Diagnosis of gastroesophageal reflux disease using a new questionnaire

Evaluation of the Additive Effect of Domperidone on Patients with Refractory Gastroesophageal Reflux Disease; A Randomized Double Blind Clinical Trial

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common problem with annoying symptoms. It is associated with negative impact on quality of life. Prokinetic agents may be used in combination with acid suppression agents as an adjunctive in patients with GERD refractory to proton pump inhibitors (PPI) therapy, rather than as sole treatment. This study aimed to evaluate the efficacy of combination of PPI with domperidone (a prokinetic agent) compared with PPI alone in the treatment of patients with refractory GERD.

METHODS

This study was a double blind clinical trial on 29 patients with GERD refractory to PPI during the period of one month. By randomization, the patients were divided into two groups. Group A was treated by pantoprazole 40 mg twice daily and domperidone three times a day for a month, while group B was treated by pantoprazole 40 mg twice daily and placebo three times a day. In this study endoscopy was performed to evaluate the prevalence of erosive esophagitis, non-erosive reflux, and hiatal hernia. Manometry was conducted to study the prevalence of dysmotility. GERD symptom questionnaires including the Gastrointestinal Symptom Rating Scale (GSRS), Carlson Dennett, and the Medical Outcomes Study Short Form-36 health survey (SF36) were used before and after treatment for screening GERD and assessing treatment response.

RESULTS

There were 17 (58.62%) women and 12 (41.37%) men. The prevalence of erosive esophagitis and non-erosive reflux, was 10.34% and 89.66%, respectively. There was a significant difference comparing reflux symptoms before and after treatment between the two groups according to reflux and Carlson Dennett questionnaires. At the end of the study, symptoms of reflux significantly improved by treatment. Although, the quality of life questionnaire scores improved by treatment, there was no statistically significant difference in response to treatment between the two groups.

CONCLUSION

In this research, we showed that adding domperidone to PPI could not make any improvement in patients with refractory reflux regarding the quality of life and improving the symptoms.

Decline in perception of acid regurgitation symptoms from gastroesophageal reflux disease in diabetes mellitus patients

Objectives

To determine if a discrepancy exists between subjective symptoms and the grade of endoscopic gastroesophageal reflux disease (GERD) in diabetes mellitus (DM) patients.

Methods

All 2,884 patients who underwent esophagogastroduodenoscopy completed the modified Gastrointestinal Symptom Rating Scale (GSRS), an interview-based rating scale consisting of 16 items including a question on acid regurgitation. Patients were divided into DM and non-DM groups (1,135 and 1,749 patients, respectively). GERD was diagnosed endoscopically and graded according to the Los Angeles classification. Grade B or more severe GERD was defined as severe endoscopic GERD. The intergroup GSRS score was compared statistically.

Results

In severe endoscopic GERD patients, the prevalence of patients with a positive GSRS score in the acid regurgitation question was statistically lower in DM patients than non-DM patients. Of the 60 non-DM patients with severe endoscopic GERD, 40 patients (67%) had a positive GSRS score for acid regurgitation; however, of the 51 DM patients with severe endoscopic GERD, 23 patients (45%) had a positive GSRS score. Multivariate analysis showed that severe endoscopic GERD (OR: 2.01; 95% CI: 1.21–3.33; p = 0.0066), non-DM (OR: 0.74; 95% CI: 0.54–0.94; p = 0.0157), younger age (OR: 0.98; 95% CI: 0.97–0.99; p = 0.0125), and hiatal hernia (OR: 1.46; 95% CI: 1.12–1.90; p = 0.0042) were associated with acid regurgitation symptoms.

Conclusions

There is a discrepancy between subjective symptoms and endoscopic GERD grade in DM patients. The ability of DM patients to feel acid regurgitation may be decreased.

Otitis media in adults as a symptom of gastroesophageal reflux

OBJECTIVE: To investigate the clinical relationship between gastroesophageal reflux (GER) and otitis media with effusion (OME) in adults.

STUDY DESIGN AND SETTING: Sixty patients with OME with unknown causes were asked to answer a new questionnaire specific for the diagnosis of GER disease; pepsinogen (PG) levels in their middle-ear effusions (MEEs) were measured.

RESULTS: The percentage of patients with high PG concentrations in their MEEs was significantly higher in those with questionnaire-positive GER than in those with questionnaire-negative GER. OME was present bilaterally in a significantly higher percentage of patients with questionnaire-positive GER. The PG levels decreased in some of the patients after receiving proton pump inhibitors, which also decreased the symptoms of GER.

CONCLUSION: The presence of PG in MEEs supports the existence of GER; treatment for GER should be considered in patients with ear complaints, especially in those who have GER-related symptoms.

© 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Characteristics of symptomatic reflux episodes in Japanese proton pump inhibitor-refractory non-erosive reflux disease patients

AIM: To clarify the pathogenesis of gastroesophageal reflux disease symptoms in non-erosive reflux disease (NERD) patients.

METHODS: Thirty-five NERD patients with persistent symptoms, despite taking rabeprazole 10 mg twice daily for at least 8 wk, were included in this study. All patients underwent 24 h combined impedance - pH on rabeprazole. The symptom index (SI) was considered to be positive if ≥ 50%, and proximal reflux episodes were determined when reflux reached 15 cm above the proximal margin of the lower esophageal sphincter.

RESULTS: In 14 (40%) SI-positive patients, with liquid weakly acid reflux, the occurrence rate of reflux symptoms was significantly more frequent in proximal reflux episodes (46.7%) than in distal ones (5.7%) (P < 0.001). With liquid acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (38.5%) and distal ones (20.5%) (NS). With mixed liquid-gas weakly acid reflux, the occurrence rate of reflux symptoms in proximal reflux episodes was significantly more frequent (31.0%) than in distal reflux ones (3.3%) (P < 0.001). With mixed liquid-gas acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (29.4%) and distal ones (14.3%) (NS).

CONCLUSION: The proximal extent of weakly acidic liquid and mixed liquid-gas reflux is a major factor associated with reflux perception in SI-positive patients on proton pump inhibitor therapy.

Atypical symptoms and health-related quality of life of patients with asymptomatic reflux esophagitis

BACKGROUND AND AIM

Asymptomatic reflux esophagitis (RE) is simply regarded as RE without the typical reflux symptoms, but it is unknown whether patients with asymptomatic RE have atypical symptoms. The aim of this study was to examine the clinical characteristics and health-related quality of life (HRQOL) of patients with asymptomatic RE.

PATIENTS AND METHODS

Consecutive patients with RE were enrolled during January 2010 to August 2012, and of them, 41 who had taken acid-suppressing drugs were excluded, leaving 280 patients as the study group. The patients' symptoms were evaluated using a self-completed questionnaire (modified Frequency Scale for the Symptoms of gastroesophageal reflux disease [FSSG]), as well as an HRQOL questionnaire (SF-8). We defined the typical symptoms of RE as heartburn and regurgitation. Asymptomatic RE was defined if the total symptom score was 0 or the minimum (1 point) for typical reflux symptoms in the modified FSSG.

RESULTS

Of the 280 RE patients, 71.8% (n = 201) were symptomatic and 28.2% (n = 79) were asymptomatic. The atypical symptom scores were significantly lower in asymptomatic RE (2.2 ± 2.2) than in symptomatic RE patients (6.9 ± 5.2) (P < 0.0001), and the HRQOL scores were significantly higher in asymptomatic RE than in symptomatic RE (P < 0.0001). Sleep was significantly less disturbed and chronic cough less frequent in asymptomatic RE than in symptomatic RE.

CONCLUSION

Frequency and severity of atypical symptoms in patients with asymptomatic RE were significantly less than in patients with symptomatic RE, and the HRQOL score was significantly higher in those patients. These observations suggest a specific patient cohort that is truly unlikely to manifest symptoms.

Current concepts of otitis media in adults as a reflux-related disease

OBJECTIVE

To review the findings of otitis media in adults in relation to supraesophageal reflux of gastrointestinal contents and summarize current concepts.

DATA SOURCES

Literature published in English-language journals from 2001 to the present identified by searching electronic databases (MEDLINE and Web of Science).

STUDY SELECTION

Clinical articles that contained the terms reflux, ear, otitis media, and adult and relevant animal studies.

DATA EXTRACTION

Findings of searchable case reports and results of animal studies were included.

DATA SYNTHESIS

Current findings were reviewed for the following points: 1) proposed effect of reflux, 2) prevalence and characteristics, 3) risk factors, and 4) treatment.

CONCLUSION

Published literature concerning reflux and otitis media in adults is limited to clinical case series. Reflux is likely present in a significant number of adult cases with otitis media and may lead to Eustachian tube dysfunction in such subjects. Reflux in adult subjects with otitis media is potentially different from the physiologic events observed in children, but the causal link between them remains unclear. Evaluation of more cases that could be diagnosed as reflux-induced otitis media is necessary for better understanding of the disease entity.

Systematic review: questionnaires for assessment of gastroesophageal reflux disease

Numerous questionnaires with a wide variety of characteristics have been developed for the assessment of gastroesophageal reflux disease (GERD). Four well-defined dimensions are noticeable in these GERD questionnaires, which are symptoms, response to treatment, diagnosis, and burden on the quality of life of GERD patients. The aim of this review is to develop a complete overview of all available questionnaires, categorized per dimension of the assessment of GERD. A systematic search of the literature up to January 2013 using the Pubmed database and the Embase database, and search of references and conference abstract books were conducted. A total number of 65 questionnaires were extracted and evaluated. Thirty-nine questionnaires were found applicable for the assessment of GERD symptoms, three of which are generic gastrointestinal questionnaires. For the assessment of response to treatment, 14 questionnaires were considered applicable. Seven questionnaires with diagnostic purposes were found. In the assessment of quality of life in GERD patients, 18 questionnaires were found and evaluated. Twenty questionnaires were found to be used for more than one assessment dimension, and eight questionnaires were found for GERD assessment in infants and/or children. A wide variety of GERD questionnaires is available, of which the majority is used for assessment of GERD symptoms. Questionnaires differ in aspects such as design, validation and translations. Also, numerous multidimensional questionnaires are available, of which the Reflux Disease Questionnaire is widely applicable. We provided an overview of GERD questionnaires to aid investigators and clinicians in their search for the most appropriate questionnaire for their specific purposes.

Overlap of functional dyspepsia and GERD--diagnostic and treatment implications

GERD and functional dyspepsia are the two most prevalent upper gastrointestinal disorders. Gastro-oesophageal reflux is most commonly diagnosed using the cardinal symptoms of heartburn and regurgitation. Patients might also be diagnosed using a questionnaire, after empiric treatment with an acid suppressant, after upper endoscopy or by pH testing. Functional dyspepsia is best diagnosed using symptoms outlined by the Rome committee in conjunction with a normal upper endoscopy. Theoretically, distinguishing these two populations should be easy for all health-care providers. In reality, however, carefully separating out these two populations can be quite difficult, as substantial overlap exists epidemiologically, symptomatically and even diagnostically. This overlap renders precise diagnosis a challenge; given the limited treatment options, the primary goal is to identify those patients who will respond to acid suppressive therapy. Despite the frequency with which functional dyspepsia and GERD overlap, remarkably few studies have investigated this overlap. Most recommendations are based on data derived from separate studies of functional dyspepsia and GERD. A further limitation of existing studies is their failure to differentiate between the various diagnostic categories into which the individual presenting with heartburn might belong.

A prospective study to compare a symptom-based reflux disease questionnaire to 48-h wireless pH monitoring for the identification of gastroesophageal reflux (revised 2-26-11)

OBJECTIVES

The gastroesophageal reflux disease questionnaire (GerdQ) is a validated questionnaire that identifies patients with gastroesophageal reflux disease (GERD). The aim of this study was to prospectively evaluate the association between GerdQ scores and 48-h wireless pH recording in patients studied either on or off acid suppression.

METHODS

Demographics, symptoms, acid suppressant use, and GerdQ scores were obtained from consecutive patients referred for wireless pH testing; 48-h pH data and endoscopic findings were recorded. Multivariate logistic regression models controlling for age, gender, and body mass index (BMI) were used to evaluate the association between GerdQ scores, acid reflux, and symptom association probability (SAP) scores.

RESULTS

Wireless pH-metry was completed in 180 patients off proton pump inhibitor (PPI) (mean (s.d.) age, 50 (14) years; BMI, 28.08 (6.87) kg/m(2)) and 178 patients on PPI (mean (s.d.) age, 52 (14) years; BMI, 29.00 (6.90) kg/m(2)). Abnormal acid exposure was noted in 26% of patients on and 61% off PPI therapy. The odds of an abnormal study were 5.04 (95% confidence interval (CI), 3.14-8.11) times greater in patients studied off PPI therapy compared with patients studied on PPI therapy. The odds ratio of the SAP being >95% was 5.69 (95% CI, 3.36-9.64; P<0.001) for patients studied off PPI therapy compared with on PPI therapy. The mean (s.d.) GerdQ score was 7.48 (4.53) in patients on PPI therapy and 9.11 (1.25) in patients off PPI therapy (P<0.001). The odds of having an abnormal pH study was 1.08 (95% CI, 0.99-1.16; P=0.07) in patients studied off PPI therapy and 1.00 (95% CI, 0.92-1.08; P=0.94) in patients on PPI therapy for each point increase on the GerdQ. The odds of an abnormal SAP 95% in patients studied off PPI therapy was 1.18 (95% CI, 1.09-1.28; P<0.001) and 1.10 (95% CI, 1.01-1.21; P<0.03) in patients studied on PPI therapy for each point increase in the GerdQ score.

CONCLUSIONS

Higher GerdQ scores were predictive of an abnormal pH study in patients studied off PPI therapy. Compared with wireless pH capsule monitoring, the GerdQ has only modest sensitivity and specificity at diagnosing acid reflux and thus cannot be recommended as a screening tool for GERD.

Exhaled breath marker in asthma patients with gastroesophageal reflux disease

Prevention of acid is important in gastroesophageal reflex disease (GERD)-related asthma therapy. Proton pump inhibitors (PPI) and H₂-receptor blockers have been reported as useful therapies for improving asthma symptoms. GERD prevalence is high in asthma; however, methods for validating GERD existence based on questionnaire, endoscopic examination and 24h-pH monitoring do not directly determine GERD influence on the airway. Exhaled breath condensate analysis is a novel and non-invasive tool for assessing information directly from the airway. Breath collected by cooling can be applied to pH, 8-isoprostane and cytokine analysis in patients with GERD-related asthma, and the pH and 8-isoprostane levels have been shown to reflect the effects of PPI therapy in these patients. Although the analysis of cooled breath has not yet been established in a clinical setting, this method is expected to provide a novel tool for monitoring airway acidification associated with GERD.

The value of Carlsson-dent questionnaire in diagnosis of gastroesophageal reflux disease in area with low prevalence of gastroesophageal reflux disease

Background/Aims

Symptom-based diagnosis for gastroesophageal reflux disease (GERD) has been accepted in the population with high prevalence. Carlsson-Dent questionnaire (CDQ) is a standardized symptom-based diagnosis tool for GERD. The value of this tool in the population with low prevalence is unknown. The aim of this study was to determine CDQ performance for diagnosis of GERD in Thai population with low prevalence versus endoscopy or 24 hour pH monitoring.

Methods

Patients with dyspepsia by Rome II criteria were recruited. All patients completed a Thai version of CDQ and underwent endoscopic examination. Those without esophagitis or peptic ulcer and positive CDQ score took pH monitoring.

Results

One hundred patients (68 female) with mean age ± SD of 45.6 ± 12.4 years were recruited. Six with Los Angeles grade A esophagitis had negative CDQ score. In 44 with positive CDQ score, 3 had Los Angeles grade B esophagitis and 41 had pH monitoring done with 8 having positive test. The GERD diagnosis by CDQ was confirmed in 11 of 44 patients (25%). CDQ detected 11 out of 17 GERD detected by endoscopy and pH monitoring and the sensitivity of CDQ was 64%.

Conclusions

CDQ diagnosed more GERD in Thai population with low prevalence compared with endoscopy and pH monitoring. This may be due to some patients with functional heartburn were picked up by CDQ and some patients with GERD were not detected by endoscopy and pH monitoring.

Abdominal symptom-related QOL in individuals visiting an outpatient clinic and those attending an annual health check

OBJECTIVE

Quality of life (QOL) impairment of patients who visit an outpatient clinic for abdominal symptoms has not been clarified. We investigated symptom-related QOL impairment that led patients to seek medical care.

PATIENTS AND METHODS

Abdominal symptom-related QOL was determined using the Izumo scale instrument in 172 patients who visited a clinic for their abdominal symptoms and in 961 healthy subjects who attended an annual health check.

RESULTS

QOL was more strongly impaired in the patients with abdominal symptoms than in subjects who attended health checks. Patients with heartburn consulted physicians even when QOL impairment was minimal, while those with epigastric fullness tended to consult a physician only when QOL impairment was significant.

CONCLUSION

Abdominal symptom-related QOL impairment is considered to lead patients to seek medical care, though different symptoms have varying levels of influence.

Gastroesophageal reflux disease in Asia: A historical perspective and present challenges

Gastroesophageal reflux disease (GERD), previously uncommon in Asia, has now become an important disease in the region. Although much variability exists between studies, most endoscopy-based studies show a prevalence of erosive esophagitis of more than 10%. Symptom-based studies also show a prevalence of 6-10%. Two longitudinal follow-up studies on GERD symptoms have shown an increase with time, and several endoscopy-based time trend studies have also shown a significant increase in erosive reflux esophagitis. Studies on Barrett's esophagus have been confounded by the description of short (SSBE) and long segment (LSBE) Barrett's esophagus. Great variation in prevalence rates has been reported. SSBE vary from 0.1% to more than 20% while LSBE vary from 1-2%. Of the putative causative factors, obesity has been the most important. Many studies have linked GERD-esophagitis as well as occurrence of reflux symptoms with an increase in body mass index (BMI), obesity, especially visceral or central obesity, and metabolic syndrome. A decline in Helicobacter pylori infection with growing affluence in Asia has been broadly thought to result in healthier stomachs and a higher gastric acid output resulting in reflux disease. However, variable results have been obtained from association and H. pylori eradication studies.

The diagnosis of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease is a highly prevalent condition that imposes a significant economic impact on the US health care system. The utility of commonly used tests for the diagnosis of gastroesophageal reflux disease has not been adequately reviewed.

METHODS

A comprehensive review of the literature was undertaken to provide an evidence-based approach to the diagnosis of gastroesophageal reflux disease. EMBASE (1980-December 2008), OVID MEDLINE, and PubMed, (1966-December 2008) were searched using "gastroesophageal reflux" and "adults" with other terms, including medications, diagnostic tests, symptoms, and epidemiologic terms. Studies were limited to human trials, English language, and full articles.

RESULTS

Heartburn is a reasonably sensitive symptom for the diagnosis of gastroesophageal reflux disease, although it does not reliably predict esophagitis. Standardized questionnaires have limited specificity, whereas the double-contrast barium swallow has a low sensitivity to diagnose gastroesophageal reflux. The role of esophageal manometry is limited to accurate placement of a pH-measuring device. pH testing has reasonable sensitivity and specificity for the diagnosis of gastroesophageal reflux disease. The sensitivity of upper endoscopy to diagnose gastroesophageal reflux is lower than that of pH tests.

CONCLUSION

The diagnosis of gastroesophageal reflux disease remains difficult. In the absence of alarm symptoms, empiric treatment with acid suppression is warranted. pH testing provides valuable information in many patients, although the clinical utility of newer tests needs to be determined. Endoscopy should not be the first test used to diagnose gastroesophageal reflux.

Comparison of a composite symptom score assessing both symptom frequency and severity with a score that assesses frequency alone: a preliminary study to develop a practical symptom score to detect gastro-oesophageal reflux disease in a resource-poor setting

BACKGROUND

There is a need for a practical instrument to screen for gastro-oesophageal reflux disease (GORD) in epidemiological studies.

OBJECTIVES

To develop a practical score to detect GORD and compare assessment of both symptom frequency and severity with frequency alone.

METHODS

One hundred patients with upper gastrointestinal symptoms and 150 volunteers with no such past history faced an interviewer-administered questionnaire assessing seven symptoms, graded for frequency and severity. Two scores were generated. Score 1, the sum of frequency of symptoms and score 2, the sum of products of frequency and severity of each. Internal consistency, test-retest reliability and criterion validity against 24-h pH monitoring were assessed. Cut-off scores were generated by receiver operating characteristic curves using scores of half the volunteers and patients selected randomly and validated on the other half.

RESULTS

Cut-off scores and area under the curve for score 1 were >/=10.5 and 0.93, and score 2 were >/=12.5 and 0.93, respectively. The sensitivity and specificity of diagnosing the disease in the remaining participants using score 1 was 89.7 and 92.4% and score 2 was 93.8 and 94.0%, respectively. The instrument had good internal consistency (Cronbach alpha = 0.73) and reliability (intraclass correlation coefficient of scores 1 and 2 were 0.94 and 0.95, respectively). Score 2 showed better correlation with 24-h pH monitoring parameters (Spearman's rank correlation, P = 0.01).

CONCLUSION

Our score is valid, reliable and can detect GORD with high sensitivity and specificity. A score assessing both frequency and severity of symptoms correlates better to an objective measure of GORD.

Lack of correlation between a self-administered subjective GERD questionnaire and pathologic GERD diagnosed by 24-h esophageal pH monitoring

INTRODUCTION

Self-reported reflux symptoms do not always correspond to pathologic gastroesophageal reflux disease (GERD). We evaluated whether GERD-related symptoms in the self-reported Mayo-GERD questionnaire (GERDQ) were correlated with current gold standard definitions of pathologic GERD.

METHODS

Three hundred thirty-six consecutive consenting individuals with GERD symptoms referred for 24-h esophageal pH monitoring completed a baseline GERDQ. Univariate and multivariate analyses identified questions that were most associated with percent total time pH<4 at distal probe (DT) >4% or DeMeester score (DS) >or=14.7, two accepted definitions of pathologic GERD. A risk score was created from these analyses, followed by generation of receiver operating characteristic curves and determination of C-statistics, sensitivity, and specificities at various cut points, with prespecified minimal values of each that would be required to meet the definition of "potential clinical utility."

RESULTS

Forty-nine percent of patients were found to have pathologic GERD; half the patients (not necessarily those with pathologic GERD) described suffering from severe or very severe heartburn or acid regurgitation in the past year. Univariate logistic regression analysis identified six of 22 key GERD questions that were significantly related to DT or DS, in addition to age and gender. Three questions (duration of symptoms, nocturnal heartburn, hiatal hernia) along with age and gender remained significant in multivariate analyses. A risk score (RS) was created from these five questions separately for DT and DS. For DT, the C-statistic for RS was 0.75, and at the optimal cut point of >or=6 that maximizes sensitivity (SS) and specificity (SP), SS was 68% and SP was 72%. For DS, the C-statistic was 0.73, and at the optimal cut point, SS was 82%and SP 60%. When considering other cut points, the rare extreme case of very low RS (<or=2) was strongly predictive of lack of pathologic GERD: for DT, SS 100%/SP 18%, negative predictive value (NPV) 100%; and for DS, SS 97%, SP 25%, NPV 88%. However, only 10-15% of patients referred for pH testing had RS scores of <or=2.

CONCLUSION

Self-reported prolonged history of GERD-like symptoms, nocturnal heartburn, history of a hiatus hernia, and male gender were associated with abnormal 24-h esophageal pH monitoring. However, these factors lack clinical utility to predict pathologic GERD in patients referred for pH testing. We found that 51% of patients with severe GERD symptoms do not have true pathological GERD on objective testing. The clinical implications of this study are significant in that treatment with acid-suppressing medication in such patients would be inappropriate.

The use of frequency scale for the symptoms of GERD in assessment of gastro-oesophageal reflex symptoms in asthma

In adult asthmatics the incidence of gastro-oesophageal reflux disease (GERD) reportedly ranges from 34% to 89%. Oesophageal pH monitoring and endoscopy are not required in the patient with typical GERD symptoms before the initiation of a therapeutic trial. Diagnosis of GERD on the basis of history is the simplest and quickest method, placing no demand on patients. Recently, a new questionnaire (FSSG; Frequency Scale for the Symptoms of GERD) was produced to evaluate the severity and the therapeutic response of GERD. The FSSG (F-scale) was used to assess the GERD in subjects with persistent moderate to severe asthma treated with anti-inflammatory asthma medication. In the present study, 27.4% of the patients with asthma had symptoms suggestive of GERD. There is significant correlation between GERD symptom (F-scale score) and severity of cough and sputum. The observations suggested that reflux symptoms, not gastric dysmotility symptoms, significantly associated with severity of cough, not of sputum. It is the first such study to use a FSSG as incidence of GERD symptoms in asthmatics and examine the relationship between F-scale score and asthmatic symptoms.

Epidemiology and clinical characteristics of GERD in the Japanese population

We reviewed articles on the epidemiology and clinical characteristics of gastroesophageal reflux disease (GERD) in Japan to clarify these features of GERD in this country. Although the definition of GERD depends on the individual study, the prevalence of GERD has been increasing since the end of the 1990s. The reasons for the increase in the prevalence of GERD may be due to increases in gastric acid secretion, a decrease in the Helicobacter pylori infection rate, more attention being paid to GERD, and advances in the concept of GERD. More than half of GERD patients had non-erosive reflux disease, and the majority (87%) of erosive esophagitis was mild type, such as Los Angeles classification grade A and grade B. There were several identified risk factors, such as older age, obesity, and hiatal hernia. In particular, mild gastric atrophy and absence of H. pylori infection influence the characteristics of GERD in the Japanese population. We also discuss GERD in the elderly; asymptomatic GERD; the natural history of GERD; and associations between GERD and peptic ulcer disease and H. pylori eradication. We examined the prevalence of GERD in patients with specific diseases, and found a higher prevalence of GERD, compared with that in the general population, in patients with diabetes mellitus, those with obstructive sleep apnea syndrome, and those with bronchial asthma. We provide a comprehensive review of GERD in the Japanese population and raise several clinical issues.

Comparison of endoscopic findings with symptom assessment systems (FSSG and QUEST) for gastroesophageal reflux disease in Japanese centres

BACKGROUND AND AIM

We compared endoscopic findings of the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), a written questionnaire developed in Japan, to that for the questionnaire for the diagnosis of reflux esophagitis (QUEST) for the diagnosis of reflux esophagitis.

METHODS

We registered 475 patients with untreated symptoms of upper abdominal pain (male/female: 252/223, average age 52.4 +/- 17.8 years). Subjects were assessed first with the FSSG and QUEST questionnaires, then by endoscopy, before allocation to a gastric ulcer (GU), duodenal ulcer (DU), gastroesophageal reflux disease (GERD) or functional dyspepsia (FD) group.

RESULTS

On the basis of the endoscopic findings the diagnoses for the 475 subjects were as follows: FD 52.2%, DU 7.6%, GU 7.8%, and GERD 32.4% (Grade M 10.1%, Grade A + B 20.2%, Grade C + D 2.3%). There was no difference between the FSSG and QUEST in sensitivity, specificity or accuracy for any condition. The FSSG score rose with increasing endoscopic severity of GERD, but there was no correlation between the QUEST score and endoscopic severity. The FSSG total score was inferior to QUEST in terms of distinguishing GERD from other conditions, but when only the questions relating to reflux symptoms were used, the FSSG was able to distinguish GERD from other conditions as well as QUEST.

CONCLUSIONS

The FSSG score reflects the severity of the endoscopic findings of GERD.

It is possible to classify non-erosive reflux disease (NERD) patients into endoscopically normal groups and minimal change groups by subjective symptoms and responsiveness to rabeprazole -- a report from a study with Japanese patients

The hypothesis that non-erosive reflux disease (NERD) patients comprise various subgroups is gaining popularity. This study was conducted to investigate the possibility of categorizing NERD patients according to symptom types and response to acid-suppressive drug rabeprazole (RPZ) 10 mg/day. NERD patients were classified as grade N (endoscopically normal), M (minimal change), or erosive GERD, and answered a 51-item, yes-or-no questionnaire pre and post-treatment. Compared to erosive GERD, clear differences existed in pretreatment prevalence of symptoms and responsiveness to RPZ in grades N and M; the results suggested stomachaches (especially at night) were significant symptoms in grade N and dysmotility-like symptoms like bloated stomach were significant in grade M while gastroesophageal reflux symptoms were significant in erosive GERD. Clinical significance of classifying NERD was indicated from different symptoms and responsiveness to PPI.

Differences in recognition of heartburn symptoms between Japanese patients with gastroesophageal reflux, physicians, nurses, and healthy lay subjects

OBJECTIVE

Patients who complain of "heartburn" to their general practitioner tend to use the word to indicate a variety of symptoms. The aim of this study was to investigate the differences in recognition of "heartburn" between normal healthy lay subjects (HS), patients with gastroesophageal reflux disease (GERD), nurses, and physicians.

MATERIAL AND METHODS

An anonymous questionnaire survey concerning "heartburn" obtained responses from 583 persons including 198 GERD patients (140 with non-erosive reflux disease (NERD) and 58 with reflux esophagitis (RE)) who were evaluated at Kawasaki Medical School Hospital and affiliated facilities, as well as 170 HS, 111 nurses, and 104 physicians. Subjects were asked to choose the option most closely describing a symptom that they would recognize as heartburn.

RESULTS

Recognition did not differ between RE patients and physicians, whereas NERD patients did not recognize "regurgitation" or "burning sensation in the chest" as heartburn as often as physicians, while confusing "stomach ache" with heartburn. Significantly more NERD patients chose "stomach ache" than RE patients.

CONCLUSIONS

Differences in recognition of heartburn were noticed between HS, GERD patients, nurses, and physicians. RE patients and physicians showed similar recognition patterns among the descriptions of heartburn, whereas NERD patients differed from physicians and RE patients.

Endoscopic reflux esophagitis in patients with upper abdominal pain-predominant dyspepsia

BACKGROUND

Reflux symptom assessment had reliable accuracy in the diagnosis of gastroesophageal reflux disease (GERD). However, patients may recognize heartburn or regurgitation as dyspepsia because of inaccurate understanding or atypical presentation. The aim of the present study was to estimate endoscopic reflux esophagitis in patients with upper abdominal pain as a predominant symptom in the absence of heartburn or regurgitation.

METHODS

Two hundred and sixty-three consecutive patients presenting dyspepsia without heartburn or regurgitation were enrolled. Patients with heartburn or regurgitation were excluded using the symptom interviewer method. Dyspepsia was categorized into pain-predominant or dysmotility-predominant groups according to the Rome II proposal. Endoscopic reflux esophagitis was graded using the Los Angeles classification.

RESULTS

One hundred and five patients were included in the pain-predominant group and 119 in the dysmotility-predominant group. Reflux esophagitis was found in 18.8% (42/224) of all dyspeptic patients. Grade A esophagitis was noted in 27.6% (29/105) of the pain-predominant group and in 7.6% (9/119) of the dysmotility-predominant group. Grade B was noted in two patients in each group. A total of 29.5% (31/105) and 9.3% (11/119) had reflux esophagitis, respectively (P < 0.001). Comparing patients with or without reflux esophagitis, there was no difference in body mass index, smoking habit, alcohol consumption, or Helicobacter pylori infection status.

CONCLUSIONS

A significant proportion of patients presenting dyspepsia, especially pain-predominant dyspepsia, have endoscopic reflux esophagitis. In view of GERD, pain-predominant dyspepsia should be investigated and managed differently from dysmotility-predominant dyspepsia.

High prevalence of gastroesophageal reflux disease with minimal mucosal change in asthmatic patients

It is known that the prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients is high. Although an endoscopic diagnosis of GERD based on the established Los Angeles (LA) classification requires the detection of erosive mucosal breaks, there are patients with GERD who have prominent erythema of the esophageal membrane without erosive mucosal breaks. Non-erosive mucosal change denotes the minimal change of the discoloring type of reflux esophagitis. This study was undertaken to determine the prevalence of GERD in asthmatic patients using the LA classification with the inclusion of minimal change, compared to the prevalence determined using the established LA classification without minimal change. The presence of GERD in asthmatic patients (n = 78), non-asthmatic disease control patients (n = 56), and healthy subjects (n = 150) was evaluated by endoscopic examination. The frequency of GERD in asthmatic patients based on the LA classification with minimal change was higher (54/78, 69.2%) than in asthmatic patients based on the LA classification without minimal change (37/78, 47.4%) (p < 0.05). The prevalence of GERD in asthmatic patients (69.2%) was higher than that in disease control patients (17/56, 30.4%) and healthy subjects (27/150, 18.0%) based on the LA classification with minimum change. These data indicate that asthmatic patients have a high frequency of GERD. In addition, without the inclusion of minimum change to the diagnosis of GERD, the prevalence of GERD appears to be underestimated in asthmatic patients. Therefore, physicians should carefully observe asthmatic patients with minimal change on endoscopy.

A proton pump inhibitor, lansoprazole, ameliorates asthma symptoms in asthmatic patients with gastroesophageal reflux disease

Aspiration of acid to the airway causes airway inflammation, and acid stress to the airway caused by gastroesophageal reflux disease (GERD) has been known as a potential mechanism of deteriorated asthma symptoms. However, the efficacy of the acid suppressive drugs, H(2)-receptor blockers (H(2) blocker) and proton pump inhibitors, on asthma symptoms and pulmonary functions remains controversial. We therefore designed the randomized prospective study to determine the efficacy of an H(2) blocker (roxatidine, 150 mg/day) and a proton pump inhibitor (lansoprazole, 30 mg/day) on asthma symptoms of 30 asthmatic patients with GERD. These patients were divided in the two groups (15 patients for each group) and treated with either roxatidine or lansoprazole. The diagnosis of GERD was established by the method of Los Angeles classification including mucosal minimum change of Grade M and questionnaire for the diagnosis of reflux disease (QUEST) score. The efficacy of acid suppressive drugs was evaluated by peak expiratory flow (PEF), asthma control questionnaire (ACQ) that evaluates the improvement of asthma symptoms, and forced expiratory volume in 1 second (FEV(1.0)). Lansoprazole, but not roxatidine, significantly improved PEF and ACQ scores (p < 0.05) with the improved QUEST scores. However, these acid suppressive drugs did not change the pulmonary function of FEV(1.0) in asthmatic patients. In conclusion, treatment with a proton pump inhibitor, lansoprazole, appears to be useful in improvement of asthma symptoms in asthmatic patients with GERD.