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Norton BC, Papaefthymiou A, Aslam N, Telese A, Murray C, Murino A, Johnson G, Haidry R. The endoscopic management of oesophageal strictures. Best Pract Res Clin Gastroenterol 2024; 69:101899. [PMID: 38749578 DOI: 10.1016/j.bpg.2024.101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/04/2024] [Accepted: 02/25/2024] [Indexed: 05/26/2024]
Abstract
An oesophageal stricture refers to a narrowing of the oesophageal lumen, which may be benign or malignant. The cardinal feature is dysphagia, and this may result from intrinsic oesophageal disease or extrinsic compression. Oesophageal strictures can be further classified as simple or complex depending on stricture length, location, diameter, and underlying aetiology. Many endoscopic options are now available for treating oesophageal strictures including dilatation, injectional therapy, stenting, stricturotomy, and ablation. Self-expanding metal stents have revolutionised the palliation of malignant dysphagia, but oesophageal dilatation with balloon or bougienage remains first-line therapy for most benign strictures. The increase in endoscopic and surgical interventions on the oesophagus has seen more benign refractory oesophageal strictures that are difficult to treat, and often require advanced endoscopic techniques. In this review, we provide a practical overview on the evidence-based management of both benign and malignant oesophageal strictures, including a practical algorithm for managing benign refractory strictures.
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Affiliation(s)
- Benjamin Charles Norton
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK; Centre for Obesity Research, Department of Medicine, University College London, Rayne Institute, 5 University St, London, WC1E 6JF, UK.
| | - Apostolis Papaefthymiou
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Nasar Aslam
- Department of Gastroenterology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - Andrea Telese
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK; Division of Surgery and Interventional Science, University College London, Royal Free Hospital, 10 Pond Street, London, NW3 2PS, UK
| | - Charles Murray
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Alberto Murino
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Gavin Johnson
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Rehan Haidry
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
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Sami SS, Haboubi HN, Ang Y, Boger P, Bhandari P, de Caestecker J, Griffiths H, Haidry R, Laasch HU, Patel P, Paterson S, Ragunath K, Watson P, Siersema PD, Attwood SE. UK guidelines on oesophageal dilatation in clinical practice. Gut 2018; 67:1000-1023. [PMID: 29478034 PMCID: PMC5969363 DOI: 10.1136/gutjnl-2017-315414] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/03/2018] [Accepted: 01/14/2018] [Indexed: 01/10/2023]
Abstract
These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.
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Affiliation(s)
- Sarmed S Sami
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea Medical School, Swansea University, Swansea, UK
| | - Yeng Ang
- Department of GI Sciences, University of Manchester, Manchester, UK,Salford Royal NHS Foundation Trust, Salford, UK
| | - Philip Boger
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - John de Caestecker
- Digestive Diseases Centre, University Hospitals of Leicester, Leicester, UK
| | - Helen Griffiths
- Department of Gastroenterology, Wye Valley NHS Trust, Wye Valley, UK
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, London, UK
| | - Hans-Ulrich Laasch
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Praful Patel
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Stuart Paterson
- Department of Gastroenterology, NHS Forth Valley, Stirling, UK
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Queens Medical Centre, Belfast, UK
| | - Peter Watson
- Faculty of Medicine Health and Life Sciences, Queen’s University Belfast, Belfast, UK
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Abdel Jalil AA, Katzka DA, Castell DO. Approach to the patient with dysphagia. Am J Med 2015; 128:1138.e17-23. [PMID: 26007674 DOI: 10.1016/j.amjmed.2015.04.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 04/15/2015] [Accepted: 04/16/2015] [Indexed: 12/17/2022]
Abstract
Dysphagia is a fascinating symptom. It is ostensibly simple when defined by trouble swallowing, yet its subtleties in deciphering and its variations in pathophysiology almost mandate a thorough knowledge of medicine itself. With patience and careful questioning, a multitude of various disorders may be suggested before an objective test is performed. Indeed, the ability to diligently and comprehensively explore the symptom of dysphagia is not only rewarding but also a real test for a physician who prides himself or herself on good history taking.
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Affiliation(s)
- Ala' A Abdel Jalil
- Esophageal Disorders Program, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston.
| | - David A Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn
| | - Donald O Castell
- Esophageal Disorders Program, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston
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Abstract
Dysphagia is a symptom of swallowing dysfunction that occurs between the mouth and the stomach. Although oropharyngeal dysphagia is a highly prevalent condition (occurring in up to 50% of elderly people and 50% of patients with neurological conditions) and is associated with aspiration, severe nutritional and respiratory complications and even death, most patients are not diagnosed and do not receive any treatment. By contrast, oesophageal dysphagia is less prevalent and less severe, but with better recognized symptoms caused by diseases affecting the enteric nervous system and/or oesophageal muscular layers. Recognition of the clinical relevance and complications of oesophageal and oropharyngeal dysphagia is growing among health-care professionals in many fields. In addition, the emergence of new methods to screen and assess swallow function at both the oropharynx and oesophagus, and marked advances in understanding the pathophysiology of these conditions, is paving the way for a new era of intensive research and active therapeutic strategies for affected patients. Indeed, a unified field of deglutology is developing, with new professional profiles to cover the needs of all patients with dysphagia in a nonfragmented way.
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Abstract
Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign stricture or progression of GERD to Barrett's esophagus and even esophageal cancer, and LES hypertension impairing esophageal emptying with subsequent development of pulsion esophageal diverticulum. This article details the causes, clinical presentation, workup, and treatment of esophageal stricture and epiphrenic esophageal diverticulum. Other types of esophageal diverticula (Zenker's and midesophageal) are also covered.
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Abstract
The prevalence of gastroesophageal reflux disease (GERD) symptoms increased approximately 50% until the mid-1990s, when it plateaued. The incidence of complications related to GERD including hospitalization, esophageal strictures, esophageal adenocarcinoma, and mortality also increased during that time period, but the increase in esophageal adenocarcinoma has since slowed, and the incidence of strictures has decreased since the mid-1990s. GERD is responsible for the greatest direct costs in the United States of any gastrointestinal disease, and most of those expenditures are for pharmacotherapy. Risk factors for GERD include obesity, poor diet, lack of physical activity, consumption of tobacco and alcohol, and respiratory diseases.
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Affiliation(s)
- Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Joan W Chen
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, MI, USA
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Thrift AP, Whiteman DC. The incidence of esophageal adenocarcinoma continues to rise: analysis of period and birth cohort effects on recent trends. Ann Oncol 2012; 23:3155-3162. [PMID: 22847812 DOI: 10.1093/annonc/mds181] [Citation(s) in RCA: 266] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND During the past four decades, the incidence of esophageal adenocarcinoma (EAC) has increased markedly in Western populations. Recent reports have suggested that the rate of increase has slowed or plateaued. PATIENTS AND METHODS Using data from cancer registries in Australia, the United States and Sweden, we examined incidence trends for esophageal and gastric cardia tumors between 1984 and 2008 using joinpoint analyses and age-period-cohort models. RESULTS EAC incidence continues to undergo statistically significant annual increases in Australia and the United States, although the rate of increase has slowed. Among men, incidence increased annually by 2.2% [95% confidence interval (CI) 1.5% to 2.9%] between 1994 and 2008 in Australia and 1.5% (95% CI 0.2% to 2.8%) between 1998 and 2008 in the United States. EAC incidence among men remained unchanged in Sweden between 2001 and 2008 (P = 0.52). EAC incidence among women showed significant linear increases between 1984 and 2008. Age-period-cohort models suggested strong effects for both period and birth cohort on EAC incidence in Australia and the United States, and a strong period effect for Sweden. CONCLUSIONS EAC incidence continues to increase in Australia and the United States. The continued increases, even among more recent birth cohorts, suggest that EAC incidence will continue to rise during coming decades.
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Affiliation(s)
- A P Thrift
- Population Health Department, Queensland Institute of Medical Research, Brisbane, Queensland; School of Population Health, The University of Queensland, Brisbane, Queensland, Australia.
| | - D C Whiteman
- Population Health Department, Queensland Institute of Medical Research, Brisbane, Queensland
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Abstract
Proton pump inhibitors (PPIs) are among the most widely used agents in the world. The prevalence of reflux disease is increasing, as is the incidence of oesophageal adenocarcinoma, a complication that is strongly correlated with chronic reflux disease. Although these agents are generally safe, a number of potential side effects have been described and a careful assessment of the risks and benefits of PPI therapy is required in all patients being prescribed long-term therapy. Overutilization of PPIs is a problem in clinical practice and needs further attention. PPI use has been associated with osteoporosis and bone fracture, hypomagnesaemia, the development of gastric polyps, enteric infections, interstitial nephritis and pneumonia. Patients on long-term therapy should be periodically evaluated for the indications for continued therapy. Despite widespread publicity in the lay press, and regulatory guidance regarding a number of associations, the evidence for serious side effects is poor and the risk of confounding remains a real possibility for many associations. Patients are more concerned about the absolute risk of developing a complication than a relative risk. The absolute risk of all the complications attributed to PPIs is low and patients who need long-term PPI therapy need a clear discussion of the available data on the risk of therapy and also a discussion of the risk of continued reflux.
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Affiliation(s)
- Nimish Vakil
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison WI, USA.
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Hvid-Jensen F, Pedersen L, Munk EM, Drewes AM, Funch-Jensen P. Long-term complications to reflux disease in community practice. A 17-year cohort study of 4706 patients. Scand J Gastroenterol 2011; 46:1179-86. [PMID: 21793632 DOI: 10.3109/00365521.2011.594084] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine the risk of developing strictures in patients with erosive and non-erosive gastroesophageal reflux disease in a community-based setting, since controlled trials indicate that the use of proton pump inhibitors renders the risk of strictures insignificant. MATERIAL AND METHODS A 17-year cohort study of 4706 patients referred to endoscopy due to upper GI symptoms, with a population comparison cohort of 47,060 individuals. All patients were followed and treated according to prevailing guidelines by their usual care provider. Main outcomes were relative risks (RR) and 95% confidence intervals (CI) for incident strictures and dilatations. RESULTS 776 (16.5%) patients were diagnosed with erosive esophagitis, particularly men (61.2%). Over a period of 1-17 years (mean 10.5), 20 patients (2.6%) in the esophagitis group developed a peptic stricture, necessitating one or more dilatations in 16 patients (2.1%). Among the non-esophagitis patients, the incidences for both outcomes were 1.2%. Male gender doubled the risk of developing strictures, and alcohol abuse raised the risk four folds. Erosive patients had a risk of developing strictures eight times (95% CI: 5.0-13.0) higher than controls, whereas non-erosive patients' risk was 4.0 (95% CI: 2.8-5.7). The majority of strictures developed within the first 10 years after a diagnosis of esophagitis. CONCLUSION Patients with esophagitis had eight times higher risk of strictures than population controls and two times higher than dyspeptic patients without esophagitis. This indicates that long-term outcomes in general practice are poorer than in controlled trials, most likely due to a lack of compliance with medication.
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Affiliation(s)
- Frederik Hvid-Jensen
- Department of Surgical Gastroenterology L, Aarhus University Hospital, Aarhus, Denmark
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Ryan C, Khan M, Delgado E, Berquist W, Longhurst C. A 15-year-old girl with dysphagia, failure to thrive. Pediatr Ann 2011; 40:397-400. [PMID: 21815600 DOI: 10.3928/00904481-20110708-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Christina Ryan
- Department of Pediatrics, Lucile Salter Packard Children's Hospital, Stanford University, Palo Alto, CA, USA.
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11
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Disease definition, clinical manifestations, epidemiology and natural history of GERD. Best Pract Res Clin Gastroenterol 2010; 24:759-64. [PMID: 21126691 DOI: 10.1016/j.bpg.2010.09.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 09/06/2010] [Accepted: 09/30/2010] [Indexed: 01/31/2023]
Abstract
Gastro-esophageal reflux disease is a global problem and affects children, adolescents and adults. The incidence of the disease appears to be increasing particularly in Asia where reflux disease has not traditionally been a major health problem in the past. Recent consensus efforts to define and classify the disease in both adults and children make it possible to obtain epidemiologic and natural history data using a universally acceptable definition and classification.
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Abstract
Esophageal dysphagia can arise from a variety of causes such as motility disorders, mechanical and inflammatory diseases. Adequate management includes a detailed history, evaluation with upper endoscopy, barium radiography and manometry. Treatment is usually tailored to the underlying disease process and in some cases, as in inoperable cancer, palliative management may be necessary.
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Affiliation(s)
- Adeyemi Lawal
- Medical College of Wisconsin, Department of Medicine, Division of Gastroenterology and Hepatology, Froedtert East, FEC-4510, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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13
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Abstract
Gastrooesophageal reflux disease, GERD, is a common problem which is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world with important risk factors being obesity and the eradication of Helicobacter pylori. Increasing research points to transient LES relaxation and spatial separation of the diaphragm and LES (hiatal hernia in chest) being the critical mechanisms of acid reflux. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory oesophageal pH testing is the most sensitive test for GERD, while endoscopy is the most specific test. Medical treatment with PPIs has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic antireflux surgery and PPIs have similar efficacy in the few available long-term trials. Currently, endoscopic treatments for GERD should not be a clinical alternative outside of research trials. New drug therapies should be directed at modulating transient LES relaxation.
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Affiliation(s)
- Joel E Richter
- Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, 801 Parkinson Pavilion, Philadelphia, PA 19140, USA.
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Abstract
BACKGROUND Rates for laparoscopic fundoplication are declining in the United States and there is no consensus on the indications for referral to surgery in gastro-oesophageal reflux disease. AIM To highlight recent studies on the outcomes of laparoscopic fundoplication in adults that cast doubt on the traditional indications for surgery in reflux disease. RESULTS Patients who are well maintained on medical therapy have more to lose with surgical intervention than to gain, and should not be offered surgery. Likewise, the notion that surgery prevents oesophageal cancer is a hypothesis that is not supported by current evidence, therefore surgical intervention should not be offered to these patients. The only clear-cut candidates for surgery include: patients with anatomic abnormalities such as a large hiatus hernia, or those with persistent regurgitation that causes troublesome symptoms despite medical therapy; and carefully selected patients with extra-oesophageal disorders who have symptoms of reflux disease such as heartburn and regurgitation, an incomplete response to medical therapy and persistent plus demonstrable reflux on pH or impedance testing that is associated with their symptoms. Patients should be aware of the high likelihood of needing continued acid inhibitory therapy following surgery and the possibility of side-effects. CONCLUSION Only a few carefully selected patients should undergo fundoplication for reflux disease.
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Affiliation(s)
- N Vakil
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Abstract
BACKGROUND The widespread use of proton pump inhibitors for gastro-oesophageal reflux disease could result in a decline in new as well as recurrent gastro-oesophageal reflux disease-related oesophageal strictures. The temporal trends of strictures have not been examined in population-based studies. METHODS To examine the temporal trends in strictures, we calculated the age-adjusted incidence rates of new oesophageal strictures with or without oesophageal dilation in a sample of Medicare beneficiaries between 1992 and 2000. We also examined recurrent dilations recorded at least 3 months after a new stricture or the preceding recurrent stricture. RESULTS The age-adjusted rates for strictures accompanied with dilation declined by approximately 11% from 215 per million to 192 per million. New oesophageal strictures with dilation declined as a proportion of all upper endoscopies procedures (from 2.6% to 1.9%). Recurrent dilation within 1 year declined dramatically from 16% (9.5% CI: 12.5-20.3) in 1992 to 8% (95% CI: 4.43-10.62) in 2000. In multivariable proportional hazards model, there was a 30% risk reduction of recurrent oesophageal strictures. CONCLUSIONS This population-based study indicates that the incidence of new as well as recurrent oesophageal strictures has been declining. In the face of rising incidence of other gastro-oesophageal reflux disease-related complications, it is important to understand the explanation of the present observations.
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Affiliation(s)
- H B El-Serag
- Section of Gastroenterology, The Houston Department of Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX, USA.
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Abstract
There is a perception that the prevalence of gastroesophageal reflux disease (GERD) is increasing, but few studies have directly tackled this issue. By using a systematic approach, this review aimed to assess objectively whether the prevalence of GERD is changing with time. First, population-based studies that reported the prevalence of at least weekly heartburn and/or acid regurgitation were subjected to a time-trend analysis with a Poisson regression model. Second, population-based studies reporting the prevalence of GERD symptoms at 2 time points in the same source population were reviewed. Third, longitudinal studies that charted the prevalence of GERD symptoms and esophagitis in primary and secondary care were examined. The Poisson model revealed a significant (P < .0001) trend for an increase in the prevalence of reflux symptoms in the general population over time. Separately, significant increases with time were found for North America (P = .0005) and Europe (P < .0001) but not Asia (P = .49). Studies of the same source population over time indicated an increase in the prevalence of GERD in the U.S., Singapore, and China but not Sweden. An increase in the prevalence of GERD or esophagitis was found in the majority of longitudinal studies. There is evidence that the prevalence of GERD has increased during the past 2 decades. If this trend continues, it could contribute to the rapidly increasing incidence of more serious complications associated with GERD, such as esophageal adenocarcinoma, as well as costs to healthcare systems and employers.
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Affiliation(s)
- Hashem B El-Serag
- Gastroenterology and Health Services Research Sections, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas 77030, USA.
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Ruigómez A, García Rodríguez LA, Wallander MA, Johansson S, Eklund S. Esophageal stricture: incidence, treatment patterns, and recurrence rate. Am J Gastroenterol 2006; 101:2685-92. [PMID: 17227515 DOI: 10.1111/j.1572-0241.2006.00828.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to determine the incidence, natural history, and recurrence rate of esophageal stricture diagnosed in primary care. METHODS From the U.K. General Practice Research Database, we identified patients with a stricture diagnosis recorded between 1994 and 2000. Diagnoses were confirmed by general practitioner-completed questionnaires. Patients with stricture were compared to an age- and sex-matched sample of controls from the original source population. We estimated the incidence of stricture, potential risk factors, and comorbidities, and relative risk (RR) for subsequent stricture recurrence and mortality. RESULTS The incidence of esophageal stricture was 1.1 per 10,000 person-years and increased markedly with age. Incidence of stricture decreased from 1994 to 2000, concomitant with a substantial increase in proton pump inhibitor (PPI) use. The majority of stricture cases (68%) were peptic. Prior dysphagia, gastroesophageal reflux disease (GERD), hiatus hernia, peptic ulcer disease, and heavy alcohol use were associated with an increased risk of stricture. The rate of stricture recurrence was 11.1 per 100 person-years. Risk of recurrence associated with long-term PPI use adjusting for other factors was 0.6 (95% CI 0.3-1.1). Mortality in patients with peptic stricture was similar to that in the control population. CONCLUSIONS Esophageal stricture is a rare event, and most cases in primary care are peptic strictures. Prior GERD, hiatus hernia, and peptic ulcer are associated with an increased risk of peptic stricture. Incidence of stricture decreased from 1994 to 2000.
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Affiliation(s)
- Ana Ruigómez
- Centro Español de Investigación Farmacoepidemiológica, Madrid, Spain
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18
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Abstract
BACKGROUND Anecdotal experience suggests that gastroenterologists are encountering fewer patients with esophageal strictures; however, the temporal trends of esophageal strictures have not been well examined in large studies. METHODS We examined the incidence rates of new esophageal strictures as well as esophageal dilations among patients presenting to VA facilities between 1998 and 2003 as a proportion of the annual frequency of all endoscopic procedures and/or imaging procedures. Recurrent strictures were defined as those recorded at least 3 months after the index date of a new stricture or the date of the preceding recurrent stricture. Stricture was defined only in the presence of an upper endoscopy or upper gastrointestinal (UGI) contrast imaging within 30 days before or after the date of diagnosis. This algorithm was validated by manually reviewing the medical records of 180 patients; the positive predictive value was approximately 84%. The risk of recurrent strictures was examined using Cox proportional hazards model for multiple failures. RESULTS There were 19,157 patients identified between fiscal year (FY) 1998 and FY 2003 with new esophageal strictures. New strictures comprised a constant annual proportion of total EGD and UGI imaging studies. New strictures declined by 11.6% as a proportion of all upper endoscopies (not including UGI imaging). However, esophageal dilations associated with new stricture diagnoses declined among patients with new esophageal strictures, 16.8% had at least one episode of recurrence. The 1-yr incidence rate of recurrent strictures declined significantly (-36.0%) from 13.9 per 100 person-years for patients diagnosed with new strictures in 1998 to 8.9 per 100 person-years in patients diagnosed with new strictures in 2003. In the full multivariable model, new strictures diagnoses during 2001-2003 were associated with a reduced risk of having recurrent strictures (19% in the first year and 13% throughout follow-up) independent of age, gender, race, geographic region, or the presence of Barrett's esophagus. CONCLUSION The incidence of recurrent strictures has declined between 1998 and 2003 by approximately one-third. Although there has been only a small decline in the incidence of new esophageal strictures among patients undergoing endoscopy, the use of esophageal dilations has declined considerably among these patients. The role of proton pump inhibitors needs to be examined.
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Affiliation(s)
- Hashem B El-Serag
- The Section of Gastroenterology at The Houston Department of Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas 77030, USA
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Bailie GR, Mason NA, Elder SJ, Andreucci VE, Greenwood RN, Akiba T, Saito A, Bragg-Gresham JL, Gillespie BW, Young EW. Large variations in prescriptions of gastrointestinal medications in hemodialysis patients on three continents: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Hemodial Int 2006; 10:180-8. [PMID: 16623672 DOI: 10.1111/j.1542-4758.2006.00092.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Little is known about proton pump inhibitor (PPI) or H(2) receptor antagonist (HA) prescription patterns or regarding use of predictors in hemodialysis patients. Proton pump inhibitor and HA prescribing patterns were investigated in 8628 hemodialysis patients from seven countries enrolled in the prospective, observational Dialysis Outcomes and Practice Patterns Study. Logistic regression examined predictors associated with PPI and HA use, adjusting for age, sex, country, time with end-stage renal disease, medications, 14 comorbid conditions, and the association between the number of comorbid conditions and the prescription of gastrointestinal (GI) medications. In a cross-section from February 1, 2000, 3.4% to 36.9% of patients received an HA and 0.8% to 26.9% took a PPI, depending upon the country. From 1996 to 2001, the prescription of HAs declined while PPI use increased. Facility use of HAs and PPIs ranged from 0% to 94% of patients. H2 receptor antagonist or PPI use was significantly and independently associated with age, narcotic use, corticosteroids, acetaminophen, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, selective serotonin reuptake inhibitors, coronary artery disease history, cardiovascular diseases other than hypertension or congestive heart failure, peripheral vascular disease, pulmonary disease, and GI bleed. Proton pump inhibitors or HAs were more likely to be prescribed in Italy, Spain, and the United Kingdom than in the United States. The odds of PPI prescription increased if serum phosphorus <5.5 mEq/L or serum albumin <3.5 g/dL. Prescription of GI medications was associated with many comorbidities and use of several medications. Extreme variability of prescription patterns suggests that there is no standard approach in treatment practices.
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Gupta SK, Hassall E, Chiu YL, Amer F, Heyman MB. Presenting symptoms of nonerosive and erosive esophagitis in pediatric patients. Dig Dis Sci 2006; 51:858-63. [PMID: 16718535 DOI: 10.1007/s10620-006-9095-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2005] [Accepted: 10/25/2005] [Indexed: 12/09/2022]
Abstract
Children and adolescents with symptomatic gastroesophageal reflux disease (GERD) and erosive esophagitis (EE) of grade >/=2 (n=45) or nonerosive esophagitis (NEE) (n=45) were assessed to determine the relationship between presenting symptoms, esophagitis severity, and patient age. Overall, regurgitation/vomiting, abdominal pain, and cough were the most frequent symptoms. The prevalence and severity of anorexia/feed refusal was significantly greater in EE versus NEE children; this symptom was also significantly more prevalent in younger (1-5 years) children (both NEE and EE groups) compared to older children. Cough was significantly less severe in NEE adolescents than in younger children. Cough, anorexia/feed refusal, and regurgitation/vomiting were more severe and heartburn was less severe in EE children aged 1-5 years compared with older patients. In conclusion, GERD in children manifests differently than that in adults and symptoms vary with patient age. Symptoms were not predictive of presence or lack of mucosal damage.
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Affiliation(s)
- Sandeep K Gupta
- Riley Hospital for Children, 702 Barnhill Dr, Room ROC 4210, Indianapolis, IN 46202, USA.
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Zacny J, Zamakhshary M, Sketris I, Veldhuyzen van Zanten S. Systematic review: the efficacy of intermittent and on-demand therapy with histamine H2-receptor antagonists or proton pump inhibitors for gastro-oesophageal reflux disease patients. Aliment Pharmacol Ther 2005; 21:1299-312. [PMID: 15932360 DOI: 10.1111/j.1365-2036.2005.02490.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIM To perform a systematic review on the efficacy of intermittent and on-demand therapy with either histamine H2-receptor antagonists or proton pump inhibitors for patients with erosive oesophagitis or symptomatic heartburn. METHOD We conducted randomized-controlled trials of non-continuous therapy in gastro-oesophageal reflux disease patients. RESULTS Fourteen studies met inclusion criteria. Because of variation in outcome measures statistical pooling of results was not possible. Results were analysed qualitatively. Four studies evaluated intermittent therapy of treatment 3 days a week with omeprazole 20 mg or daily with ranitidine which were not efficacious compared to a daily proton pump inhibitor. Famotidine 10 and 20 mg, ranitidine 75 mg and cimetidine 200 mg were efficacious in five on-demand studies for relief of symptomatic heartburn episodes. In three of four studies, evaluating only non-erosive (endoscopy-negative) gastro-oesophageal reflux disease patients, esomeprazole 20 and 40 mg and omeprazole 10 and 20 mg a day were efficacious using willingness to continue as an endpoint. Lansoprazole 30 mg and omeprazole 20 mg maintained symptom control in 60-70% of healed oesophagitis patients. CONCLUSIONS Intermittent proton pump inhibitor or H2-receptor antagonist therapy is not effective in maintaining control in oesophagitis patients. H2-receptor antagonists are effective for relief of heartburn episodes. On-demand proton pump inhibitor therapy may work in a proportion of non-erosive gastro-oesophageal reflux disease patients.
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Affiliation(s)
- J Zacny
- Division of Gastroenterology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
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