum. Indeed, physiologic alterations in esophageal mucosal integrity and chemical clearance, the presence of microscopic esophagitis, and strict symptom-reflux association support the concept that reflux hypersensitivity pertains to GERD. Surgical anti-reflux therapy has resulted in positive outcomes, even in the long term, in patients with reflux hypersensitivity and not in those with functional heartburn. Moreover, clinical trials using neuromodulators have been scarce and provided conflicting results. As a result, the real progress of the Rome IV classifications is in dispute. This article aims to summarize the most recent knowledge of non-erosive reflux disease and reflux hypersensitivity to discuss the utility of Rome IV criteria in the identification and management of functional esophageal disorders.
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Affiliation(s)
- Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Patrizia Zentilin
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Giulia Demarzo
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas, Rozzano, Milan, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Nicola De Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, Università della Campania Luigi Vanvitelli, Naples, Italy
| | - Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.
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McCormick CA, Samuels TL, Battle MA, Frolkis T, Blumin JH, Bock JM, Wells C, Yan K, Altman KW, Johnston N. H+/K+ATPase Expression in the Larynx of Laryngopharyngeal Reflux and Laryngeal Cancer Patients. Laryngoscope 2020; 131:130-135. [PMID: 32250454 DOI: 10.1002/lary.28643] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/27/2020] [Accepted: 03/03/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The gastric H+/K+ ATPase proton pump has previously been shown to be expressed in the human larynx, however its contribution to laryngopharyngeal reflux (LPR) signs, symptoms and associated diseases such as laryngeal cancer is unknown. Proton pump expression in the larynx of patients with LPR and laryngeal cancer was investigated herein. A human hypopharyngeal cell line expressing the proton pump was generated to investigate its effects. STUDY DESIGN In-vitro translational. METHODS Laryngeal biopsies were obtained from three LPR and eight LSCC patients. ATP4A, ATP4B and HRPT1 were assayed via qPCR. Human hypopharyngeal FaDu cell lines stably expressing proton pump were created using lentiviral transduction and examined via transmission electron microscopy and qPCR for genes associated with inflammation or laryngeal cancer. RESULTS Expression of ATP4A and ATP4B was detected in 3/3 LPR, 4/8 LSCC-tumor and 3/8 LSCC-adjacent specimens. Expression of ATP4A and ATP4B in FaDu elicited mitochondrial damage and expression of IL1B, PTGS2, and TNFA (P < .0001); expression of ATP4B alone did not. CONCLUSIONS Gastric proton pump subunits are expressed in the larynx of LPR and LSCC patients. Mitochondrial damage and changes in gene expression observed in cells expressing the full proton pump, absent in those expressing a single subunit, suggest that acid secretion by functional proton pumps expressed in upper airway mucosa may elicit local cell and molecular changes associated with inflammation and cancer. LEVEL OF EVIDENCE NA Laryngoscope, 131:130-135, 2021.
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Affiliation(s)
- Caroline A McCormick
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Tina L Samuels
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Michele A Battle
- Department of Cell Biology, Neurobiology, & Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Talia Frolkis
- Department of Cell Biology, Neurobiology, & Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Joel H Blumin
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Jonathan M Bock
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Clive Wells
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Ke Yan
- Department of Pediatrics Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Kenneth W Altman
- Department of Otolaryngology, Geisinger Health System, Danville, California, U.S.A
| | - Nikki Johnston
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.,Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
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Quitadamo P, Tambucci R, Mancini V, Cristofori F, Baldassarre M, Pensabene L, Francavilla R, Di Nardo G, Caldaro T, Rossi P, Mallardo S, Maggiora E, Staiano A, Cresi F, Salvatore S, Borrelli O. Esophageal pH-impedance monitoring in children: position paper on indications, methodology and interpretation by the SIGENP working group. Dig Liver Dis 2019; 51:1522-1536. [PMID: 31526716 DOI: 10.1016/j.dld.2019.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/02/2019] [Accepted: 07/20/2019] [Indexed: 12/11/2022]
Abstract
Multichannel intraluminal impedance pH (MII-pH) monitoring currently represents the gold standard diagnostic technique for the detection of gastro-esophageal reflux (GER), since it allows to quantify and characterize all reflux events and their possible relation with symptoms. Over the last ten years, thanks to its strengths and along with the publication of several clinical studies, its worldwide use has gradually increased, particularly in infants and children. Nevertheless, factors such as the limited pediatric reference values and limited therapeutic options still weaken its current clinical impact. Through an up-to-date review of the available scientific evidence, our aim was to produce a position paper on behalf of the working group on neurogastroenterology and acid-related disorders of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) on MII-pH monitoring technique, indications and interpretation in pediatric age, in order to standardise its use and to help clinicians in the diagnostic approach to children with GER symptoms.
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Affiliation(s)
- Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy; Department of Translational Medical Science,"Federico II", University of Naples, Italy.
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, Saronno Hospital, Saronno, Italy
| | - Fernanda Cristofori
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Mariella Baldassarre
- Department of Biomedical Science and Human Oncology-neonatology and Nicu section, University "Aldo Moro", Bari, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Ruggiero Francavilla
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Giovanni Di Nardo
- NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Rossi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Saverio Mallardo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Elena Maggiora
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science,"Federico II", University of Naples, Italy
| | - Francesco Cresi
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute ofChild Health and Great OrmondStreet Hospital, London, UK
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Lai K, Shen H, Zhou X, Qiu Z, Cai S, Huang K, Wang Q, Wang C, Lin J, Hao C, Kong L, Zhang S, Chen Y, Luo W, Jiang M, Xie J, Zhong N. Clinical Practice Guidelines for Diagnosis and Management of Cough-Chinese Thoracic Society (CTS) Asthma Consortium. J Thorac Dis 2018; 10:6314-6351. [PMID: 30622806 PMCID: PMC6297434 DOI: 10.21037/jtd.2018.09.153] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 09/10/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Kefang Lai
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Huahao Shen
- The Second Hospital Affiliated to Medical College of Zhejiang University, Hangzhou 310009, China
| | - Xin Zhou
- Shanghai Jiaotong University Affiliated Shanghai No. 1 People’s Hospital, Shanghai 200080, China
| | - Zhongmin Qiu
- Tongji Affiliated Tongji Hospital, Shanghai 200065, China
| | - Shaoxi Cai
- Southern Medical University Affiliated Nanfang Hospital, Guangzhou 510515, China
| | - Kewu Huang
- Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing 100020, China
| | | | - Changzheng Wang
- Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Jiangtao Lin
- China-Japan Friendship Hospital, Beijing 100029, China
| | - Chuangli Hao
- Children’s Hospital of Soochow University, Suzhou 215025, China
| | - Lingfei Kong
- The First Hospital of China Medical University, Shenyang 110001, China
| | - Shunan Zhang
- China-Japan Friendship Hospital, Beijing 100029, China
| | - Yaolong Chen
- Evidence-based Medical Center of Lanzhou University, Lanzhou 730000, China
| | - Wei Luo
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Jiaxing Xie
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Nanshan Zhong
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
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Azzam RS. ARE THE PERSISTENT SYMPTOMS TO PROTON PUMP INHIBITOR THERAPY DUE TO REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE OR TO OTHER DISORDERS? ARQUIVOS DE GASTROENTEROLOGIA 2018; 55Suppl 1:85-91. [PMID: 30304291 DOI: 10.1590/s0004-2803.201800000-48] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/11/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a clinical condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Transient lower esophageal sphincter relaxation is the main pathophysiological mechanism of GERD. Symptoms and complications can be related to the reflux of gastric contents into the esophagus, oral cavity, larynx and/or the lung. Symptoms and other possible manifestations of GERD are heartburn, regurgitation, dysphagia, non-cardiac chest pain, chronic cough, chronic laryngitis, asthma and dental erosions. The proton pump inhibitor (PPI) is the first-choice drug and the most commonly medication used for the treatment of GERD. The most widespread definition of Refractory GERD is the clinical condition that presents symptoms with partial or absent response to twice-daily PPI therapy. Persistence of symptoms occurs in 25% to 42% of patients who use PPI once-daily and in 10% to 20% who use PPI twice-daily. OBJECTIVE The objective is to describe a review of the current literature, highlighting the causes, diagnostic aspects and therapeutic approach of the cases with suspected reflux symptoms and unresponsive to PPI. CONCLUSION Initially, the management of PPI refractoriness consists in correcting low adherence to PPI therapy, adjusting the PPI dosage and emphasizing the recommendations on lifestyle modification change, avoiding food and activities that trigger symptoms. PPI decreases the number of episodes of acid reflux; however, the number of "non-acid" reflux increases and the patient continues to have reflux despite PPI. In this way, it is possible to greatly reduce greatly the occurrence of symptoms, especially those dependent on the acidity of the refluxed material. Response to PPI therapy can be evaluated through clinical, endoscopic, and reflux monitoring parameters. In the persistence of the symptoms and/or complications, other causes of Refractory GERD should be suspected. Then, diagnostic investigation must be initiated, which is supported by clinical parameters and complementary exams such as upper digestive endoscopy, esophageal manometry and ambulatory reflux monitoring (esophageal pH monitoring or esophageal impedance-pH monitoring). Causes of refractoriness to PPI therapy may be due to the true Refractory GERD, or even to other non-reflux diseases, which can generate symptoms similar to GERD. There are several causes contributing to PPI refractoriness, such as inappropriate use of the drug (lack of patient adherence to PPI therapy, inadequate dosage of PPI), residual acid reflux due to inadequate acid suppression, nocturnal acid escape, "non-acid" reflux, rapid metabolism of PPI, slow gastric emptying, and misdiagnosis of GERD. This is a common cause of failure of the clinical treatment and, in this case, the problem is not the treatment but the diagnosis. Causes of misdiagnosis of GERD are functional heartburn, achalasia, megaesophagus, eosinophilic esophagitis, other types of esophagitis, and other causes. The diagnosis and treatment are specific to each of these causes of refractoriness to clinical therapy with PPI.
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Affiliation(s)
- Rimon Sobhi Azzam
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Gastroenterologia, São Paulo, SP, Brasil
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9
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Callaway JP, Vaezi MF. Hiatal and Paraesophageal Hernias. Clin Gastroenterol Hepatol 2018; 16:810-813. [PMID: 29306040 DOI: 10.1016/j.cgh.2017.12.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 12/19/2017] [Indexed: 12/21/2022]
Affiliation(s)
- James P Callaway
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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10
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Gallusi G, Pontone S. Treatment of PPI-resistant gastro-oesophageal reflux: A systematic review. Arab J Gastroenterol 2018; 19:51-55. [PMID: 29935866 DOI: 10.1016/j.ajg.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 05/10/2017] [Accepted: 02/20/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND STUDY AIMS Several studies have demonstrated the superiority of proton-pump inhibitors (PPIs) in resolving erosive gastro-oesophageal reflux disease (GORD). However, this first line of treatment can fail to control symptoms in around 30% of cases, especially in the presence of non-erosive GORD. In situations where the first line of treatment fails, there is a lack of concordance regarding the best strategy to apply. This study presents a systematic review of the trials which have tested second-line treatments after PPI failure. METHODS The study was conducted according to the PRISMA statement. The systematic review included medical trials written in English which were published between 2000 and 2016 and were retrieved from PubMed and Scopus using the keywords 'PPI-resistant gastro-oesophageal reflux', 'alginate AND gastro-oesophageal reflux', 'hyaluronic acid AND gastro-oesophageal reflux', 'prokinetics AND gastro-oesophageal reflux', 'sucralfate AND gastro-oesophageal reflux' and 'baclofen AND gastro-oesophageal reflux'. RESULTS Ten randomised and non-randomised studies were included, which included 1515 patients of both sexes (mean age = 49.19 years, age range = 18-85, males = 700; 46.2%). CONCLUSIONS A personalised choice of the best treatment for PPI-resistant GORD should be based on the results of an upper endoscopy and pH/MII monitoring. For patients in situations where the first line of treatment fails, we encourage the execution of trials for testing double doses of PPIs against alternative medicaments.
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Affiliation(s)
- Giulia Gallusi
- Division of Gastroenterology, Department of Clinical Medicine "Sapienza" University of Rome, Italy
| | - Stefano Pontone
- Department of Surgical Sciences, "Sapienza" University of Rome, Italy.
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11
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Roman S, Gyawali CP, Savarino E, Yadlapati R, Zerbib F, Wu J, Vela M, Tutuian R, Tatum R, Sifrim D, Keller J, Fox M, Pandolfino JE, Bredenoord AJ. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: Update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil 2017; 29:1-15. [PMID: 28370768 DOI: 10.1111/nmo.13067] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/20/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND An international group of experts evaluated and revised recommendations for ambulatory reflux monitoring for the diagnosis of gastro-esophageal reflux disease (GERD). METHODS Literature search was focused on indications and technical recommendations for GERD testing and phenotypes definitions. Statements were proposed and discussed during several structured meetings. KEY RESULTS Reflux testing should be performed after cessation of acid suppressive medication in patients with a low likelihood of GERD. In this setting, testing can be either catheter-based or wireless pH-monitoring or pH-impedance monitoring. In patients with a high probability of GERD (esophagitis grade C and D, histology proven Barrett's mucosa >1 cm, peptic stricture, previous positive pH monitoring) and persistent symptoms, pH-impedance monitoring should be performed on treatment. Recommendations are provided for data acquisition and analysis. Esophageal acid exposure is considered as pathological if acid exposure time (AET) is greater than 6% on pH testing. Number of reflux episodes and baseline impedance are exploratory metrics that may complement AET. Positive symptom reflux association is defined as symptom index (SI) >50% or symptom association probability (SAP) >95%. A positive symptom-reflux association in the absence of pathological AET defines hypersensitivity to reflux. CONCLUSIONS AND INFERENCES The consensus group determined that grade C or D esophagitis, peptic stricture, histology proven Barrett's mucosa >1 cm, and esophageal acid exposure greater >6% are sufficient to define pathological GERD. Further testing should be considered when none of these criteria are fulfilled.
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Affiliation(s)
- S Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University, Inserm U1032, LabTAU, Lyon, France
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - E Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, Padua, Italy
| | - R Yadlapati
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - F Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, and Université de Bordeaux, Bordeaux, France
| | - J Wu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - M Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - R Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - R Tatum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - D Sifrim
- Center for Digestive Diseases, Bart's and the London School and Dentistry, London, UK
| | - J Keller
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - M Fox
- Department of Gastroenterology, Abdominal Center, St. Claraspital, Basel, Switzerland
| | - J E Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - A J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Kahrilas P, Yadlapati R, Roman S. Emerging dilemmas in the diagnosis and management of gastroesophageal reflux disease. F1000Res 2017; 6:1748. [PMID: 29034088 PMCID: PMC5615773 DOI: 10.12688/f1000research.11918.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2017] [Indexed: 12/15/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is common, but less so than widely reported because of inconsistencies in definition. In clinical practice, the diagnosis is usually based on a symptom assessment without testing, and the extent of diagnostic testing pursued should be limited to that which guides management or which protects the patient from the risks of a potentially morbid treatment or an undetected early (or imminent) esophageal adenocarcinoma or which does both. When testing is pursued, upper gastrointestinal endoscopy is the most useful initial diagnostic test because it evaluates for the major potential morbidities (Barrett's, stricture, and cancer) associated with GERD and facilitates the identification of some alternative diagnostic possibilities such as eosinophilic esophagitis. However, endoscopy is insensitive for diagnosing GERD because most patients with GERD have non-erosive reflux disease, a persistent diagnostic dilemma. Although many studies have tried to objectify the diagnosis of GERD with improved technology, this is ultimately a pragmatic diagnosis based on response to proton pump inhibitor (PPI) therapy, and, in the end, response to PPI therapy becomes the major indication for continued PPI therapy. Conversely, in the absence of objective criteria for GERD and the absence of apparent clinical benefit, PPI therapy is not indicated and should be discontinued. PPIs are well tolerated and safe, but nothing is perfectly safe, and in the absence of measurable benefit, even a miniscule risk dominates the risk-benefit assessment.
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Affiliation(s)
- Peter Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 St. Clair Street, 14th floor, Chicago, IL, 60611-2951, USA
| | - Rena Yadlapati
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 St. Clair Street, 14th floor, Chicago, IL, 60611-2951, USA
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University, Lyon, France
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Ranaldo N, Losurdo G, Iannone A, Principi M, Barone M, De Carne M, Ierardi E, Di Leo A. Tailored therapy guided by multichannel intraluminal impedance pH monitoring for refractory non-erosive reflux disease. Cell Death Dis 2017; 8:e3040. [PMID: 28880273 PMCID: PMC5636981 DOI: 10.1038/cddis.2017.436] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/04/2017] [Indexed: 02/06/2023]
Abstract
A relevant percentage of non-erosive reflux disease (NERD) is refractory to proton pump inhibitors (PPIs) treatment. Multichannel intraluminal impedance pH (MII-pH) monitoring should give useful pathophysiological information about refractoriness. Therefore, our aim was to assess whether this technique could be useful to guide a 'tailored' therapy in refractory NERD. We retrospectively recruited NERD patients undergoing MII-pH monitoring for unsuccessful treatment. All patients had undergone upper endoscopy, and those with erosive esophagitis were excluded. No patient received PPI during MII-pH monitoring. Subjects were subgrouped into three categories: acid reflux, non-acid reflux and functional heartburn. MII-pH-guided therapy was performed for 4 weeks as follows: patients with acid reflux received PPI at double dose, patients with non-acid reflux PPI at full dose plus alginate four times a day and patients with functional heartburn levosulpiride 75 mg per day. A visual analog scale (VAS) ranging from 0 to 100 mm was administered before and after such tailored therapy to evaluate overall symptoms. Responders were defined by VAS improvement of at least 40%. Sixty-nine patients with refractory NERD were selected (female-male ratio 43 : 26, mean age 47.6±15.2 years). Overall effectiveness of tailored therapy was 84% without statistical difference among subgroups (88.5% acid reflux, 92% non-acid reflux, 66.6% functional heartburn; P=0.06). Univariate analysis showed that therapy failure directly correlated with functional heartburn diagnosis (OR=4.60) and suggested a trend toward a negative correlation with smoking and a positive one with nausea. However, at multivariate analysis, these parameters were not significant. Functional heartburn experienced a lower median percent VAS reduction than acid reflux (52.5% versus 66.6%, P<0.01) even if equal to non-acid reflux (66.6%). In conclusion, a tailored approach to refractory NERD, guided by MII-pH monitoring, demonstrated to be effective and should be promising to cure symptom persistence after conventional therapy failure. Nevertheless, standardized guidelines are advisable.
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Affiliation(s)
- Nunzio Ranaldo
- Gastroenterology Section, Department of Emergency and Organ Transplantation, Piazza Giulio Cesare, University of Bari, Bari, Italy
| | - Giuseppe Losurdo
- Gastroenterology Section, Department of Emergency and Organ Transplantation, Piazza Giulio Cesare, University of Bari, Bari, Italy
| | - Andrea Iannone
- Gastroenterology Section, Department of Emergency and Organ Transplantation, Piazza Giulio Cesare, University of Bari, Bari, Italy
| | - Mariabeatrice Principi
- Gastroenterology Section, Department of Emergency and Organ Transplantation, Piazza Giulio Cesare, University of Bari, Bari, Italy
| | - Michele Barone
- Gastroenterology Section, Department of Emergency and Organ Transplantation, Piazza Giulio Cesare, University of Bari, Bari, Italy
| | - Massimo De Carne
- Gastroenterology Section, IRCCS 'De Bellis', Castellana Grotte (BA), Italy
| | - Enzo Ierardi
- Gastroenterology Section, Department of Emergency and Organ Transplantation, Piazza Giulio Cesare, University of Bari, Bari, Italy
| | - Alfredo Di Leo
- Gastroenterology Section, Department of Emergency and Organ Transplantation, Piazza Giulio Cesare, University of Bari, Bari, Italy
- Gastroenterology Section, Department of Emergency and Organ Transplantation, University of Bari, Bari 70124, Italy. Tel: +39 080 5592577; Fax: +39 080 5593088; E-mail:
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Mizuki A, Tatemichi M, Sakakibara T, Miura Y, Zeki S, Ohata M, Matsuo K, Kawamura F, Nagata H. A Multicenter, Randomized, Open-Label Trial: Efficacy of Once-Daily Versus Twice-Daily Double-Dose Rabeprazole on Refractory Gastroesophageal Reflux Disease-Related Symptoms and Quality of Life. Curr Ther Res Clin Exp 2016; 79:1-7. [PMID: 28066515 PMCID: PMC5200872 DOI: 10.1016/j.curtheres.2016.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2016] [Indexed: 12/15/2022] Open
Abstract
Background Approximately 20% to 40% of patients with gastroesophageal reflux disease (GERD) are refractory to standard-dose proton-pump inhibitor (PPI) treatment. Objective We compared the efficacy and quality-of-life effects of 20 mg once daily (QD) versus 10 mg twice daily (BID) rabeprazole (RPZ) in patients with refractory GERD-related symptoms and sleep disturbances. Methods This multicenter, prospective, randomized, open-label study included patients in whom PPI treatment >4 weeks was ineffective. According to the Global Overall Symptom (GOS) scale, PPI-refractory GERD was defined as ≥1 category with >3 points among 10 specific upper gastrointestinal symptoms. Seventy-eight patients were randomly assigned to 20 mg QD and 10 mg BID RPZ groups for 8 weeks. Efficacy was evaluated using self-reported questionnaires, including the GOS scale and Pittsburg Sleep Quality Index (PSQI), whereas quality of life was assessed using the Short-Form 8 Health Survey (SF-8), at 4 and 8 weeks. Patients showing improvement at 8 weeks received follow-up every 4 to 8 weeks. Results GOS scale scores were significantly improved at 8 weeks in both groups, with no significant intergroup differences. Although SF-8 scores showed an increasing trend over 8 weeks in both groups, the physical component summaries in the 10 mg BID group significantly improved. The mental component summaries clearly improved in the 10 mg BID group. Of the 74 cases (4 missing), 51 (68.9%) had PSQI scores ≥5.5. PSQI scores remained unchanged during follow-up in both groups. The recurrence rate was not significantly different (46.1% vs 47.1% in the 20 mg QD and 10 mg BID groups, respectively) during the follow-up period at median (interquartile range) 24.0 (30.5) months. Conclusions In patients with refractory GERD, there was no significant difference in GOS scale score, PSQI, or recurrence rate between the groups. With regard to subscores of the SF-8, the 10 mg BID group might be potentially effective. This multicenter prospective randomized comparative study compares the efficacy on symptoms, QOL and sleep disturbance between two ways of double dose PPI; once-daily 20mg RPZ or twice-daily 10mg RPZ. The patients with PPI refractory GERD were suffered from severe acid reflux symptoms, sleep disturbance and general distress. For these reasons, to establish the treatments to refractory GERD was important to improve their QOL. In patients with refractory GERD, there was no significant difference in GOS, PSQI, or recurrence rate between the groups.
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Affiliation(s)
- Akira Mizuki
- Department of Internal Medicine, Keiyu Hospital, Yokohama, Japan
| | - Masayuki Tatemichi
- Department of Preventive Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | | | | | | | | | | | - Hiroshi Nagata
- Department of Preventive Medicine, Tokai University School of Medicine, Isehara, Japan
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Herbella FAM, Andolfi C, Vigneswaran Y, Patti MG, Pinna BR. Importance of esophageal manometry and pH monitoring for the evaluation of otorhinolaryngologic (ENT) manifestations of GERD. A multicenter study. J Gastrointest Surg 2016; 20:1673-8. [PMID: 27456014 DOI: 10.1007/s11605-016-3212-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS Patients with otorhinolaryngologic (ear, nose, and throat-ENT) symptoms attributed to gastroesophageal reflux disease (GERD) are usually treated with medication based on the findings of nasal endoscopy and laryngoscopy only. This study aims to determine sensitivity and specificity of symptoms, nasal endoscopy, and laryngoscopy for the diagnosis of GERD as compared to pH monitoring. METHODS We studied 79 patients (mean age 53 years, 38 % males) in whom ENT symptoms were assumed to be secondary to GERD. All patients underwent a transnasal laryngoscopy by the ENT team and upper endoscopy and esophageal function tests by the surgical team. GERD was defined by a pathological pH monitoring. RESULTS Pathologic reflux by pH monitoring was documented in 36 of the 79 patients (46 %), with a mean DeMeester score of 44. In 25 of the 36 patients (69 %), distal and proximal reflux was present. Among patients with negative pH monitoring, one patient was diagnosed with achalasia. ENT symptom sensitivity for globus, hoarseness and throat clearing was respectively 11, 58, and 33 %; specificity was respectively 77, 42, and 58 %. Positive predictive value for nasal endoscopy and laryngoscopy was 46 %. Among patients with positive pH monitoring, 13 (36 %) had a hypotensive lower esophageal sphincter (p < 0.01) and 27 (34 %) had abnormal peristalsis (p < 0.01). CONCLUSIONS In conclusion, the results of this study showed that (a) ENT symptoms were unreliable for the diagnosis of GERD and (b) laryngoscopy had a low positive predictive value for the diagnosis of GERD. These data confirm the importance of esophageal manometry and pH monitoring in any patient with suspected ENT manifestations of GERD before starting empiric therapy with acid-reducing medications since pathologic reflux by pH monitoring was confirmed in less than half of the patients with suspected GERD.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087, cj 301, São Paulo, SP, 04037-003, Brazil.
| | - Ciro Andolfi
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Yalini Vigneswaran
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Marco G Patti
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Bruno R Pinna
- Department of Otorhinolaryngology, Escola Paulista de Medicina, Federal University of Sao Paulo, São Paulo, Brazil
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Savarino E, Ottonello A, Tolone S, Bartolo O, Baeg MK, Farjah F, Kuribayashi S, Shetler KP, Lottrup C, Stein E. Novel insights into esophageal diagnostic procedures. Ann N Y Acad Sci 2016; 1380:162-177. [PMID: 27681220 DOI: 10.1111/nyas.13255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/12/2016] [Accepted: 08/22/2016] [Indexed: 12/14/2022]
Abstract
The 21st century offers new advances in diagnostic procedures and protocols in the management of esophageal diseases. This review highlights the most recent advances in esophageal diagnostic technologies, including clinical applications of novel endoscopic devices, such as ultrathin endoscopy and confocal laser endomicroscopy for diagnosis and management of Barrett's esophagus; novel parameters and protocols in high-resolution esophageal manometry for the identification and better classification of motility abnormalities; innovative connections between esophageal motility disorder diagnosis and detection of gastroesophageal reflux disease (GERD); impedance-pH testing for detecting the various GERD phenotypes; performance of distensibility testing for better pathophysiological knowledge of the esophagus and other gastrointestinal abnormalities; and a modern view of positron emission tomography scanning in metastatic disease detection in the era of accountability as a model for examining other new technologies. We now have better tools than ever for the detection of esophageal diseases and disorders, and emerging data are helping to define how well these tools change management and provide value to clinicians. This review features novel insights from multidisciplinary perspectives, including both surgical and medical perspectives, into these new tools, and it offers guidance on the use of novel technologies in clinical practice and future directions for research.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Andrea Ottonello
- Department of Surgical and Diagnostic Integrated Sciences, University of Genoa, Genoa, Italy
| | - Salvatore Tolone
- Division of General and Bariatric Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - Ottavia Bartolo
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Myong Ki Baeg
- Division of Gastroenterology, Department of Internal Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, South Korea
| | - Farhood Farjah
- Division of Cardiothoracic Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Hospital, Maebashi, Japan
| | - Katerina P Shetler
- Division of Gastroenterology, Palo Alto Medical Foundation, Mountain View, California
| | - Christian Lottrup
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark.,Department of Medicine, North Jutland Regional Hospital, Hjørring, Denmark
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Scarpellini E, Ang D, Pauwels A, De Santis A, Vanuytsel T, Tack J. Management of refractory typical GERD symptoms. Nat Rev Gastroenterol Hepatol 2016; 13:281-94. [PMID: 27075264 DOI: 10.1038/nrgastro.2016.50] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of patients with refractory GERD (rGERD) is a major clinical challenge for gastroenterologists. In up to 30% of patients with typical GERD symptoms (heartburn and/or regurgitation), acid-suppressive therapy does not provide clinical benefit. In this Review, we discuss the current management algorithm for GERD and the features and management of patients who do not respond to treatment (such as those individuals with an incorrect diagnosis of GERD, inadequate PPI intake, persisting acid reflux and persisting weakly acidic reflux). Symptom response to existing surgical techniques, novel antireflux procedures, and the value of add-on medical therapies (including prokinetics and reflux inhibitors) for rGERD symptoms are discussed. Pharmaceutical agents targeting oesophageal sensitivity, a condition that can contribute to symptom generation in rGERD, are also discussed. Finally, on the basis of available published data and our expert opinion, we present an outline of a current, usable algorithm for management of patients with rGERD that considers the timing and diagnostic use of pH-impedance monitoring on or off PPI, additional diagnostic tests, the clinical use of baclofen and the use of add-on neuromodulators (tricyclic agents and selective serotonin reuptake inhibitors).
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Affiliation(s)
- Emidio Scarpellini
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Division Gastroenterology, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Daphne Ang
- Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Ans Pauwels
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Adriano De Santis
- Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Tim Vanuytsel
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Jan Tack
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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pH Impedance vs. traditional pH monitoring in clinical practice: an outcome study. J Gastroenterol 2016; 51:130-7. [PMID: 26033511 DOI: 10.1007/s00535-015-1090-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/16/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The addition of impedance to 24-h pH monitoring has allowed detection of weakly acidic reflux, but the extent to which pH-impedance (pH-MII) monitoring improves outcomes is unknown. METHODS This was a prospective observational study. Patients referred for pH or pH-MII monitoring completed a standardized questionnaire on improvement in the dominant symptom, their satisfaction, and treatment at 3 and 12 months after the test during a telephone interview. RESULTS A total of 184 patients (mean age, 52 years, range, 19-82 years; 35 % with typical symptoms; and 89 % tested off therapy) completed pH (n = 92) or pH-MII monitoring (n = 92) over a period of 15 months. The two arms were similar in terms of demographic, clinical, and endoscopic variables. Ten patients in the pH-MII arm showed evidence of weakly acidic reflux disease. There was no difference in the percentage of patients in the pH and pH-MII monitoring arms who experienced improvement in their dominant symptom after 3 (58 vs. 63 %; p = 0.621) or 12 months (66 vs. 70 %; p = 0.234), and the same was true for patient satisfaction. There were also no between-group difference in the use of proton pump inhibitors (PPIs) after 3 (63 vs. 68.5 %; p = 0.437) or 12 months (47 vs. 60.5 %; p = 0.051). PPIs were prescribed more frequently after a positive test (p < 0.001) although they were used by 45.6 % of the negative patients. Only one patient underwent fundoplication. CONCLUSIONS Two-thirds of patients undergoing pH-MII monitoring experience a positive outcome, similarly to what occurs after traditional pH monitoring. Physicians often pay little attention to the test results, especially if they are negative.
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Xiao Y, Liang M, Peng S, Zhang N, Chen M. Tailored therapy for the refractory GERD patients by combined multichannel intraluminal impedance-pH monitoring. J Gastroenterol Hepatol 2016. [PMID: 26202002 DOI: 10.1111/jgh.13049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS About 30% of patients with gastroesophageal reflux disease (GERD) are refractory to proton pump inhibitor (PPI). The reason for the PPI failure in Asian GERD patients has rarely been studied, and the therapy remained unclear. The aims were to explore the possible reasons for PPI failure and to treat these patients with the guidance of 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring. METHODS Thirty-nine consecutive patients with refractory GERD were enrolled; 24-h MII-pH monitoring was performed on PPI. The refractory GERD patients were grouped into acid overexposure, non-acid reflux, and functional heartburn after the MII-pH monitoring. Double dose of either PPI or paroxetine was administered to refractory GERD patients within different groups. RESULTS The number of patients in groups of acid overexposure, non-acid reflux, and functional heartburn was 6, 12, and 21, respectively. The acid overexposure group had the most acid reflux events. Among the acid overexposure group, five (5/6) patients accomplish symptom relief with double dose of esomeprazole. For the patients in non-acid reflux group, double dose of esomeprazole made half (6/12) of the patients obtain symptom relief. For the patients in functional heartburn group, the paroxetine had relieved the symptoms in 14 patients among all the 21 patients. In total, with the guidance of MII-pH monitoring, 64.1% (25/39) of refractory GERD patients accomplished symptom relief. CONCLUSIONS Acid overexposure, non-acid reflux, and functional heartburn were the common reasons for persistent reflux symptoms despite PPI. With the guidance of MII-pH, a tailored therapy could resolve the persistent reflux symptoms among two-third of patients.
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Affiliation(s)
| | - Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Sui Peng
- Department of Gastroenterology and Hepatolgy
| | - Ning Zhang
- Department of Gastroenterology and Hepatolgy
| | - Minhu Chen
- Department of Gastroenterology and Hepatolgy
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Becker V, Drabner R, Graf S, Schlag C, Nennstiel S, Buchberger AM, Schmid RM, Saur D, Bajbouj M. New aspects in the pathomechanism and diagnosis of the laryngopharyngeal reflux-clinical impact of laryngeal proton pumps and pharyngeal pH metry in extraesophageal gastroesophageal reflux disease. World J Gastroenterol 2015; 21:982-987. [PMID: 25624734 PMCID: PMC4299353 DOI: 10.3748/wjg.v21.i3.982] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/22/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the laryngeal H+K+-ATPase and pharyngeal pH in patients with laryngopharyngeal reflux (LPR)-symptoms as well as to assess the symptom scores during PPI therapy.
METHODS: Endoscopy was performed to exclude neoplasia and to collect biopsies from the posterior cricoid area (immunohistochemistry and PCR analysis). Immunohistochemical staining was performed with monoclonal mouse antibodies against human H+K+-ATPase. Quantitative real-time RT-PCR for each of the H+K+-ATPase subunits was performed. The pH values were assessed in the aerosolized environment of the oropharynx (DxpH Catheter) and compared to a subsequently applied combined pH/MII measurement.
RESULTS: Twenty patients with LPR symptoms were included. In only one patient, the laryngeal H+K+-ATPase was verified by immunohistochemical staining. In another patient, real-time RT-PCR for each H+K+-ATPase subunit was positive. Fourteen out of twenty patients had pathological results in DxpH, and 6/20 patients had pathological results in pH/MII. Four patients had pathological results in both functional tests. Nine out of twenty patients responded to PPIs.
CONCLUSION: The laryngeal H+K+-ATPase can only be sporadically detected in patients with LPR symptoms and is unlikely to cause the LPR symptoms. Alternative hypotheses for the pathomechanism are needed. The role of pharyngeal pH-metry remains unclear and its use can only be recommended for patients in a research study setting.
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Becker V, Grotz S, Schlag C, Nennstiel S, Beitz A, Haller B, Schmid RM, Meining A, Bajbouj M. Positive predictors for gastroesophageal reflux disease and the therapeutic response to proton-pump inhibitors. World J Gastroenterol 2014; 20:4017-4024. [PMID: 24744591 PMCID: PMC3983457 DOI: 10.3748/wjg.v20.i14.4017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/12/2013] [Accepted: 01/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify objective and subjective predictors for the reliable diagnosis of gastroesophageal reflux disease (GERD) and the response to proton pump inhibitor (PPI) therapy.
METHODS: Retrospectively, 683 consecutive patients suspected for GERD who underwent pH-metry/impedance measurement (pH/MII) were analyzed. All patients had previously undergone standard PPI treatment (e.g., pantoprazole 40 mg/d or comparable). Four hundred sixty patients were at least 10 d off PPIs (group A), whereas 223 patients were analyzed during their ongoing PPI therapy (group B). In addition, all patients completed a standardized symptom- and lifestyle-based questionnaire, including the therapeutic response to previous PPI trials on a 10-point scale. Uni- and multivariance analyses were performed to identify criteria associated with positive therapeutic response to PPIs.
RESULTS: In group A, positive predictors (PPs) for response in empirical PPI trials were typical GERD symptoms (heartburn and regurgitation), a positive symptom index (SI) and pathological results in pH/MII, along with atypical symptoms, including hoarseness and fullness. In group B, regular alcohol consumption was associated with the therapeutic response. The PPs for pathological results in pH/MII in group A included positive SI, male gender, obesity, heartburn and regurgitation. In group B, the PPs were positive SI and vomiting. Analyzing for positive SI, the PPs were pathological pH and/or MII, heartburn regurgitation, fullness, nausea and vomiting in group A and pathological pH and/or MII in group B.
CONCLUSION: Anamnestic parameters (gender, obesity, alcohol) can predict PPI responses. In non-obese, female patients with non-typical reflux symptoms, pH/MII should be considered instead of empirical PPIs.
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Nennstiel S, Bajbouj M, Schmid RM, Becker V. Prucalopride reduces the number of reflux episodes and improves subjective symptoms in gastroesophageal reflux disease: a case series. J Med Case Rep 2014; 8:34. [PMID: 24502186 PMCID: PMC3923556 DOI: 10.1186/1752-1947-8-34] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/02/2013] [Indexed: 01/01/2023] Open
Abstract
Introduction Treatment of persistence to proton pump inhibitors or non-acid reflux episodes in patients with gastroesophageal reflux disease is challenging. Prucalopride, a selective high affinity serotonin (5-HT4) receptor agonist, might offer a possible new therapeutic alterative. Case presentations We report four chronically constipated female gastroesophageal reflux disease-patients with reflux symptoms and an increased number of reflux episodes in combined esophageal pH and multichannel impedance monitoring treated with prucalopride (2mg per day). Symptoms were persistent to proton pump inhibitors and ranitidine. Gastroesophageal reflux was detected by pH or multichannel impedance (MII) monitoring. Numbers of all reflux episodes as well as non-acid reflux episodes were reduced in all of our patients. The objective findings were concordant with subjective reports of symptom relief. There were no major adverse events in any patient during therapy with prucalopride. Conclusion Administration of prucalopride showed promising results in the treatment of persisting or weakly and/or non-acid reflux episodes in our case series in four constipated patients. Therefore, prucalopride can be regarded as a possible therapeutic option in the treatment of standard proton pump inhibitor-persistent reflux in the chronically constipated patient. However, further prospective trials are needed to prove our findings.
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Affiliation(s)
| | | | | | - Valentin Becker
- Klinikum rechts der Isar der Technischen Universität München, II, Medizinische Klinik und Poliklinik, Ismaninger Strasse 22, 81675 München, Germany.
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Wan Y, Yan Y, Ma F, Wang L, Lu P, Maytag A, Jiang JJ. LPR: how different diagnostic tools shape the outcomes of treatment. J Voice 2014; 28:362-8. [PMID: 24491501 DOI: 10.1016/j.jvoice.2013.12.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 12/06/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To seek a deeper and more comprehensive understanding of two major diagnostic methods for laryngopharyngeal reflux by exploring whether and how differences exist before and after treatment between patients diagnosed by either Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) or 24-hour pH monitoring. MATERIALS AND METHODS Two groups of patients who confirmed laryngopharyngeal reflux disease (LPRD) by either a combination of RSI and RFS (Questionnaire group, 35 patients) or 24-hour multichannel intraluminal impedance (MII) pH monitoring (pH Group, 23 patients) were recruited. All patients were prescribed esomeprazole 20 mg twice a day for 1 month. RSI, RFS, and acoustic parameters before and after treatment were compared between the two groups. Intrinsic correlations involving multiple parameters were investigated as well. RESULTS Except for excess throat mucus (P = 0.019) and subglottic edema (P = 0.042), most RSI and RFS items before treatment were not significantly different between the Questionnaire and pH Groups, and nearly all such items in both groups exhibited distinct remission after therapy (P < 0.05). Absolute value of remission in RSI after treatment was more prominent in pH Group than in the Questionnaire group (P = 0.007). Jitter (P = 0.252), shimmer (P = 0.815), and harmonics-to-noise ratio (P = 0.117) descended to normal value after treatment. Moderate to high levels of correlation were found between the patient's original status and the absolute value of remission in most items of RSI and RFS as well as voice parameters. CONCLUSION The 24-hour MII pH monitoring and a combination of RSI and RFS are quite competitive with each other in selecting LPRD patients. Although treatment worked out on nearly all the symptoms, laryngeal images and voice parameters, 24-hour MII pH seems to be more promising in a greater symptom relief. The extent of relief that can take place in most of the measurements is considerably determined by their initial status.
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Affiliation(s)
- Yichen Wan
- Department of Otolaryngology - Head and Neck Surgery, Peking University, Third Hospital, Beijing, People's Republic of China; Department of Otolaryngology- Head and Neck Surgery, Peking University, International Hospital, Beijing, People's Republic of China
| | - Yan Yan
- Department of Otolaryngology - Head and Neck Surgery, Peking University, Third Hospital, Beijing, People's Republic of China
| | - Furong Ma
- Department of Otolaryngology - Head and Neck Surgery, Peking University, Third Hospital, Beijing, People's Republic of China.
| | - Li Wang
- Department of Otolaryngology - Head and Neck Surgery, Peking University, Third Hospital, Beijing, People's Republic of China
| | - Peiquan Lu
- Department of Otolaryngology - Head and Neck Surgery, Peking University, Third Hospital, Beijing, People's Republic of China
| | - Allison Maytag
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jack J Jiang
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Cicala M, Emerenziani S, Guarino MPL, Ribolsi M. Proton pump inhibitor resistance, the real challenge in gastro-esophageal reflux disease. World J Gastroenterol 2013; 19:6529-6535. [PMID: 24151377 PMCID: PMC3801364 DOI: 10.3748/wjg.v19.i39.6529] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 07/30/2013] [Accepted: 08/16/2013] [Indexed: 02/06/2023] Open
Abstract
Gastro-esophageal reflux disease (GERD) is one of the most prevalent chronic diseases. Although proton pump inhibitors (PPIs) represent the mainstay of treatment both for healing erosive esophagitis and for symptom relief, several studies have shown that up to 40% of GERD patients reported either partial or complete lack of response of their symptoms to a standard PPI dose once daily. Several mechanisms have been proposed as involved in PPIs resistance, including ineffective control of gastric acid secretion, esophageal hypersensitivity, ultrastructural and functional changes in the esophageal epithelium. The diagnostic evaluation of a refractory GERD patients should include an accurate clinical evaluation, upper endoscopy, esophageal manometry and ambulatory pH-impedance monitoring, which allows to discriminate non-erosive reflux disease patients from those presenting esophageal hypersensitivity or functional heartburn. Treatment has been primarily based on doubling the PPI dose or switching to another PPI. Patients with proven disease, not responding to PPI twice daily, are eligible for anti-reflux surgery.
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Ates F, Vaezi MF. Approach to the patient with presumed extraoesophageal GERD. Best Pract Res Clin Gastroenterol 2013; 27:415-31. [PMID: 23998979 DOI: 10.1016/j.bpg.2013.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 01/31/2023]
Abstract
Reflux related cough, asthma and laryngitis are frequently encountered and are considered part of extraoesophageal syndromes. The diagnosis of extraoesophageal reflux is difficult due to the lack of gold standard diagnostic criteria. Esophagogastroduodenoscopy and esophageal pH monitoring are inadequate diagnostic tools for due to poor sensitivity and specificity. For this reason, empirical PPI therapy is recommended as an initial approach to diagnose and treat the potential underlying cause of these symptoms in patients without alarm symptoms. Diagnostic testing with esophageal pH and/or impedance monitoring and esophageal motility testing is usually reserved for those who continue to be symptomatic despite a trial of therapy with PPIs. Recent developments have increased our understanding of this difficult to treat group of patients but more research into reflux related extraoesophageal symptoms are needed to better diagnose and treat this group.
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Affiliation(s)
- Fehmi Ates
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN Nashville, TN, USA
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Abstract
This article discusses the current state of knowledge regarding the relationship between gastroesophageal reflux disease (GERD) and pulmonary and ear/nose/throat manifestations of reflux and outlines the recent developments in the diagnostic and treatment strategies for this difficult group of patients. Upper gastrointestinal endoscopy and pH monitoring are poorly sensitive for diagnosing reflux in this group of patients. Instead it is recommended that in those without warning symptoms, an empiric trial of proton-pump inhibitors be the initial approach to diagnosing and treating the potential underlying cause of these extraesophageal symptoms.
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27
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Joo MK, Park JJ, Lee BJ, Kim JH, Yeon JE, Kim JS, Byun KS, Bak YT. The effect of a proton pump inhibitor on bone metabolism in ovariectomized rats. Mol Med Rep 2013; 7:1267-72. [PMID: 23426758 DOI: 10.3892/mmr.2013.1327] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 02/13/2013] [Indexed: 11/06/2022] Open
Abstract
Recent studies revealed that long-term intake of proton pump inhibitor (PPI) increases the risk of vertebral or hip fracture; however, the exact mechanism for this is not known. To evaluate the effect of long-term PPI therapy on bone turnover, we analyzed the signaling pathway involved in osteoclast differentiation and bone resorption/formation markers using ovariectomized rats. Six-week-old Sprague-Dawley (S-D) rats were ovariectomized, and two weeks later they were divided into four groups (group A, normal diet + placebo; group B, low calcium diet + placebo; group C, normal diet + PPI; and group D, low calcium diet + PPI). Omeprazole, at a concentration of 30 mg/kg, was administered orally for eight weeks and the rats were sacrificed when they were 16 weeks old. The relative expression levels of the receptor activator of NF-κB ligand (RANKL)/osteoprotegerin (OPG) ratio, c-Fos, nuclear factor of activated T cells c1 (NFATc1) and osteocalcin in femoral bone marrow cells were compared, and serum C-terminal cross-linking telopeptide of type I (CTX-1) levels were determined. The relative ratio of RANKL/OPG was increased in group D, and gene expression levels of c-Fos and NFATc1 were upregulated in groups B and D, which are involved in differentiation and activation of osteoclasts. Furthermore, expression levels of osteocalcin, a bone formation marker, were decreased and levels of serum CTX-1, a bone resorption marker, were increased in group D. Taken together, a low calcium diet and PPI administration are thought to collaborate in order to alter osteoclast activity and bone resorption signaling.
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Affiliation(s)
- Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Seoul 152-703, Republic of Korea
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Turk H, Hauser B, Brecelj J, Vandenplas Y, Orel R. Effect of proton pump inhibition on acid, weakly acid and weakly alkaline gastro-esophageal reflux in children. World J Pediatr 2013; 9:36-41. [PMID: 23389331 DOI: 10.1007/s12519-013-0405-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 03/22/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effect of proton pump inhibitors on the characteristics of gastroesophageal reflux (GER) in children and adolescents was evaluated. METHODS Twenty-one children and adolescents with symptoms suggesting GER disease (GERD) underwent upper endoscopy and a 24-hour multichannel intraluminal impedance/pH (MII-pH) monitoring before and at the end of 2 months of therapy with proton pump inhibitors (PPIs). RESULTS Fourteen (67%) patients reported clinically relevant symptom improvement after 2 months of PPIs intake. At the first endoscopy, 8 (38%) patients had macroscopic signs of reflux esophagitis; after two months of therapy, 6/8 (75%) patients had a complete mucosal recovery. There was a significant reduction in the total percentage of mean acid reflux time (from 13.1% to 3.8%), and the De Meester score dropped to normal (from 46.4 to 13.1). The mean number of acid refluxes decreased significantly from 48 to 15 per 24 hours, while inversely, the mean number of weakly acid refluxes increased significantly from 26 to 64 per 24 hours. PPI therapy did not affect the total number of reflux episodes, the number of liquid and mixed refluxes, the duration of esophageal bolus exposure and proximal extent of the reflux. CONCLUSIONS In children and adolescents with GERD, PPIs do not affect the total number of reflux episodes. PPIs only decrease the acidity of refluxate. Nevertheless, the majority of patients with typical reflux symptoms may report symptom improvement. Esophagitis can be healed after PPI treatment. The treatment of weakly acid and weakly alkaline reflux remains a challenge for physicians in the future.
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Affiliation(s)
- Helena Turk
- University Children's Hospital, University Medical Centre, Ljubljana, Slovenia
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29
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Prolonged 2-day esophageal pH-metry with impedance monitoring improves symptom-reflux association analysis. Dig Dis Sci 2013; 58:2556-63. [PMID: 23589144 PMCID: PMC3766517 DOI: 10.1007/s10620-013-2672-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 03/27/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND The day-to-day variability in the number of reflux episodes and symptoms of gastro-esophageal reflux disease is high; therefore, the assessment of reflux disease based on 24-h monitoring may be inaccurate. AIMS The aim of the study was to compare prolonged (48 h) and standard (24 h) pH-impedance monitoring (pH-MII). METHODS Fifty-four consecutive patients with typical and atypical reflux symptoms underwent 48-h pH-MII. Acid exposure time (AET), total number of reflux episodes (TR), number of symptoms, and symptom association probability (SAP) were analyzed after the first 24 h and compared with the results obtained during 48 h of monitoring. RESULTS The differences between the fractions of patients with normal and abnormal total AET and TR on both days were not significant. The percentage of patients with positive SAP was 57.9% at 24 h and 71.9% at 48 h (difference: 14.81%, 95% CI 0.7-21.29, P<0.05). There were ten patients (10/54, 18.5%) with positive SAP after 48 h that had been negative in the first 24 h. In comparison to 24 h monitoring, patients reported a significantly increased number of various symptoms correlated with reflux after 48 h. CONCLUSIONS Extending pH-MII monitoring to 48 h does not improve the detection of abnormal acid exposure. However, it does increase the fraction of patients with positive symptom-reflux association by as much as 18.5%.
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30
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Carroll TL, Fedore LW, Aldahlawi MM. pH Impedance and high-resolution manometry in laryngopharyngeal reflux disease high-dose proton pump inhibitor failures. Laryngoscope 2012; 122:2473-81. [PMID: 22965767 DOI: 10.1002/lary.23518] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 04/17/2012] [Accepted: 05/23/2012] [Indexed: 12/19/2022]
Abstract
OBJECTIVES/HYPOTHESIS Laryngopharyngeal reflux disease (LPRD) patients often fail empiric treatment with high-dose, twice-daily (BID) proton pump inhibitors (PPIs). Further testing is warranted to rule in or out nonacid reflux (NAR) or breakthrough acid reflux (BAR) as the etiology of the symptoms. Results of coordinated multichannel intraluminal pH impedance (MII) and high-resolution esophageal manometry (HRM) testing while patients are on high-dose BID PPIs is lacking in the LPRD population. The objective of this study is to evaluate if coordinated MII and HRM aid in the management of patients with persistent LPRD symptoms despite high dose BID PPIs. STUDY DESIGN Retrospective case series. METHODS MII and HRM were administered while on medication to 23 persistent LPRD subjects who had failed 3 months of high-dose BID PPIs. Number and pH of total and proximal reflux episodes, DeMeester score, reflux symptom correlation, and motility/physiology findings were recorded. Subjects were grouped into significant NAR, BAR, or nonsignificant NAR. RESULTS Fifty-two percent of subjects had significant NAR and 22% had BAR despite high-dose BID PPIs. Statistically significant differences were found between groups for the MII outcomes of DeMeester score, number of total and proximal reflux events, and nonacid reflux events. HRM demonstrated dysmotility in five subjects. CONCLUSIONS For recalcitrant LPRD subjects who fail empiric high-dose BID PPI therapy, this study demonstrated significant NAR or BAR in 74% of subjects. Evaluation by MII and HRM performed on PPI therapy proved useful for diagnosis and further management.
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Affiliation(s)
- Thomas L Carroll
- Department of Otolaryngology, Tufts Medical Center, Boston, Massachusetts 02111, USA..
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Becker V, Graf S, Schlag C, Schuster T, Feussner H, Schmid RM, Bajbouj M. First agreement analysis and day-to-day comparison of pharyngeal pH monitoring with pH/impedance monitoring in patients with suspected laryngopharyngeal reflux. J Gastrointest Surg 2012; 16:1096-101. [PMID: 22450948 DOI: 10.1007/s11605-012-1866-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 03/05/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Diagnosis of laryngopharyngeal reflux (LPR) is still challenging. Recently a diagnostic device for pH values in the aerosolized environment of the pharynx has been introduced (Dx-pH). We evaluated results of Dx-pH with objective criteria of pH/impedance monitoring (MII) and subjective reflux scoring systems and assessed day-to-day variability. DESIGN This study makes use of a prospective single-center trial. Thirty patients with suspected LPR were analyzed. Upper endoscopic examination, manometry, phoniatric examination, and reflux scores were assessed. Dx-pH was performed on two consecutive days, first in combination with MII and second as single measurement. Thereafter, proton pump inhibitor (PPI) trial was performed. Patients were interviewed about symptom relief after 3 months. RESULTS There were considerable differences between MII and results on Dx-pH: day 1 (agreement 11 out of 30, kappa 0.137) and day 2 (agreement 14 out of 30, kappa 0.036). Statistically significant differences were detected correlating all single reflux episodes (n = 453) of Dx-pH with MII and vice versa. Furthermore acidic reflux episodes did not result in pH drops of the pharynx. There was a fair agreement between Dx-pH measurements on subsequent days. After follow-up, 3 out of 18 patients with pathological Dx-pH results reported positive response to PPIs, in contrast to 5 out of 6 patients with pathological MII. CONCLUSION According to our data, acid pharyngeal pH levels detected with Dx-pH are not related to GERD and acid esophageal reflux episodes do not result in pharyngeal pH alterations. Hence, present etiology of LPR needs to be reconsidered since neither mixed nor gas reflux events result in pharyngeal pH alteration. Other acid-producing or retaining factors should be taken into account.
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Affiliation(s)
- Valentin Becker
- Medical Department, Klinikum rechts der Isar, Technical University of Munich, II, Munich, Germany.
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Abstract
Refractory gastroesophageal reflux disease may affect up to one-third of the patients that consume proton pump inhibitor (PPI) once daily. Treatment in clinical practice has been primarily focused on doubling the PPI dose, despite lack of evidence of its value. In patients who failed PPI twice daily, medical treatment has been primarily focused on reducing transient lower esophageal sphincter relaxation rate or attenuating esophageal pain perception using visceral analgesics. In patients with evidence of reflux as the direct trigger of their symptoms, endoscopic treatment or antireflux surgery may be helpful in remitting symptoms. The role of psychological interventions, as well as non-traditional therapeutic strategies remains to be further elucidated.
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Affiliation(s)
- Ronnie Fass
- The Neuroenteric Clinical Research Group, Southern Arizona VA Health Care System, University of Arizona, Tucson, Arizona 85723-0001, USA.
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Richter JE, Penagini R, Tenca A, Pohl D, Dvorak K, Goldman A, Savarino E, Zentilin P, Savarino V, Watson JT, Wong RKH, Pace F, Casini V, Peura DA, Herzig SJ, Kamiya T, Pelosini I, Scarpignato C, Armstrong D, DeVault KR, Bechi P, Taddei A, Freschi G, Ringressi MN, Degli'Innocenti DR, Castiglione F, Masini E, Hunt RH. Barrett's esophagus: proton pump inhibitors and chemoprevention II. Ann N Y Acad Sci 2011; 1232:114-39. [PMID: 21950810 DOI: 10.1111/j.1749-6632.2011.06048.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The following on proton pump inhibitors (PPIs) and chemoprevention in relation to Barrett's esophagus includes commentaries on 48-h pH monitoring, pH-impedence, bile acid testing, dyspepsia, long/short segment Barrett's esophagus, nonerosive reflux disease (NERD), functional heartburn, dual-release delivery PPIs, immediate-release PPIs, long-term PPI use, prokinetic agents, obesity, baclofen, nocturnal acid breakthrough, nonsteroidal anti-inflammatory drugs (NSAIDs), and new PPIs.
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Affiliation(s)
- Joel E Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
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Abstract
The incidence of gastroesophageal reflux disease (GERD) is increasing drastically in China. GERD could probably cause reflux esophagitis, chronic cough, asthma, Barrett's esophagus and adenocarcinoma, and frequently affects health-related quality of life. The use of proton pump inhibitors (PPIs) provides effective symptomatic relief in most patients; however, some patients appear refractory to the treatment with PPIs. The long term use of PPIs might also cause adverse effects, such as interstitial nephritis, fracture and small intestinal bacterial overgrowth. Many new drugs for GERD have emerged recently. This article reviews the advances in drug therapy for GERD.
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Karamanolis G, Kotsalidis G, Triantafyllou K, Polymeros D, Gaglia A, Fessatou S, Triantafyllou M, Papanikolaou I, Ladas SD. Yield of combined impedance-pH monitoring for refractory reflux symptoms in clinical practice. J Neurogastroenterol Motil 2011; 17:158-63. [PMID: 21602992 PMCID: PMC3093007 DOI: 10.5056/jnm.2011.17.2.158] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 02/23/2011] [Accepted: 02/25/2011] [Indexed: 11/23/2022] Open
Abstract
Background/Aims In patients with gastroesophageal reflux disease, persistent symptoms on proton pump inhibitor (PPI) therapy may be due to residual acid or non-acid reflux. Combined impedance-pH has been suggested to be superior to pH alone in the management of refractory patients to PPI. The utility of implementation of this technique in every day clinical practice is still unknown. The aim of this study was to investigate the outcomes of patients studied with combined impedance-pH and to evaluate the yield of additional impedance monitoring over pH alone in patients with persistent gastroesophageal reflux disease symptoms. Methods Seventy-one patients (31 men; mean age, 49.1 ± 15.5 years) on PPI therapy underwent combined impedance-pH for persistent typical (76%) or atypical (49%) symptoms. Results During impedance-pH study, 44 (62%) patients reported symptoms. A positive symptom index (SI) was found in 21 (48%) patients: 8 (18.2%) had a positive SI for acid reflux, 9 (20.5%) for non-acid reflux and 4 (9.1%) for mixed reflux. Addition of impedance allowed association between reflux and symptoms in 20.5% of patients who would have been missed by pH study alone. Heartburn was the most prevalent symptom associated with acid reflux, whereas regurgitation and ear, nose and throat symptoms were associated with non-acid reflux. Conclusions The use of combined impedance-pH monitoring substantially increased the diagnostic yield compared to pH alone. With SI analysis, 20.5% of patients received a diagnosis that could not have been achieved with pH testing alone.
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Affiliation(s)
- Georgios Karamanolis
- Hepatogastroenteroly Unit, 2nd Department of Internal Medicine - Propaedeutic, Attikon University General Hospital, Athens Medical School, Athens, Greece.
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Frazzoni M, Conigliaro R, Melotti G. Weakly acidic refluxes have a major role in the pathogenesis of proton pump inhibitor-resistant reflux oesophagitis. Aliment Pharmacol Ther 2011; 33:601-6. [PMID: 21198705 DOI: 10.1111/j.1365-2036.2010.04550.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In patients with heartburn that persists despite proton pump inhibitor (PPI) therapy, reflux oesophagitis is found rarely, and its pathogenesis has been scarcely studied. AIM To assess reflux parameters by impedance-pH monitoring in PPI-resistant reflux oesophagitis. METHODS Impedance-pH monitoring was performed on PPI therapy in patients with symptomatic reflux oesophagitis detected despite standard or high-dose PPI therapy of at least 8-week duration. RESULTS Twenty patients, ten on once daily and ten on twice daily PPI regimens, were studied. The gastric acid exposure time (per cent time pH <4) ranged from 10% to 81% and was >30% in 70% of cases, but the oesophageal acid exposure time (per cent time pH <4) was abnormal in 20% of patients only. The number of acid, weakly acidic and weakly alkaline refluxes was abnormal in 25%, 100% and 15% of patients, respectively. CONCLUSIONS Weakly acidic refluxes were above the normal range in all cases, whereas acid reflux parameters and weakly alkaline refluxes were normal in the vast majority of cases. Gastric acid secretion, with consequent intra-gastric pepsins activation, persists despite ongoing PPI therapy and activated pepsins may well be present in weakly acidic refluxes. As activated pepsins maintain their proteolytic activity in a weakly acidic environment, they may be responsible for mucosal damage. We conclude that weakly acidic refluxes have a major role in the pathogenesis of PPI-resistant reflux oesophagitis. Therapeutic interventions in patients with PPI-resistant reflux oesophagitis should be tailored on the basis of impedance-pH-monitoring results.
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Affiliation(s)
- M Frazzoni
- Nuovo Ospedale S. Agostino, Modena, Italy.
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Dolder M, Tutuian R. Laboratory based investigations for diagnosing gastroesophageal reflux disease. Best Pract Res Clin Gastroenterol 2010; 24:787-98. [PMID: 21126694 DOI: 10.1016/j.bpg.2010.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 10/08/2010] [Indexed: 01/31/2023]
Abstract
Gastroesophageal reflux disease (GERD) still remains the most common out- GI-related condition in the out-patient setting. While primary care physicians often use empiric trials with proton pump inhibitors (PPI trial) to diagnose GERD, often specialised tests are required to confirm or exclude gastroesophageal reflux causing esophageal or extraesophageal symptoms. The most commonly used procedures to diagnose GERD include: conventional (catheter based) pH monitoring, wireless esophageal pH monitoring (Bravo), bilirubin monitoring (Bilitec), and combined multichannel intraluminal impedance-pH monitoring (MII-pH). Each technique has strengths and limitations of which clinicians and investigators should be aware when deciding which one to choose.
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Affiliation(s)
- Mathias Dolder
- University Clinics of Visceral Surgery and Medicine, Bern University Hospital, Switzerland
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Patient and physician satisfaction with proton pump inhibitors (PPIs): are there opportunities for improvement? Dig Dis Sci 2010; 55:3415-22. [PMID: 20397047 DOI: 10.1007/s10620-010-1209-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 03/21/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Few studies have explored the satisfaction with proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD). AIM The aim of this study was to assess patient and physician satisfaction with currently prescribed PPIs for patients with GERD. METHODS Separate online surveys were completed by 1,002 physicians and 1,013 GERD patients. Physician surveys examined satisfaction, symptom relief, long-term therapy, side-effects, breakthrough symptoms, and use of supplemental medications with PPIs. Patient surveys evaluated PPI regimen, length of therapy, satisfaction with PPI, symptom relief, use of supplemental medications, and perceptions about long-term use and side-effects. RESULTS Most respondents were satisfied with PPI therapy, but 35.4% of GERD patients and 34.8% of physicians perceived patients as "somewhat satisfied" to "completely dissatisfied" with PPI therapy. Patients who were highly satisfied were more likely to indicate complete symptom relief (P < 0.001) relative to patients who were less satisfied. However, over 35% of patients on once-daily and 54% on twice-daily PPI indicated that therapy failed to completely relieve symptoms. Patients who were highly satisfied were more likely to recommend medication to patients with the same symptoms (P < 0.001) and less likely to report that the medication is too expensive (P < 0.001), worry about long-term use (P < 0.001), or add OTC medications for supplemental control (P < 0.004). CONCLUSIONS Approximately one-third of GERD patients reported persistent symptoms and were dissatisfied with PPI therapy.
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Hershcovici T, Fass R. An algorithm for diagnosis and treatment of refractory GERD. Best Pract Res Clin Gastroenterol 2010; 24:923-36. [PMID: 21126704 DOI: 10.1016/j.bpg.2010.10.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 10/08/2010] [Indexed: 01/31/2023]
Abstract
Patients with gastro-esophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade. Upper endoscopy appears to have a limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for weakly or residual acidic reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxation rate. Esophageal pain modulators are commonly offered to patients with functional heartburn although supportive clinical studies are still missing.
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Cho YK, Kim GH, Kim JH, Jung HY, Lee JS, Kim NY. [Diagnosis of gastroesophageal reflux disease: a systematic review]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 55:279-95. [PMID: 20697188 DOI: 10.4166/kjg.2010.55.5.279] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The prevalence of gastoesophageal reflux disease (GERD) has been rapidly increased in Korea during last 20 years. However, there has been no systematic review regarding this disease. The aim of this article was to provide a review of available diagnostic modalities for GERD. This review includes proton pump inhibitor (PPI) test, endoscopy, ambulatory pH monitoring, impedance pH monitoring, and esophageal manometry in order to provide a basis for the currently applicable recommendations in the diagnosis of GERD in Korea. With weekly heartburn or acid regurgitation, the prevalence of GERD has been reported as 3.4% to 7.9%, indicating an increase of GERD in Korea. As the prevalence of Barrett's esophagus has been reported to be low, the screening endoscopy for Barrett's esophagus is not recommended. Several recent meta-analyses re-evaluated the value of the PPI test in patients with typical GERD symptoms and non-cardiac chest pain. That is, the PPI test has been proven to be a sensitive tool for diagnosing GERD in patients with non-cardiac chest pain and in some preliminary trials regarding extraesophageal manifestations of GERD. Ambulatory pH monitoring of the esophagus helps to confirm gastroesophageal reflux in patients with persistent symptoms (both typical and atypical) in the absence of esophageal mucosal damage, especially when a trial of acid suppression has failed. Impedance pH test is useful in refractory reflux patients with primary complaints of typical GERD symptoms, but this value has not been proved in patients with non-cardiac chest pain or extraesophageal symptoms. This systematic review is targeted to establish the strategy of GERD diagnosis, which is essential for the current clinical practice.
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Affiliation(s)
- Yu Kyung Cho
- Department of Internal Medicine, Seoul Nationsal University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Tsoukali E, Sifrim D. The role of weakly acidic reflux in proton pump inhibitor failure, has dust settled? J Neurogastroenterol Motil 2010; 16:258-64. [PMID: 20680164 PMCID: PMC2912118 DOI: 10.5056/jnm.2010.16.3.258] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 06/15/2010] [Accepted: 06/24/2010] [Indexed: 12/11/2022] Open
Abstract
Patients that do not respond satisfactorily to standard proton pump inhibitor (PPI) treatment have become the most common presentation of gastro-esophageal reflux disease (GERD) in third referral gastrointestinal practices. The causes of refractory GERD include lack of compliance with treatment, residual acid reflux and weakly acidic reflux, esophageal hypersensitivity and persistent symptoms not associated with reflux. A role for weakly acidic reflux in symptom generation has been proposed since the availability of impedance-pH monitoring. The possible mechanisms by which persistent weakly acidic reflux might contribute to persistent symptoms in patients under PPI treatment may include esophageal distension by increased reflux volume, persistent impaired mucosal integrity (ie, dilation of intercellular spaces) and/or esophageal hypersensitivity to weakly acidic reflux events. To establish a definite role of weakly acidic reflux in refractory GERD, outcome studies targeting this type of reflux are still lacking. Treatment strategies to reduce the number or effect of weakly acidic reflux could involve drugs that decrease transient lower esophageal sphincter relaxations (ie, baclofen or similar), improve oesophageal mucosa resistance or visceral pain modulators. Finally, anti-reflux surgery can be considered, only if a clear symptom-weakly acidic reflux association was demonstrated.
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Affiliation(s)
- Emmanouela Tsoukali
- Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, UK
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Management of gastroesophageal reflux disease that does not respond well to proton pump inhibitors. Curr Opin Gastroenterol 2010; 26:367-78. [PMID: 20571388 DOI: 10.1097/mog.0b013e32833ae2be] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Patients with gastroesophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade and presently pose a significant therapeutic challenge to the practicing physician. We reviewed newly accumulated information about the management of PPI failure that has been published over the past 2 years. RECENT FINDINGS There are diverse mechanisms that contribute to the failure of PPI treatment in GERD patients and they are not limited to residual reflux. Some of the causes of PPI failure may coincide in the same patient. Upper endoscopy appears to have limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for residual reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxations. Esophageal pain modulators are commonly offered to patients with functional heartburn, although supportive clinical studies are still missing. SUMMARY Management of refractory GERD patients remains an important clinical challenge. Recent studies have cemented the value of impedance-pH testing in pursuing proper treatment. Presently, the most promising therapeutic development for this patient population is transient lower esophageal sphincter relaxation reducers.
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Dellon ES, Shaheen NJ. Persistent reflux symptoms in the proton pump inhibitor era: the changing face of gastroesophageal reflux disease. Gastroenterology 2010; 139:7-13.e3. [PMID: 20493864 DOI: 10.1053/j.gastro.2010.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Esophageal motility in nonacid reflux compared with acid reflux. Dig Dis Sci 2009; 54:1926-32. [PMID: 19051027 DOI: 10.1007/s10620-008-0580-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 10/13/2008] [Indexed: 01/23/2023]
Abstract
Esophageal motility has been well studied in gastroesophageal reflux disease (GERD) and acid reflux, but not in nonacid reflux. Consecutive patients who had both 24-h multichannel intraluminal impedance-pH (MII-pH) and esophageal motility tests for suspected GERD were studied. Patients were grouped into nonacid refluxers, acid refluxers, and nonrefluxers based on positive symptom correlation and objective findings of acid reflux. Of 96 patients enrolled, 21 patients (22%) were nonacid refluxers, 44 patients (46%) were acid refluxers, and 31 patients (32%) had no objective evidence of reflux. Normal motility was recorded in 86% of nonacid refluxers, 71% of acid refluxers, and 60% of nonrefluxers. Ineffective esophageal motility was seen in 24% of acid refluxers, and 5% of nonacid refluxers (P = 0.11). Symptomatic nonacid reflux events comprised 22% of patients studied for GERD symptoms by MII-pH. Esophageal motility in nonacid reflux is normal 86% of the time.
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Pohl D, Tutuian R. Reflux monitoring: pH-metry, Bilitec and oesophageal impedance measurements. Best Pract Res Clin Gastroenterol 2009; 23:299-311. [PMID: 19505660 DOI: 10.1016/j.bpg.2009.04.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Gastro-oesophageal reflux disease (GERD) is a highly prevalent condition in Western countries leading to millions of outpatient visits per year. GERD symptoms including heartburn, regurgitation and chest pain are caused by reflux of gastric content in the oesophagus even in the absence of endoscopically visible mucosal lesions. Several procedures are used to identify gastro-oesophageal reflux, the clinically widely used are: conventional (catheter-based) pH monitoring, wireless oesophageal pH monitoring (Bravo), bilirubin monitoring (Bilitec), and combined multichannel intraluminal impedance-pH monitoring (MII-pH). Each technique has strengths and limitations of which clinicians and investigators should be aware when deciding which to choose in a particular patient. Important is the ability to quantify gastro-oesophageal reflux and evaluate the relationship between symptoms and reflux episodes. The present review summarises the technical aspects in performing and interpreting esophageal reflux monitoring procedures.
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Affiliation(s)
- Daniel Pohl
- Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC 29425, USA
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Conchillo JM, Smout AJ. Review article: intra-oesophageal impedance monitoring for the assessment of bolus transit and gastro-oesophageal reflux. Aliment Pharmacol Ther 2009; 29:3-14. [PMID: 18945260 DOI: 10.1111/j.1365-2036.2008.03863.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intra-oesophageal impedance monitoring can be used to assess the clearance of a swallowed bolus (oesophageal transit) and to detect gastro-oesophageal reflux independent of its acidity. AIM To discuss the clinical application of the impedance technique for the assessment of bolus transit and gastro-oesophageal reflux. METHODS Review of the literature on intra-oesophageal impedance monitoring of bolus transit and gastro-oesophageal reflux. RESULTS Using impedance criteria, normal oesophageal bolus clearance can be defined as complete clearance of at least 80% of liquid boluses and at least 70% of viscous boluses. Impedance recording identifies oesophageal function abnormalities in non-obstructive dysphagia patients and in patients with postfundoplication dysphagia. The impedance technique seems to be less suitable for the most severe end of the dysphagia spectrum like achalasia. Intra-oesophageal impedance monitoring detects reflux events independent of the pH of the refluxate, which allows identification of non-acid reflux episodes. In addition, use of impedance monitoring enables assessment of the composition (liquid, gas, mixed) and proximal extent of the refluxate. Combined impedance-pH monitoring is more accurate than pH alone for the detection of both acid and weakly acidic reflux. Furthermore, addition of impedance monitoring to pH increases the yield of symptom association analysis both in patients off and on proton pump inhibitor therapy. CONCLUSIONS Intra-oesophageal impedance monitoring is a feasible technique for the assessment of bolus transit and gastro-oesophageal reflux. Combined impedance-manometry provides clinically important information about oesophageal function abnormalities and combined impedance-pH monitoring identifies the relationship between symptoms and all types of reflux events regarding acidity and composition.
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Affiliation(s)
- J M Conchillo
- Department of Gastroenterology and Hepatology, University Hospital Maastricht, Maastricht, The Netherlands.
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Abstract
Various techniques have been devised to diagnose, characterize, and classify gastroesophageal reflux (GER). Stationary techniques, such as fluoroscopy and scintigraphy, provide interesting anatomic and functional information related to GER but are not sensitive enough and are usually performed in nonphysiologic conditions. Ambulatory techniques for GER monitoring have been developed and used since 1974. The current available techniques include catheter and wireless pH-metry, Bilitec, and impedance-pH monitoring. Prolonged wireless pH monitoring can be useful to evaluate patients off and on proton pump inhibitor (PPI) treatment. Impedance-pH monitoring is being used increasingly in patients who have persistent symptoms on PPI therapy because it can establish an association between symptoms and weakly acidic or nonacid reflux. Bilitec is performed in patients suspected to have increased duodenogastroesophageal reflux (DGER). This article discusses the technical details, clinical indications, and applications of these diagnostic techniques.
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Rey E. ¿Cuál es la utilidad de la impedanciometría en el diagnóstico del reflujo? GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:709-10. [DOI: 10.1016/s0210-5705(08)75823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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