The influence of co-morbid IBS and psychological distress on outcomes and quality of life following PPI therapy in patients with gastro-oesophageal reflux disease

Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología

INTRODUCTION

Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment.

AIM

The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD.

METHODS

The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires.

RESULTS

Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient.

CONCLUSIONS

An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.

Association Between Psychosocial Disorders and Gastroesophageal Reflux Disease: A Systematic Review and Meta-analysis

Background/Aims

The incidence of gastroesophageal reflux disease (GERD) is increasing annually. Studies have suggested that psychosocial disorders may be linked to the development of GERD. However, studies evaluating the association between psychosocial disorders and GERD have been inconsistent. Thus, we conducted a systematic review and meta-analysis of observational studies that evaluated the association between psychosocial disorders and GERD.

Methods

We systematically searched the PubMed, Embase, Cochrane, and Web of Science databases until October 17, 2020. Pooled OR with 95% CI and subgroup analyses were calculated using a random-effects model. Subgroup analyses were performed to identify the sources of heterogeneity. Sensitivity analysis by one-study removal was used to test the robustness of our results.

Results

This meta-analysis included 1 485 268 participants from 9 studies. Studies using psychosocial disorders as the outcome showed that patients with GERD had a higher incidence of psychosocial disorders compared to that in patients without GERD (OR, 2.57; 95% CI, 1.87-3.54; I2 = 93.8%; P < 0.001). Studies using GERD as an outcome showed an association between psychosocial disorders and an increased risk of GERD (OR, 2.23; 95% CI, 1.42-3.51; I2 = 97.1%; P < 0.001). The results of the subgroup analysis showed that the non-erosive reflux disease group had a higher increased risk of anxiety than erosive reflux disease group (OR, 9.45; 95% CI, 5.54- 16.13; I2 = 12.6%; P = 0.285).

Conclusion

Results of our meta-analysis showed that psychosocial disorders are associated with GERD; there is an interaction between the two.

Randomized controlled trial of robotic-assisted versus conventional laparoscopic fundoplication: 12 years follow-up

Aims

Numerous reports have addressed the feasibility and safety of robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF). Long-term follow-up after direct comparison of these two minimally invasive approaches is scarce. The aim of the present study was to assess long-term disease-specific symptoms and quality of life (QOL) in patients with gastroesophageal reflux disease (GERD) treated with RALF or CLF after 12 years in the randomized ROLAF trial.

Methods

In the ROLAF trial 40 patients with GERD were randomized to RALF (n = 20) or CLF (n = 20) between August 2004 and December 2005. At 12 years after surgery, all patients were invited to complete the standardized Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). Failure of treatment was assessed according to Lundell score.

Results

The GSRS score was similar for RALF (n = 15) and CLF (n = 15) at 12 years´ follow-up (2.1 ± 0.7 vs. 2.2 ± 1.3, p = 0.740). There was no difference in QOLRAD score (RALF 6.4 ± 1.2; CLF 6.4 ± 1.5, p = 0.656) and the QOLRAD score sub items. Long-term failure of treatment according to the definition by Lundell was not different between RALF and CLF [46% (6/13) vs. 33% (4/12), p = 0.806].

Conclusion

In accordance with previous short-term outcome studies, the long-term results 12 years after surgery showed no difference between RALF and CLF regarding postoperative symptoms, QOL and failure of treatment. Relief of symptoms and patient satisfaction were high after both procedures on the long-term. Registration number: DRKS00014690 (https://www.drks.de).

Functional gastrointestinal disorders. Overlap syndrome Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine and Gastroenterological Scientific Society of Russia

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Incomplete Response of Gastroesophageal Reflux Symptoms Poorly Predicts Erosive Esophagitis or Barrett's Esophagus

BACKGROUND & AIMS

Many patients with symptoms of gastroesophageal reflux disease (GERD) not responding to a proton pump inhibitor (PPI) undergo an upper endoscopy. We hypothesized that an incomplete response to a PPI is not associated with findings of esophageal pathology on endoscopy, and that psychological distress is associated inversely with pathology.

METHODS

We enrolled consecutive individuals aged 40 to 79 years with prior heartburn or regurgitation. Logistic regression was used to estimate the effects of incomplete response of GERD symptoms and psychological distress on the odds of finding erosive esophagitis or Barrett's esophagus.

RESULTS

A total of 625 patients completed the study. A total of 254 (66.8% of those taking PPI) had GERD symptoms incompletely responsive to a PPI and 352 (56.3%) had severe somatization. An incomplete response to a PPI was associated with psychological distress (P < .001). Erosive esophagitis was found in 148 subjects (23.7%) and Barrett's esophagus in 58 (9.3%). Overall, an incomplete response to a PPI was not found to be associated with these pathologies (odds ratio, 1.17; 95% CI, 0.720-1.91). In contrast, greater psychological distress was associated inversely with erosive esophagitis or Barrett's esophagus (in particular, highest vs lowest tertile somatization: odds ratio, 0.590; 95% CI, 0.365-0.952).

CONCLUSIONS

Patients undergoing upper endoscopy frequently have GERD symptoms incompletely responding to a PPI and a high burden of somatization. However, an incomplete response of GERD symptoms is a poor predictor for endoscopic pathology, and should not be relied upon for selecting patients for screening for Barrett's esophagus. Patients with high psychological distress are less likely to have esophageal pathology.

ESNM/ANMS consensus paper: Diagnosis and management of refractory gastro-esophageal reflux disease

Up to 40% of patients with symptoms suspicious of gastroesophageal reflux disease (GERD) do not respond completely to proton pump inhibitor (PPI) therapy. The term "refractory GERD" has been used loosely in the literature. A distinction should be made between refractory symptoms (ie, symptoms may or may not be GERD-related), refractory GERD symptoms (ie, persisting symptoms in patients with proven GERD, regardless of relationship to ongoing reflux), and refractory GERD (ie, objective evidence of GERD despite adequate medical management). The present ESNM/ANMS consensus paper proposes use the term "refractory GERD symptoms" only in patients with persisting symptoms and previously proven GERD by either endoscopy or esophageal pH monitoring. Even in this context, symptoms may or may not be reflux related. Objective evaluation, including endoscopy and esophageal physiologic testing, is requisite to provide insights into mechanisms of symptom generation and evidence of true refractory GERD. Some patients may have true ongoing refractory acid or weakly acidic reflux despite PPIs, while others have no evidence of ongoing reflux, and yet others have functional esophageal disorders (overlapping with proven GERD confirmed off therapy). In this context, attention should also be paid to supragastric belching and rumination syndrome, which may be important contributors to refractory symptoms.

GWAS of peptic ulcer disease implicates Helicobacter pylori infection, other gastrointestinal disorders and depression

Genetic factors are recognized to contribute to peptic ulcer disease (PUD) and other gastrointestinal diseases, such as gastro-oesophageal reflux disease (GORD), irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Here, genome-wide association study (GWAS) analyses based on 456,327 UK Biobank (UKB) individuals identify 8 independent and significant loci for PUD at, or near, genes MUC1, MUC6, FUT2, PSCA, ABO, CDX2, GAST and CCKBR. There are previously established roles in susceptibility to Helicobacter pylori infection, response to counteract infection-related damage, gastric acid secretion or gastrointestinal motility for these genes. Only two associations have been previously reported for duodenal ulcer, here replicated trans-ancestrally. The results highlight the role of host genetic susceptibility to infection. Post-GWAS analyses for PUD, GORD, IBS and IBD add insights into relationships between these gastrointestinal diseases and their relationships with depression, a commonly comorbid disorder.

Prevalence, risk factors, and healthcare-seeking among subjects with esophageal symptoms: A community-based study in a rural Bangladeshi population

BACKGROUND AND AIM

As there is a scarcity of data on overall prevalence, risk factors, and health-care utilization of esophageal symptoms using the Rome criteria in the rural population in Asia, we undertook a study with the aims to evaluate: (i) the prevalence of heartburn, chest pain, globus, and dysphagia of presumed esophageal origin; (ii) the prevalence of functional esophageal disorders by Rome III criteria; (iii) the risk factors for esophageal symptoms; and (iv) the health-care utilization.

METHODS

This door-to-door survey was conducted in three villages (Charcharia, Churain of Dhaka district, and Kharrah of Munshiganj district of Bangladesh) among the adult population (≥18 years) using the translated and validated Enhanced Asian Rome III questionnaire.

RESULTS

Of 3559 individuals, 3351 (94.15%) responded (mean age 40.41 ± 16.04 years, female, 1924 [57.4%]). Heartburn was the most common symptom, 863 (25.8%), followed by chest pain, 367 (11%); globus, 285 (8.5%); and dysphagia, 146 (4.4%). At least one symptom was present in 1108 (33.1%) respondents. Based on Rome III criteria, 428 (12.8%), 41 (1.2%), 49 (1.5%), 26 (0.8%), and 524 (15.6%) had heartburn, chest pain, globus, dysphagia, and at least one functional esophageal disorder, respectively. Female gender, lower family income, presence of functional dyspepsia-irritable bowel syndrome (FD-IBS) overlap, FD only, and psychological distress were found to be risk factors for esophageal symptoms on multivariate analysis. Among the subjects with any esophageal disorders, 156 (14.1%) consulted any health-care provider, and 517 (46.6%) took antisecretory medications.

CONCLUSION

Esophageal symptoms are common in the rural community of Bangladesh and are associated with substantial health resource utilization.

AGA Clinical Practice Update on Functional Heartburn: Expert Review

BEST PRACTICE ADVICE 1: A diagnosis of functional heartburn should be considered when retrosternal burning pain or discomfort persists despite maximal (double-dose) proton pump inhibitor (PPI) therapy taken appropriately before meals during a 3-month period. BEST PRACTICE ADVICE 2: A diagnosis of functional heartburn requires upper endoscopy with esophageal biopsies to rule out anatomic and mucosal abnormalities, esophageal high-resolution manometry to rule out major motor disorders, and pH monitoring off PPI therapy (or pH-impedance monitoring on therapy in patients with proven gastroesophageal reflux disease [GERD]), to document physiologic levels of esophageal acid exposure in the distal esophagus with absence of reflux-symptom association (ie, negative symptom index and symptom association probability). BEST PRACTICE ADVICE 3: Overlap of functional heartburn with proven GERD is diagnosed according to Rome IV criteria when heartburn persists despite maximal PPI therapy in patients with history of proven GERD (ie, positive pH study, erosive esophagitis, Barrett's esophagus, or esophageal ulcer), and pH impedance testing on PPI therapy demonstrates physiologic acid exposure without reflux-symptom association (ie, negative symptom index and symptom association probability). BEST PRACTICE ADVICE 4: PPIs have no therapeutic value in functional heartburn, the exception being proven GERD that overlaps with functional heartburn. BEST PRACTICE ADVICE 5: Neuromodulators, including tricyclic antidepressants, selective serotonin reuptake inhibitors, tegaserod, and histamine-2 receptor antagonists have benefit as either primary therapy in functional heartburn or as add-on therapy in functional heartburn that overlaps with proven GERD. BEST PRACTICE ADVICE 6: Based on available evidence, acupuncture and hypnotherapy may have benefit as monotherapy in functional heartburn, or as adjunctive therapy combined with other therapeutic modalities. BEST PRACTICE ADVICE 7: Based on available evidence, anti-reflux surgery and endoscopic GERD treatment modalities have no therapeutic benefit in functional heartburn and should not be recommended.

Tojapride prevents CaSR-mediated NLRP3 inflammasome activation in oesophageal epithelium irritated by acidic bile salts

Impairment of the oesophageal epithelium in patients with reflux oesophagitis (RE) is a cytokine-mediated injury rather than a chemical burn. The present study was conducted to explore CaSR/NLRP3 inflammasome pathway activation and cytokines IL-1β and IL-18 release in oesophageal epithelia injured by refluxates and the effects of Tojapride on that signal regulation. Using a modified RE rat model with Tojapride administration and Tojapride-pretreated SV40-immortalized human oesophageal epithelial cells (HET-1A) exposed to acidic bile salts pretreated with Tojapride, we evaluated the therapeutic effects of Tojapride on oesophageal epithelial barrier function, the expression of CaSR/NLRP3 inflammasome pathway-related proteins and the release of downstream cytokines in response to acidic bile salt irritation. In vivo, Tojapride treatment ameliorated the general condition and pathological lesions of the oesophageal epithelium in modified RE rats. In addition, Tojapride effectively blocked the CaSR-mediated NLRP3 inflammasome activation in modified RE rats. In vitro, Tojapride treatment can reverse the harmful effect of acidic bile salts, which reduced transepithelial electrical resistance (TEER), up-regulated the CaSR-mediated NLRP3 inflammasome pathway and increased caspase-1 activity, LDH release and cytokines secretion. Taken together, these data show that Tojapride can prevent CaSR-mediated NLRP3 inflammasome activation and alleviate oesophageal epithelial injury induced by acidic bile salt exposure.

Impact of gastroesophageal reflux disease on the quality of life of Polish patients

BACKGROUND

Gastro-esophageal reflux disease (GERD) is a serious health and social problem leading to a considerable decrease in the quality of life of patients. Among the risk factors associated with reflux symptoms and that decrease the quality of life are stress, overweight and an increase in body weight. The concept of health-related quality of life (HRQL) covers an expanded effect of the disease on a patient’s wellbeing and daily activities and is one of the measures of widely understood quality of life. HRQL is commonly measured using a self-administered, disease-specific questionnaires.

AIM

To determine the effect of reflux symptoms, stress and body mass index (BMI) on the quality of life.

METHODS

The study included 118 patients diagnosed with reflux disease who reported to an outpatient department of gastroenterology or a specialist hospital ward for planned diagnostic tests. Assessment of the level of reflux was based on the frequency of 5 typical of GERD symptoms. HRQL was measured by a 36-item Short Form Health Survey (SF-36) and level of stress using the 10-item Perceived Stress Scale. Multi-variable relationships were analyzed using multiple regression.

RESULTS

Eleven models of analysis were performed in which the scale of the SF-36 was included as an explained variable. In all models, the same set of explanatory variables: Gender, age, reflux symptoms, stress and BMI, were included. The frequency of GERD symptoms resulted in a decrease in patients’ results according to 6 out of 8 SF-36 scales- except for mental health and vitality scales. Stress resulted in a decrease in patient function in all domains measured using the SF-36. Age resulted in a decrease in physical function and in overall assessment of self-reported state of health. An increasing BMI exerted a negative effect on physical fitness and limitations in functioning resulting from this decrease.

CONCLUSION

In GERD patients, HRQL is negatively determined by the frequency of reflux symptoms and by stress, furthermore an increasing BMI and age decreases the level of physical function.

Impact of Comorbid Irritable Bowel Syndrome on Treatment Outcome in Non-Erosive Reflux Disease on Long-Term Proton Pump Inhibitor in Japan

BACKGROUND/AIMS

Irritable bowel syndrome (IBS) frequently coexists with non-erosive reflux disease (NERD). Efficacy of long-term proton pump inhibitor (PPI) treatment on NERD with or without IBS is controversial. The impact of comorbid IBS in NERD on quality of life (QOL) remains uncertain. We verified the hypothesis that NERD patients with IBS symptoms demonstrated poor responses to long-term PPI treatments, deteriorated QOL, and high frequency of psychological deviations in Japan.

METHODS

In all, 141 NERD patients who had been taking PPIs for more than 6 months were enrolled and analyzed. Patient profiles were assessed by GerdQ, IBS Severity Index (IBSSI-J)/Gastrointestinal Symptoms Rating Scale (GSRS)/SF-8, and Hospital Anxiety and Depression Scale (HADS).

RESULTS

IBS existed in 37 out of 141 NERD patients. Patients with IBS (the positive-IBS group) demonstrated significantly higher frequencies of extant reflux symptoms than those without IBS (64.9 vs. 40.4%). In the positive-IBS group, 40.5% were classified as middle grade by IBSSI-J. The SF-8 and GSRS scores in this group were significantly lower than those without IBS (the negative-IBS group). Prevalence of depression and anxiety by HADS in the positive-IBS group was significantly higher than that in the negative-IBS group.

CONCLUSION

These results proved the hypothesis that considering comorbid IBS among NERD patients on long-term PPI seems recommended in Japan.

Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions

A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist.

Refractory gastroesophageal reflux disease: Current status and perspectives

Patients with gastroesophageal reflux disease (GERD) who do not respond to an 8-12 wk course of acid-suppressive therapy with a proton pump inhibitor twice daily, with symptoms such as heartburn and acid reflux symptoms persisting after therapy, can be diagnosed with refractory GERD (RGERD). It is estimated that RGERD accounts for approximately 10%-40% of all GERD cases. Due to complicated causes, the clinical recognition of RGERD is insufficient. Thanks to the advances in the basic and clinical research of RGERD in recent years, there have been updated consensus guidelines on the diagnosis and treatment of RGERD in America and Asia (including China). This paper reviews the definition, epidemiology, pathophysiology, diagnostic evaluation, and treatment of RGERD.

Esophageal Motility and Rikkunshito Treatment for Proton Pump Inhibitor-Refractory Nonerosive Reflux Disease: A Prospective, Uncontrolled, Open-Label Pilot Study Trial

Background

Only a few reports focused on esophageal motility in patients with proton pump inhibitor (PPI)-refractory nonerosive reflux disease (NERD) and there has been no established strategy for treatment.

Objective

To clarify the characteristics of esophageal motility in patients with PPI-refractory NERD, we evaluated esophageal function using combined multichannel intraluminal impedance and esophageal manometry (MII-EM). In addition, we evaluated the efficacy of rikkunshito (RKT), which is a gastrointestinal prokinetic agent.

Methods

Thirty patients with NERD were enrolled and underwent MII-EM. After 8 weeks of RKT (7.5 g/d) treatment, MII-EM was repeated on patients with PPI-refractory NERD. Symptoms were assessed by the Gastrointestinal Symptom Rating Scale.

Results

In patients with PPI-refractory NERD, measures of complete bolus transit, peristaltic contractions, and residual pressure of the lower esophageal sphincter during swallowing deviated from the standard values and esophageal clearance was found to be deteriorated. RKT significantly improved the peristaltic contractions (P < 0.05), the complete bolus transit (P < 0.01), and the residual pressure of lower esophageal sphincter (P < 0.05) in these patients. The overall score (P < 0.01) and the subscale scores of acid reflux syndrome (P < 0.05), abdominal pain (P < 0.05), and indigestion syndrome (P < 0.01) in the Gastrointestinal Symptom Rating Scale were significantly improved by the 8-week RKT treatment.

Conclusions

In the pilot study, patients with PPI-refractory NERD had disorders of esophageal and lower esophageal sphincter motility that were improved by RKT. Further studies examining esophageal motor activity of RKT in PPI-refractory NERD are required. University hospital Medical Information Network (UMIN) Clinical Trial Registry identifier: UMIN000003092.

Factors associated with nonresponse to proton pump inhibitors therapy in patients referred for esophageal pH-impedance monitoring

Nonresponse to proton pump inhibitors (PPI) concerns up to 40% of patients treated for gastroesophageal reflux disease (GERD). Identifying predictive factors of nonresponse might help to optimize patients' treatment. The aim of this study was to determine clinical factors associated with nonresponse to PPI therapy in patients referred for pH-impedance monitoring. One hundred and sixty-eight consecutive patients (105 females, mean age 52 years, range 17-83) were included between October 2011 and May 2013. Before the realization of high-resolution manometry and 24-hour pH-impedance monitoring they completed a questionnaire including Rome III criteria for functional dyspepsia and irritable bowel syndrome (IBS). Comparisons between patients with and without PPI response were performed using chi-square or analysis of variance tests. One hundred and twenty-six patients (83%) were considered as PPI nonresponders and 26 (17%) as responders. No significant difference was observed for age and body mass index. No manometric and pH-impedance profiles were identified as associated with PPI response. The percentage of patients with functional dyspepsia and IBS was higher in PPI nonresponders patients than in responders (65.6% and 27.2%, respectively, vs. 38.5% and 7.7%, P = 0.01 and P = 0.03). This study confirms that functional digestive disorders are more frequent in patients with persistent GERD symptoms on PPI and they might be indicative of nonresponse to PPI therapy.

Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2015

As an increase in gastroesophageal reflux disease (GERD) has been reported in Japan, and public interest in GERD has been increasing, the Japanese Society of Gastroenterology published the Evidence-based Clinical Practice Guidelines for GERD (1st edition) in 2009. Six years have passed since its publication, and there have been a large number of reports in Japan concerning the epidemiology, pathophysiology, treatment, and Barrett's esophagus during this period. By incorporating the contents of these reports, the guidelines were completely revised, and a new edition was published in October 2015. The revised edition consists of eight items: epidemiology, pathophysiology, diagnosis, internal treatment, surgical treatment, esophagitis after surgery of the upper gastrointestinal tract, extraesophageal symptoms, and Barrett's esophagus. This paper summarizes these guidelines, particularly the parts related to the treatment for GERD. In the present revision, aggressive proton pump inhibitor (PPI) maintenance therapy is recommended for severe erosive GERD, and on-demand therapy or continuous maintenance therapy is recommended for mild erosive GERD or PPI-responsive non-erosive GERD. Moreover, PPI-resistant GERD (insufficient symptomatic improvement and/or esophageal mucosal break persisting despite the administration of PPI at a standard dose for 8 weeks) is defined, and a standard-dose PPI twice a day, change in PPI, change in the PPI timing of dosing, addition of a prokinetic drug, addition of rikkunshito (traditional Japanese herbal medicine), and addition of histamine H2-receptor antagonist are recommended for its treatment. If no improvement is observed even after these treatments, pathophysiological evaluation with esophageal impedance-pH monitoring or esophageal manometry at an expert facility for diseases of the esophagus is recommended.

Gender differences in symptoms in partial responders to proton pump inhibitors for gastro-oesophageal reflux disease

BACKGROUND

Gender differences may exist in the symptom experience of patients with gastro-oesophageal reflux disease (GERD) who have a partial response to proton pump inhibitors (PPIs).

OBJECTIVE

The purpose of this study was to analyse gender differences in partial responders to PPIs.

METHODS

Patients with GERD who responded partially to PPIs (n = 580; NCT00703534) completed the Reflux Symptom Questionnaire 7-day recall (RESQ-7) and the Gastrointestinal Symptom Rating Scale (GSRS). Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale.

RESULTS

Women had significantly higher RESQ-7 domain scores than men for Heartburn (frequency: 4.3 vs 3.9; intensity: 3.1 vs 2.8), Burping (frequency: 4.9 vs 4.4; intensity: 3.1 vs 2.8) and Hoarseness, cough and difficulty swallowing (frequency: 2.6 vs 2.2; intensity: 1.8 vs 1.5), and had higher GSRS domain discomfort scores than men for Abdominal pain (3.51 vs 3.23), Indigestion (3.80 vs 3.45) and Constipation (2.69 vs 2.17) (all p < 0.05). Anxiety and depression were significantly more prevalent in women than in men.

CONCLUSION

In this population of partial responders, women had more frequent/intense heartburn and extra-oesophageal symptoms and more discomfort from abdominal pain, indigestion and constipation than men. Comorbid anxiety and depression may contribute to the increased symptom burden in women.

Overlap of gastroesophageal reflux disease and functional bowel disorders in the general Chinese rural population

OBJECTIVE

This study aimed to investigate the prevalence of the overlap between gastroesophageal reflux disease (GERD) and functional bowel disorders (FBD) in the general population in rural areas in China.

METHODS

A population-based cross-sectional study was conducted in six villages in Nanmazhuang area in Lankao County (Henan Province, China) from December 2010 to October 2011. The GERD questionnaire (GerdQ) and Rome III criteria were used for the diagnosis of GERD and FBD and to determine the prevalence of GERD-FBD overlap.

RESULTS

The response rate to the questionnaires of the patients was 91.5%. In all, 2950 of 3700 residents with a mean age of 42.4 ± 16.8 years were included. Among them, 4.8% were diagnosed with GERD and 4.6% with FBD. The proportion of respondents with FBD was significantly higher in the GERD group than that in the non-GERD group (25.53% vs 3.60%, P < 0.05). The prevalence of GERD in the FBD group was significantly higher than that in the non-FBD group (26.28% vs 3.73%, P < 0.05). The prevalence of GERD-FBD overlap in the general rural population was 1.22%. Logistic regression analysis indicated that anxiety was an independent predictor for the GERD-FBD overlap in GERD and FBD (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.02-1.09 and OR 1.06, 95% CI 1.02-1.10, respectively).

CONCLUSION

GERD-FBD overlap is more common than expected by chance in the general rural population, and anxiety is significantly related to the overlap.

Risk factors and populations at risk: selection of patients for screening for Barrett's oesophagus

Screening for Barrett's oesophagus is an attractive notion due to the rising incidence of oesophageal adenocarcinoma, the relative ease of acquiring tissue from the oesophagus, and the availability of endoscopic therapy for early neoplastic lesions. If screening is recommended, the question remains: which patients should be screened? Endoscopy is frequently performed in patients with symptoms of gastro-oesophageal reflux disease, but the vast majority of patients diagnosed with oesophageal adenocarcinoma have never undergone a prior endoscopy. The efficiency of screening needs to be improved. A number of tools for predicting the presence of Barrett's oesophagus or future risk of developing oesophageal adenocarcinoma are available. More research is needed to validate these tools and to identify the thresholds at which screening should be offered.

Predictive factors of response to proton pump inhibitors in korean patients with gastroesophageal reflux disease

Background/Aims

Proton pump inhibitors (PPIs) are widely used in the treatment of gastroesophageal reflux disease (GERD). However, some patients fail to respond to PPI therapy. We investigated the efficacy of response to PPI therapy in patients with GERD symptoms.

Methods

A total of 179 subjects with GERD symptoms were prospectively enrolled and diagnosed with non-erosive reflux disease (NERD, n = 100) and erosive reflux disease (n = 79) by gastroscopy and Bernstein test and/or 24-hour esophageal pH testing. Subjects then received a standard dose of daily PPI therapy for at least 4 weeks. PPI therapy response was evaluated using questionnaires including questions about demographics, GERD symptoms, GERD impact scale, Epworth sleepiness scale, Pittsburgh sleep quality index (PSQI), hospital anxiety and depression scale, and abbreviated version of the World Health Organization quality of life scale.

Results

The rates of complete (≥ 80%), satisfactory (≥ 50%), partial (< 50%), and refractory response in the 179 participants were 41.3%, 30.2%, 18.4%, and 10.1%, respectively. Thus, overall response rate (complete and satisfactory responses) was 71.5%. Multivariate analysis showed body mass index < 23 kg/m² (OR, 2.20; 95% CI, 1.12–4.34), higher total PSQI score (OR, 1.20; 95% CI, 1.05–1.35), history of psychotherapy or neuropsychiatric medication (OR, 2.44; 95% CI, 1.23–4.85), and NERD (OR, 3.30; 95% CI, 1.54–7.11) were associated with poor response to PPI therapy.

Conclusions

Psychological factors, sleep dysfunction, body mass index < 23 kg/m², and NERD seem to be the major factors that lead to a poor response to PPI treatment in patients with GERD symptoms.

Factors influencing treatment outcome in patients with gastroesophageal reflux disease: outcome of a prospective pragmatic trial in Asian patients

BACKGROUND

Predicting response to proton pump inhibitor (PPI) treatment can aid the effective management of gastroesophageal reflux disease (GERD). The aim was to investigate the predictors of symptomatic response to pantoprazole in Asian patients with GERD; the first study of its kind in Asian patients.

METHODS

Asian patients with GERD symptoms (N = 209) received pantoprazole 40 mg daily for 8 weeks in a multinational, prospective, open-label study. Response was assessed using ReQuest™. Baseline and demographic factors were examined using logistic regression to determine if they were related to treatment response.

RESULTS

Response rates were 44.3% (Week 4) and 63.6% (Week 8) in Asian patients versus 60.7% (P < 0.001) and 72.2% (P = 0.010) for the rest of the world. Higher response rates at 8 weeks occurred in patients with erosive reflux disease (ERD; 71.3%) versus those with non-erosive reflux disease (NERD) at baseline (48.5%). The presence of ERD (P = 0.0143) and lower ReQuest™-GI scores at baseline (P = 0.0222) were associated with response. Improvements in quality of life (QoL) and anxiety and depression at 4 and 8 weeks were associated with treatment response (both P < 0.0001). Patient satisfaction correlated with treatment response (P < 0.0001), and improvement in anxiety and depression (P < 0.0001) and QoL (P < 0.0001).

CONCLUSIONS

Asian patients with GERD, especially those with NERD, may have lower response rates to PPIs than Western populations. ERD and less severe gastrointestinal symptoms may help to predict symptomatic responses to PPIs in Asian patients.

TRIAL REGISTRATION

ClinicalTrial.gov identifier: NCT00312806.

Nonmedical therapeutic strategies for nonerosive reflux disease

There has been a marked decline over the last several years in drug development for gastroesophageal reflux disease and specifically for nonerosive reflux disease (NERD), despite there being many areas of unmet need. In contrast, we have seen a proliferation, during the same period of time, in development of novel, nonmedical therapeutic strategies for NERD using cutting-edge technology. Presently, compliance and lifestyle modifications are readily available noninvasive therapeutic interventions for NERD. Other nonmedical therapies include, the Stretta procedure, transoral incisionless fundoplication, and the magnetic sphincter augmentation device (LINX). Antireflux surgery, in experienced hands, has been repeatedly shown to be efficacious in resolving NERD-related symptoms. Psychological therapeutic interventions and alternative medicine techniques, such as acupuncture, continue to show promise, especially in NERD patients who failed antireflux treatment.

Psychological modulation in patients surgically intervened for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) has been related with certain psychological dimensions. The influence of mood, emotional intelligence, and perceived quality of life on clinical symptoms and outcome of antireflux surgery was evaluated in GERD patients with and without hiatal hernia. The study included 61 patients who were diagnosed with GERD between 2003 and 2008: 16 of them without hiatal hernia (group A) and 45 of them with hiatal hernia (group B). All of these patients had undergone laparoscopic antireflux surgery. Patients were clinically examined and evaluated with the following instruments: Short Form (SF)-36 Health Survey, Gastrointestinal Quality of Life Index, Hospital Anxiety and Depression (HAD) Scale, and Trait Meta-Mood Scale (TMMS)-24. Proportions were compared by using the chi-squared test; averages were compared by using the Student's t-test (with Bonferroni's correction). In general, our patients intervened for GERD showed results lower than normal or close to the lower limit of normal in the administered tests. Patients in the group without hernia were younger (P < 0.001) and with lower American Society of Anaesthesiologists risk. They showed higher scores in the SF-36 dimensions: Physical Functioning, Physical Role and Emotional Role, and lower scores in the Social Role (P < 0.001). They showed lower scores in the Emotional dimension of Gastrointestinal Quality of Life Index (P = 0.0068) and worse results in the Hospital Anxiety and Depression subscales of Anxiety (P < 0.001) and Depression (not significant). Men in the group without hernia showed higher scores than men in the group with hernia in the TMMS subscales corresponding to Emotional Clarity and Emotional Repair (P < 0.001). Women in the group with hernia showed higher scores than women in the group without hernia regarding Emotional Clarity (P = 0.0012). GERD patients showed poor results in all the tests, and patients without hiatal hernia compared with patients with hernia showed higher levels of anxiety, which interfered with their social life. Moreover, they showed lower tolerance to stress and higher frustration, fear, and worry. On the basis of such unfavorable phychoemotional results observed with GERD patients (especially those without hernia) in the different tests, we propose that improving our knowledge of the psychological profile of GERD patients - particularly those without hiatal hernia - could help in designing individualized medical and psychological therapies and increase success rates.

Refractory gastroesophageal reflux disease: advances and treatment

'Refractory gastroesophageal reflux disease' is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with 'refractory symptoms.' We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue.

Treatment of GORD: Three decades of progress and disappointments

The treatment of GORD has been revolutionized by the introduction, in the 1980s, of proton-pump inhibitors as the mainstay of medical therapy and by the development of laparoscopic antireflux surgery which has definitively replaced open surgery. However, despite these major advances, many unmet therapeutic needs still persist and justify novel therapeutic approaches. The aim of this historical review is to recall the main discoveries in the treatment of GORD that have occurred during the last three decades and to discuss why some initially promising drugs or techniques have not translated into clinical applications. A careful analysis of these previous disappointing experiences should help to identify high priorities and better research programmes on the management of GORD.

Comparing omeprazole with fluoxetine for treatment of patients with heartburn and normal endoscopy who failed once daily proton pump inhibitors: double-blind placebo-controlled trial

BACKGROUND

Patients with heartburn but without esophageal erosion respond less well to proton pump inhibitors (PPIs). There is a growing body of evidence implicating the role of psychological comorbidities in producing reflux symptoms. Pain modulators improve symptoms in patients with other functional gastrointestinal disorders. We aimed to compare the efficacy of fluoxetine with omeprazole and placebo to achieve symptomatic relief in patients with heartburn and normal endoscopy who failed once daily PPIs.

METHODS

Endoscopy-negative patients with heartburn who failed once daily PPIs were randomly allocated to receive 6 weeks treatment of fluoxetine, omeprazole, or placebo. Random allocation was stratified according to ambulatory pH monitoring study. Percentage of heartburn-free days and symptom severity was assessed.

KEY RESULTS

Sixty patients with abnormal and 84 patients with normal pH test were randomized. Subjects receiving fluoxetine experienced more improvement in percentage of heartburn-free days (median 35.7, IQR 21.4-57.1) than those on omeprazole (median 7.14, IQR 0-50, p < 0.001) or placebo (median 7.14, IQR 0-33.6, p < 0.001). In normal pH subgroup, fluoxetine was superior to both omeprazole and placebo regarding percentage of heartburn-free days (median improvement, 57.1, IQR 35.7-57.1 vs 13.9, IQR, 0-45.6 and 7.14, 0-23.8, respectively, p < 0.001), but no significant difference was observed between medications in abnormal pH subgroup.

CONCLUSIONS & INFERENCES

Fluoxetine was superior to omeprazole for improving the symptoms of patients with heartburn and normal endoscopy who failed once daily PPIs. The superiority of fluoxetine was mostly attributed to those with normal esophageal pH rather than those with abnormal pH (ClinicalTrials.gov, number NCT01269788).

New Approaches to Management of PPI-Refractory Gastroesophageal Reflux Disease

OPINION STATEMENT

"Refractory GERD" is one the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive, often twice-daily proton pump inhibitor therapy. The term should be replaced with "refractory symptoms." We must acknowledge that in many patients, symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus, and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to esophagogastroduodenoscopy followed by pH or impedance monitoring. In the majority of patients these tests are normal. The role of non-acid reflux measured by impedance pH testing in this group is uncertain at best and the results from this test alone should not be used to refer patients to surgical fundoplication. In patients unresponsive to acid suppressive therapy, reflux is most commonly not causal and a search for non-GERD causes must ensue.

Endotherapy for and tailored approaches to treating GERD, and refractory GERD

This paper presents commentaries on how endoluminal antireflux procedures compare to laparoscopic fundoplication; new endoscopic procedures being studied to treat refractory gastroesophageal reflux disease (GERD); the new Stretta; the relationship between obesity and proton pump inhibitor (PPI) resistance; data concerning acid hypersensitivity and sensory receptors (vallinoid, TRPV1) causing refractory GERD; whether microscopic esophagitis is relevant in determining symptoms of non-erosive reflux disease (NERD); how concomitant functional gastrointestinal disorders affect the PPI response in NERD; the evidence that a functional esophagus is associated with inflammatory bowel syndrome (IBS); the role of GABA agonists in the treatment of refractory GERD; the role of biofeedback and antidepressants in refractory GERD; and endoluminal fundoplication using the EsophyX device.

Psychological distress is not associated with treatment failure in patients with gastroesophageal reflux disease

OBJECTIVE

Symptoms of anxiety and depression are common in patients with gastroesophageal reflux disease (GERD). We aim to examine the relationship between psychological distress and response to proton pump inhibitors (PPI).

METHODS

In this prospective study, GERD patients receiving PPI once or twice daily were divided into 3 groups: responders to PPI once daily (group A, N=111), non-responders to PPI once daily (group B, N=78) and non-responders to PPI twice daily (group C, N=56). All patients completed demographic and clinical questionnaires, Rome III Diagnostic Questionnaire for irritable bowel syndrome, Hospital Anxiety and Depression Scale (HADS), Satisfaction with Life Scale (SWLS) and the Gastroparesis Cardinal Symptom Index (GCSI) questionnaires.

RESULTS

A total of 245 patients (59.3% females, 52±17.2 years) participated in this study. No differences were observed between groups with respect to age, sex, psychiatric medications or pre-existing major depression. Anxiety (HADS-anxiety>7) was seen in 32%, 31% and 34% of groups A, B and C, respectively (p=ns). Depression (HADS-depression>7) was present in 30%, 31% and 21% of groups A, B and C, respectively (p=ns). Global satisfaction with life (SWLS>20) was present in 63% of group C patients, compared to 78% of group A and 78% of group B (p=0.04, p=0.05, respectively). GCSI scores (mean±SD) were 11.1±9.2, 14.07±8.5 and 16.3±10.4, for groups A, B and C, respectively (p=0.002). GCSI correlated significantly with HADS-anxiety (r=0.20, p=0.002) and SWLS (r=-0.2, p=0.01).

CONCLUSION

Lack of response to PPI was associated with lower life satisfaction but not anxiety or depression. Symptoms suggestive of gastroparesis were associated with anxiety and low satisfaction with life in patients with GERD.

Possible etiology of improvements in both quality of life and overlapping gastroesophageal reflux disease by proton pump inhibitor treatment in a prospective randomized controlled trial

Background

Symptoms suggestive of functional dyspepsia (FD) and irritable bowel syndrome (IBS) frequently overlap with those of gastroesophageal reflux disease. Despite the high prevalence of symptomatic overlap, the underlying etiology remains poorly defined. We assessed the correlation of symptomatic relief and health-related quality of life (HRQoL) with healing of reflux esophagitis to further derive insights into the underlying etiology.

Methods

626 patients with reflux esophagitis were enrolled into one of two treatment groups (classical healing concept or the complete remission concept) to investigate differences in treatment intensity. Patients were treated with pantoprazole until esophageal mucosal healing. Remission was followed for up to 6 months without treatment. Gastro-intestinal symptoms and HRQoL were analyzed using disease-specific, psychometrically validated patient-reported outcome instruments (ReQuest™, GERDyzer™).

Results

Symptomatic burden reflected by ReQuest™ substantially decreased from baseline to end of treatment by 83% and 88% in either treatment group, respectively. ReQuest™ scores significantly decreased in patients with or without heartburn and in those with symptoms suggestive of FD and IBS, indicating response of all symptom categories to treatment (p < 0.005). Therapy-associated relief of symptoms was paralleled by substantial gains in HRQoL, which continued to stabilize post-treatment.

Conclusions

Pantoprazole is effective in relieving upper and lower gastro-intestinal symptoms overlapping with erosive esophagitis, and provides sustained improvement in HRQoL post-treatment. Our results propose a link between both healing of erosive esophagitis and the slower remission of upper and lower gastro-intestinal symptoms. Since the improvement observed is likely to be multifactorial, the possibility for an immune-mediated etiology and identification of putative susceptibility factors by genome-wide association study may provide focus for future research.

Trial registration

ClinicalTrials.gov identifier: NCT00325676.

Overlap of functional heartburn and gastroesophageal reflux disease with irritable bowel syndrome

Several studies indicate a significant degree of overlap between irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). Likewise, both functional heartburn (FH) and IBS are functional digestive disorders that may occur in the same patients. However, data establishing a solid link between FH and IBS are lacking, mainly because the clinical definition of FH has undergone substantial changes over the years. The available literature on the overlap between GERD or FH and IBS highlights considerable heterogeneity in terms of the criteria and diagnostic procedures used to assess heartburn and IBS. In particular, several epidemiological studies included patients with concomitant IBS and GERD without any attempt to distinguish FH (as defined by the Rome III criteria) from GERD via pathophysiological investigations. Independent of these critical issues, there is preliminary evidence supporting a significant degree of FH-IBS overlap. This underscores the need for studies based on updated diagnostic criteria and accurate pathophysiological classifications, particularly to distinguish FH from GERD. This distinction would represent an essential starting point to achieving a better understanding of pathophysiology in the subclasses of patients with GERD and FH and properly assessing the different degrees of overlap between IBS and the subcategories of heartburn.The present review article intends to appraise and critically discuss current evidence supporting a possible concomitance of GERD or FH with IBS in the same patients and to highlight the pathophysiological relationships between these disorders.

Current pharmacological management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), a common disorder with troublesome symptoms caused by reflux of gastric contents into the esophagus, has adverse impact on quality of life. A variety of medications have been used in GERD treatment, and acid suppression therapy is the mainstay of treatment for GERD. Although proton pump inhibitor is the most potent acid suppressant and provides good efficacy in esophagitis healing and symptom relief, about one-third of patients with GERD still have persistent symptoms with poor response to standard dose PPI. Antacids, alginate, histamine type-2 receptor antagonists, and prokinetic agents are usually used as add-on therapy to PPI in clinical practice. Development of novel therapeutic agents has focused on the underlying mechanisms of GERD, such as transient lower esophageal sphincter relaxation, motility disorder, mucosal protection, and esophageal hypersensitivity. Newer formulations of PPI with faster and longer duration of action and potassium-competitive acid blocker, a newer acid suppressant, have also been investigated in clinical trials. In this review, we summarize the current and developing therapeutic agents for GERD treatment.

Management of the patient with incomplete response to PPI therapy

Proton pump inhibitors (PPIs) remove most of the acid from the gastroesophageal refluxate. However, PPIs do not eliminate reflux and the response of specific GERD symptoms to PPI therapy depends on the degree to which acid drives those symptoms. PPIs are progressively less effective for heartburn, regurgitation, chest pain and extra-oesophageal symptoms. Hence, with an incomplete PPI response, obtaining an accurate history, detailing which symptoms are 'refractory' and exactly what evidence exists linking these symptoms to GERD is paramount. Reflux can continue to cause symptoms despite PPI therapy because of persistent acid reflux or weakly acidic reflux. Given these possibilities, diagnostic testing (pH or pH-impedance monitoring) becomes essential. Antireflux surgery is an alternative in patients if a clear relationship is established between persistent symptoms, particularly regurgitation, and reflux. Treating visceral hypersensitivity may also benefit the subset of GERD patients whose symptoms are driven by this mechanism.

Novel therapeutics for gastro-esophageal reflux symptoms

Approximately 20-30% of patients with gastro-esophageal reflux symptoms report inadequate symptom relief while on proton-pump inhibitor therapy. The mechanisms involved are failure of the antireflux barrier (transient lower esophageal sphincter relaxations), high proximal extent of the refluxate, esophageal hypersensitivity and impaired mucosal integrity. Persisting acid or nonacid reflux can be demonstrated in 40-50% of cases, suggesting that there is room for antireflux therapy in these patients. New antireflux compounds have been shown to decrease the occurrence of transient lower esophageal sphincter relaxations. The most promising classes of compounds are GABA type B agonists and metabotropic glutamate receptor 5 antagonists, which can reduce both reflux episodes and symptoms, but the development of these compounds has been abandoned for either safety issues or lack of efficacy. Esophageal hypersensitivity and impaired mucosal integrity may prove to be relevant therapeutic targets in the future.

Predictors of clinical response of acid suppression in Chinese patients with gastroesophageal reflux disease

BACKGROUND

Up to 40% of patients with gastroesophageal reflux disease fail to respond to proton pump inhibitor therapy.

AIMS

To determine predictors of clinical response of proton pump inhibitor therapy.

METHODS

Consecutive patients with gastroesophageal reflux disease were enrolled prospectively. All patients underwent upper endoscopy and 24-h multichannel intraluminal impedance and pH monitoring before receiving esomeprazole 20 mg b.i.d. for 2 months. Multivariate logistic regression analysis was used to determine the independent predictors of clinical response to proton pump inhibitor therapy.

RESULTS

A total of 204 patients with typical reflux symptoms were recruited and screened. Among them 153 patients (mean age 46.3 ± 10.6 years, 51.0% female) completed all the examinations and were assigned to proton pump inhibitor therapy. Ninety-five patients (62.1%) responded to acid suppression after 2 months. Multivariate logistic analysis showed that the predictor for response was pathological distal esophageal acid reflux (P = 0.001). The factors associated with proton pump inhibitor therapy failure were the presence of irritable bowel syndrome alone (P = 0.006), depression (P = 0.005), and overlap of irritable bowel syndrome and functional dyspepsia (P = 0.002).

CONCLUSIONS

The clinical response of acid suppression on gastroesophageal reflux disease could be predicted by clinical and pH parameters rather than impedance data.

[Updated guidelines 2012 for gastroesophageal reflux disease]

In 2010, a Korean guideline for the management of gastroesophageal reflux disease (GERD) was made by the Korean Society of Neurogastroenterology and Motility, in which the definition and diagnosis of GERD were not included. The aim of this guideline was to update the clinical approach to the diagnosis and management of GERD in adult patients. This guideline was developed by the adaptation process of the ADAPTE framework. Twelve guidelines were retrieved from initial queries through the Appraisal of Guidelines for Research & Evaluation II process. Twenty-seven statements were made as a draft and revised by modified Delphi method. Finally, 24 consensus statements for the definition (n=4), diagnosis (n=7) and management (n=13) of GERD were developed. Multidisciplinary experts participated in the development of the guideline, and the external review of the guideline was conducted at the finalization phase.

Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population

BACKGROUND

We aimed to clarify the lifestyle factors associated with erosive esophagitis and non-erosive reflux disease (NERD) in a Japanese population.

METHODS

Among 886 subjects who underwent health screening, we selected, according to their scores on the FSSG (frequency scale for symptoms of gastroesophageal reflux disease; GERD) questionnaire and the findings of upper gastrointestinal endoscopy, 138 subjects with erosive esophagitis (EE), 148 subjects with NERD (absence of esophagitis, FSSG score ≥8, and acid reflux-related symptoms score ≥4), and 565 control subjects (absence of esophagitis and FSSG score ≤7). We compared clinical characteristics and various lifestyle factors in these three groups.

RESULTS

The lifestyle factors significantly associated with NERD compared with findings in the control group were intake of egg (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.01-3.50), sleep shortage (OR 2.44, 95% CI 1.54-3.88), and strong psychological stress (OR 1.77, 95% CI 1.18-2.62). In male subjects, current smoking (OR 2.06, 95% CI 1.13-3.74; OR 1.87, 95% CI 1.09-3.20) was a significant risk factor for both NERD and EE. Moreover, alcohol >200 kcal/day (OR 3.99, 95% CI 1.03-15.55) and intake of a large quantity of food at supper (OR 7.85, 95% CI 1.66-37.05) were significant risk factors for EE in subjects with hiatal hernia. Intake of a large quantity of food at supper (OR 2.09, 95% CI 1.06-4.13) was more common in the NERD group than in the EE group.

CONCLUSIONS

There were differences in the associated lifestyle factors between patients with NERD and those with EE, and there was also a gender-related difference between these groups.

Step-by-step management of refractory gastresophageal reflux disease

Up to a third of the patients who receive proton pump inhibitor (PPI) once daily will demonstrate lack or partial response to treatment. There are various mechanisms that contribute to PPI failure and they include residual acid reflux, weakly acidic and weakly alkaline reflux, esophageal hypersensitivity, and psychological comorbidity, among others. Some of these underlying mechanisms may coincide in the same patient. Evaluation for proper compliance and adequate dosing time of PPIs should be the first management step before ordering invasive diagnostic tests. Doubling the PPI dose or switching to another PPI is the second step of management. Upper endoscopy and pH testing appear to have limited diagnostic value in patients who failed PPI treatment. In contrast, esophageal impedance with pH testing (multichannel intraluminal impedance MII-pH) on therapy appears to provide the most insightful information about the subsequent management of these patients (step 3). In step 4, treatment should be tailored to the specific underlying mechanism of patient's PPI failure. For those who demonstrate weakly acidic or weakly alkaline reflux as the underlying cause of their residual symptoms, transient lower esophageal sphincter relaxation reducers, endoscopic treatment, antireflux surgery and pain modulators should be considered. In those with functional heartburn, pain modulators are the cornerstone of therapy.

Current and emerging therapies for the management of functional gastrointestinal disorders

The functional gastrointestinal disorders are common disorders that are associated with significant quality-of-life impairment and considerable economic burden on the healthcare system. They are frequently associated with a comorbid psychiatric condition; this, together with a striking lack of effective pharmacological therapies, means they represent a considerable therapeutic challenge to the treating physician. In this overview, we examine the evidence to support the use of agents currently used in the management of the more common functional gastrointestinal disorders and review emerging therapies.

Functional heartburn: definition and management strategies

Functional heartburn (FH) is a functional gastro-intestinal disorder characterized by symptoms of heartburn not related to gastro-esophageal reflux. The absence of evidence of reflux-related symptoms relies on absence of esophagitis at endoscopy (including biopsies to exclude eosinophilic esophagitis), a normal esophageal acid exposure during esophageal pH-monitoring together with a negative symptom-reflux association analysis and an unsatisfactory response to proton pump inhibitor therapy. Addition of impedance measurement to pH-monitoring is likely to increase the number of patients with recognized reflux-related symptoms. The pathophysiology of functional heartburn remains largely unknown but involves disturbed esophageal perception and psychological factors such as depression, anxiety and somatization. The treatment of FH remains largely empirical and an individual approach is therefore recommended. The clinician should provide reassurance and refrain from performing too many invasive tests or therapeutic procedures. The use of pain modulators is recommended by most experts despite the lack of appropriate clinical trials to support it.

Frequency and clinical implications of supraesophageal and dyspeptic symptoms in gastroesophageal reflux disease

OBJECTIVE

We studied the frequency of supraesophageal and dyspeptic symptoms and their impact on the quality of life (QoL) and treatment response in patients with gastroesophageal reflux disease (GERD).

METHODS

Multicenter, prospective, observational study of patients who consulted a gastroenterologist because of typical GERD symptoms. Upper digestive symptoms were assessed using direct interviews. The Short Form-12 and the Quality of Life in Reflux and Dyspepsia questionnaires were used to measure QoL. Patients were treated with proton pump inhibitors (PPIs).

RESULTS

A total of 301 patients (58% men; mean age, 45 years) were included. Baseline symptoms were heartburn (99% of cases; nocturnal heartburn 78%), regurgitation (86%), both heartburn and regurgitation (85%), dyspeptic symptoms (91%; epigastric pain syndrome 20%, postprandial distress syndrome 4%, both 75%), and supraesophageal symptoms (58%). In 56% of cases of heartburn, 35% of regurgitation, and 34% of nocturnal heartburn, symptoms were severe or very severe. One in six patients had dysphagia. Supraesophageal and/or dyspeptic symptoms were associated with worse scores on the Short Form-12 and Quality of Life in Reflux and Dyspepsia instruments. After treatment, heartburn and regurgitation disappeared in 93 and 87% of the patients, respectively. The percentage of patients responding to PPI treatment was significantly higher (P<0.05) in those with heartburn than those without heartburn (96 vs. 86%) and in those with regurgitation than without regurgitation (95 vs. 83%), whereas no differences were observed in those with and without supraesophageal or dyspeptic symptoms.

CONCLUSION

Patients with typical GERD symptoms (heartburn and/or regurgitation) very frequently have dyspeptic and supraesophageal manifestations, which are related to a worse QoL but unrelated to PPI response.

Randomised clinical trial: sustained response to PPI treatment of symptoms resembling functional dyspepsia and irritable bowel syndrome in patients suffering from an overlap with erosive gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease (GERD), functional dyspepsia (FD) and irritable bowel syndrome (IBS) are highly prevalent gastrointestinal conditions with accumulating evidence of overlap in patients. Despite availability of a vast body of research related to individual disorders, major pharmacological breakthrough in treatment of the overlap condition is still lacking.

AIM

To assess sustainability of GERD healing and whether known beneficial effects of proton pump inhibitor treatment on GERD also extend to symptoms suggestive of FD and IBS.

METHODS

A total of 626 patients with reflux oesophagitis were treated with pantoprazole for up to 16 weeks depending on healing of GERD, followed by an observational phase of up to 6 months without treatment. Rates of patients suffering from GERD, FD or IBS were assessed at baseline, and at last visits of treatment and observational phase.

RESULTS

Rates of patients with reflux oesophagitis and concomitantly with reflux symptoms, FD or IBS were each significantly lower after pantoprazole treatment (P < 0.0001). While rates of patients with reflux signs or symptoms increased again during observational phase, rates of FD and IBS were maintained at the low level after cessation of medication (P < 0.0001).

CONCLUSIONS

Pantoprazole is efficacious in the treatment of patients suffering from signs and symptoms suggesting an overlap of GERD, FD and/or IBS, providing a sustained response post-treatment in FD and IBS symptom categories. Mechanisms underlying the beneficial effects of improvement in reflux oesophagitis on symptoms suggestive of FD or IBS still need to be determined.

Therapeutic options for refractory gastroesophageal reflux disease

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.

Gastro-oesophageal reflux disease: beyond proton pump inhibitor therapy

Gastro-oesophageal reflux disease (GORD or GERD) is a very common disorder, and advancement in drug development over the years has markedly improved disease management. Proton pump inhibitors (PPIs) remain the mainstay of treatment for GERD due to their profound and consistent inhibitory effect on acid secretion. However, PPIs do not reduce the number of reflux events and do not provide long-term cure for GERD. In addition, although the safety profile of PPIs is excellent, recent population-based studies have suggested that long-term PPI use may be associated with a variety of adverse events. They include osteoporosis-related hip and spine fractures, community-acquired and nosocomial pneumonia, various enteric and non-enteric infections, fundic gland polyps and many others. Consequently, there is growing interest by patients and physicians alike in current, as well as future, non-PPI-related therapeutic strategies for GERD. This includes repositioning histamine H(2) receptor antagonists and prokinetics in our current GERD therapeutic algorithms and a resurgence of non-medical therapeutic modalities for GERD, such as anti-reflux surgery, endoscopic treatment, alternative and complementary medicine and psychological interventions. Furthermore, there will be renewed efforts in further developing new medical and non-medical therapeutic modalities for GERD.