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Niu S, Zhang T, Li W, Wen S, Dong L, Wang S, Shi W, Shi C, Shen Y, Huang Q, Tan Y, Xu X, Yu L. Positive effect of deep diaphragmatic breathing training on gastroesophageal reflux-induced chronic cough: a clinical randomized controlled study. Respir Res 2024; 25:169. [PMID: 38637797 PMCID: PMC11027235 DOI: 10.1186/s12931-024-02783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/21/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVE To explore the efficacy of deep diaphragmatic breathing training (DEP) in patients with gastroesophageal reflux-induced chronic cough (GERC). METHODS A randomized controlled study was conducted involving 60 GERC patients who were divided into the intervention group and the control group (each with 30 patients). Both groups received routine medication treatment for GERC, while the intervention group received DEP training additionally. Both groups were evaluated by cough symptom scores, Hull airway reflux questionnaire (HARQ), gastroesophageal reflux diagnostic questionnaire (GerdQ), generalized anxiety disorder scale-7 (GAD-7), patient health questionnaire-9 (PHQ-9), Pittsburgh sleep quality index (PSQI), the Leicester cough questionnaire (LCQ), as well as capsaicin cough sensitivity testing, B-ultrasound and surface electromyography (sEMG) of the diaphragmatic muscles before and after treatment. The cough resolution rate and changes of the above indictors was compared between the two groups after eight weeks of treatment. RESULTS After eight weeks of treatment, cough symptoms improved in both groups, but the cough resolution rate in the intervention group of 94% was significantly higher than that in the control group of 77% (χ2 = 6.402, P = 0.041). The intervention group showed significant improvements to the control group in GerdQ (6.13(0.35) VS 6.57(0.77)), GAD-7 (0(0;1) VS 1(0;3)), PSQI (2(1;3) VS 4(3;6)), LCQ (17.19(1.56) VS 15.88(1.92)) and PHQ-9 (0(0;0) VS 0(0;3)) after treatment. Compared to control group, sEMG activity of the diaphragmatic muscle was significantly increased in the intervention group after treatment, measured during DEP (79.00(2.49) VS 74.65 (1.93)) and quiet breathing (72.73 (1.96) VS 67.15 (2.48)). CONCLUSION DEP training can improve cough symptoms as an adjunctive treatment in GERC patients. TRIAL REGISTRATION The protocol was registered in February 2, 2022 via the Chinese Clinical Trials Register ( http://www.chictr.org.cn/ ) [ChiCTR2200056246].
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Affiliation(s)
- Shanshan Niu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
- Department of Oncology, Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, China
| | - Tongyangzi Zhang
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Wanzhen Li
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Siwan Wen
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Lei Dong
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Shengyuan Wang
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Wenbo Shi
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Cuiqin Shi
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Yuqin Shen
- Department of Cardiac Rehabilitation, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Qianchun Huang
- Department of Cardiac Rehabilitation, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Yaling Tan
- Department of Neurology, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Xianghuai Xu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
| | - Li Yu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
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Lei WY, Yi CH, Liu TT, Hung JS, Wong MW, Chen CL. Esophageal motor abnormalities in gastroesophageal reflux disorders. Tzu Chi Med J 2024; 36:120-126. [PMID: 38645779 PMCID: PMC11025585 DOI: 10.4103/tcmj.tcmj_209_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/02/2023] [Accepted: 11/10/2023] [Indexed: 04/23/2024] Open
Abstract
Gastroesophageal reflux disease (GERD), a prevalent condition with multifactorial pathogenesis, involves esophageal motor dysmotility as a key contributing factor to its development. When suspected GERD patients have an inadequate response to proton-pump inhibitor (PPI) therapy and normal upper endoscopy results, high-resolution manometry (HRM) is utilized to rule out alternative diagnosis such as achalasia spectrum disorders, rumination, or supragastric belching. At present, HRM continues to provide supportive evidence for diagnosing GERD and determining the appropriate treatment. This review focuses on the existing understanding of the connection between esophageal motor findings and the pathogenesis of GERD, along with the significance of esophageal HRM in managing GERD patients. The International GERD Consensus Working Group introduced a three-step method, assessing the esophagogastric junction (EGJ), esophageal body motility, and contraction reserve with multiple rapid swallow (MRS) maneuvers. Crucial HRM abnormalities in GERD include frequent transient lower esophageal sphincter relaxations, disrupted EGJ, and esophageal body hypomotility. Emerging HRM metrics like EGJ-contractile integral and innovative provocative maneuver like straight leg raise have the potential to enhance our understanding of factors contributing to GERD, thereby increasing the value of HRM performed in patients who experience symptoms suspected of GERD.
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Affiliation(s)
- Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Fitzgerald PCE, Bitarafan V, Omari T, Cock C, Jones KL, Horowitz M, Feinle-Bisset C. The herbal preparation, STW5-II, reduces proximal gastric tone and stimulates antral pressures in healthy humans. Neurogastroenterol Motil 2024:e14755. [PMID: 38303121 DOI: 10.1111/nmo.14755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND The herbal preparation, STW5-II, improves upper gastrointestinal symptoms, including abdominal fullness, early satiation, and epigastric pain, in patients with functional dyspepsia, and in preclinical models decreases fundic tone and increases antral contractility. The effects of STW5-II on esophago-gastric junction pressure, proximal gastric tone and antropyloroduodenal pressures, disturbances of which may contribute to symptoms associated with disorders of gut-brain interaction, including functional dyspepsia, in humans, have, hitherto, not been evaluated. METHODS STW5-II or placebo (matched for color, aroma, and alcohol content) were each administered orally, at the recommended dose (20 drops), to healthy male and female volunteers (age: 27 ± 1 years) in a double-blind, randomized fashion, on two separate occasions, separated by 3-7 days, to evaluate effects on (i) esophago-gastric junction pressures following a standardized meal using solid-state high-resolution manometry (part 1, n = 16), (ii) proximal gastric volume using a barostat (part 2, n = 16), and (iii) antropyloroduodenal pressures assessed by high-resolution manometry (part 3, n = 18), for 120 min (part 1) or 180 min (parts 2, 3). KEY RESULTS STW5-II increased maximum intrabag volume (ml; STW5-II: 340 ± 38, placebo: 251 ± 30; p = 0.007) and intrabag volume between t = 120 and 180 min (p = 0.011), and the motility index of antral pressure waves between t = 60 and 120 min (p = 0.032), but had no effect on esophago-gastric junction, pyloric, or duodenal pressures. CONCLUSIONS & INFERENCES STW5-II has marked region-specific effects on gastric motility in humans, which may contribute to its therapeutic efficacy in functional dyspepsia.
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Affiliation(s)
- Penelope C E Fitzgerald
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Vida Bitarafan
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Taher Omari
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Charles Cock
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Karen L Jones
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael Horowitz
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christine Feinle-Bisset
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
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Barba Orozco E, Ezquerra Duran A. Study of gastroesophageal reflux. Interpretation of functional tests in the obese patient. Cir Esp 2023; 101 Suppl 4:S8-S18. [PMID: 37979941 DOI: 10.1016/j.cireng.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/09/2023] [Indexed: 11/20/2023]
Abstract
Overweight and obesity are a public health problem and in 1997 obesity was recognized as a global epidemic by the World Health Organization (WHO). Overweight and obesity affect almost 60% of adults and one in three children in Europe according to the most recent WHO report. Objectively, gastroesophageal reflux disease (GERD) is defined as the presence of characteristic esophageal mucosal damage assessed by endoscopy and/or the demonstra-tion of pathological acid exposure by reflux monitoring studies. The prevalence of GERD is increased in obese patients In overweight and obese patients, the clinical symptoms of GERD are especially present in the supine position and this correlates with more frequent episodes of nocturnal reflux in the 24-h pH monitoring, there is also an increase in the number of refluxes with content acid. In the population with symptoms, digestive endoscopy detects data of erosive esophagitis in 50% of patients, while 24-h pH-impedanciometry diagnoses 92% of patients with non-erosive reflux disease (NERD) The presence of persistent GERD in the mucosa affects esophageal motility and patients may develop ineffective esophageal motility-type disorders, so we will review the interpre-tation of the functional tests that determine motility, which is esophageal manometry, and those that determine reflux gastroesophageal, acid and non-acid, which is the pH measure-ment with or without 24-h impedanciometry.
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Affiliation(s)
- Elizabeth Barba Orozco
- Gastroenterology Department, Neurogastroenterology and Motility Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.
| | - Alberto Ezquerra Duran
- Gastroenterology Department, Neurogastroenterology and Motility Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Mozafari K, Miraaj-Raza S, Ilyas A, Joshi J, Ganesh V, Tiesenga F. Severe Paraesophageal Hiatal Hernia Repair During a Sleeve Gastrectomy Surgery in a Morbidly Obese Patient. Cureus 2023; 15:e35897. [PMID: 37033566 PMCID: PMC10080968 DOI: 10.7759/cureus.35897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Morbid obesity increases the average risk of a patient developing a paraesophageal or hiatal hernia. Paraesophageal hernias (PEH) include several types, and their treatment is indubitably one of the most contentious topics in minimally invasive surgery. Though it is rare for PEH to manifest as a strangulated, volatilized intrathoracic stomach with infection, the increased risk of mortality is an indication for many to pursue surgical repair. Moreover, morbidly obese individuals represent a substantial rate of failure of PEH repairs. The modes of confirmation diagnostics are barium swallow or upper endoscopy. This case study focuses on a 64-year-old female who presented with several comorbidities, was appropriately evaluated for laparoscopic sleeve gastrectomy, and was previously identified to have a severe type III PEH with grade IV configuration. Additionally, the pathological finding from the extracted specimen was significant for helicobacter pylori gastritis.
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Affiliation(s)
- Kaveh Mozafari
- Surgery, West Suburban Medical Center, Oak Park, USA
- Medicine, St. George's University School of Medicine, St. George, GRD
| | - Sarah Miraaj-Raza
- Medicine and Surgery, Saint James School of Medicine, The Quarter, AIA
| | - Aadil Ilyas
- Medicine and Surgery, St. George's University School of Medicine, Chicago, USA
| | - Jahanvi Joshi
- Medicine, St. George's University School of Medicine, Chicago, USA
| | - Vaishnavi Ganesh
- Medicine and Surgery, Saint James School of Medicine, Chicago, USA
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6
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Lee SW, Park J, Kim H, Jung YW, Baek YS, Lim Y, Kim K. Atopic dermatitis and risk of gastroesophageal reflux disease: A nationwide population-based study. PLoS One 2023; 18:e0281883. [PMID: 36800327 PMCID: PMC9937456 DOI: 10.1371/journal.pone.0281883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/02/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND As atopic dermatitis (AD) has been found to be related to various comorbidities as well as substantial patient burden, questions of a possible relationship between AD and nonallergic diseases beyond allergic diseases have also been raised. OBJECTIVE The aim of this nationwide matched cohort study was to evaluate whether AD would increase the development of gastroesophageal reflux disease (GERD). METHODS Patients diagnosed with AD were identified from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) 2.0 database in South Korea from 2002 to 2015. Finally, 9,164 adults with AD (≥20 years old) and age, sex, household income, region of residence, disability, and baseline year-matched 9,164 controls were included in the analysis. Hazard ratio (HR) with 95% confidence interval (CI) for the development of GERD was estimated using a Cox proportional hazard regression model. RESULTS Overall, 12.3% of the patients in the AD group developed GERD, whereas 10.4% of the individuals in the control group developed GERD. The results of the adjusted model revealed that patients with AD had a significantly increased risk of developing GERD (adjusted HR, 1.15; 95% CI, 1.06-1.26) compared with the matched controls. Increased risk of developing GERD was consistent in subgroup analyses by sex or age groups under 60 years old as well as all the sensitivity analyses performed. CONCLUSIONS This study suggested that appropriate management should be considered in adults with AD to prevent GERD, because AD was found to be associated with an increased risk of subsequent GERD.
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Affiliation(s)
- Seung Won Lee
- Institute of Pharmaceutical Science, Korea University, Sejong, South Korea
| | - Jiwon Park
- College of Pharmacy, Korea University, Sejong, South Korea
| | - Hayeon Kim
- College of Pharmacy, Korea University, Sejong, South Korea
| | - Yong Woo Jung
- Institute of Pharmaceutical Science, Korea University, Sejong, South Korea
- College of Pharmacy, Korea University, Sejong, South Korea
| | - Yoo Sang Baek
- Department of Dermatology, Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Yejee Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Kyungim Kim
- Institute of Pharmaceutical Science, Korea University, Sejong, South Korea
- College of Pharmacy, Korea University, Sejong, South Korea
- * E-mail:
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Domingues G, Moraes-Filho JPPD. GASTROESOPHAGEAL REFLUX DISEASE: A PRACTICAL APPROACH. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:525-533. [PMID: 34909861 DOI: 10.1590/s0004-2803.202100000-94] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/26/2021] [Indexed: 01/10/2023]
Abstract
Gastroesophageal reflux disease (GERD) presents typical manifestations such as heartburn and/or regurgitation as well as atypical manifestations such as throat symptoms, laryngitis, hoarseness, chronic cough, asthma, and sleep alterations. There are two phenotypes of the disease: erosive GERD, when erosions are identified by upper digestive endoscopy, and non-erosive GERD, when the esophageal mucosa presents a normal endoscopic aspect. Relevant clinical findings are usually absent in the physical examination, but it should be highlighted that obesity is an important aggravating factor of reflux. The treatment is established based on clinical findings and, according to the clinical situation, on complementary exams such as upper digestive endoscopy. In dubious cases where a precise diagnosis is required, the indicated test is esophageal pHmetry or impedance-pHmetry. Clinical treatment is divided into behavioral/dietary measures and pharmacological measures. Most patients benefit from clinical treatment, but surgical treatment may be indicated in the presence of a larger hiatal hernia and complications of the disease.
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Affiliation(s)
- Gerson Domingues
- Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Herbella FAM, Schlottmann F, Patti MG. Pitfalls in the Interpretation of Chicago Classification for Esophageal Motility Disorders. J Neurogastroenterol Motil 2021; 27:513-517. [PMID: 34642270 PMCID: PMC8521471 DOI: 10.5056/jnm20058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/17/2021] [Indexed: 11/20/2022] Open
Abstract
High-resolution manometry permitted the creation of the Chicago classification, that is the categorization for esophageal motility disorders most currently used. Despite its wide acceptance, there are few pitfalls for the correct interpretation of the tests. This technique review illustrates some difficult cases that may lead to misinterpretation of the results. Difficult cases are analyzed, such as the distinction of: (1) esophagogastric junction morphology and lower esophageal sphincter excursion, (2) intrabolus pressure pattern or common cavity, (3) hypercontractile esophagus (jackhammer) and achalasia type III, (4) absent contractility and severe ineffective esophageal motility or achalasia type I, and (5) simultaneous distal esophageal spasm and ineffective esophageal motility.
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Affiliation(s)
| | | | - Marco G Patti
- Department of Medicine and Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Zheng Z, Shang Y, Wang N, Liu X, Xin C, Yan X, Zhai Y, Yin J, Zhang J, Zhang Z. Current Advancement on the Dynamic Mechanism of Gastroesophageal Reflux Disease. Int J Biol Sci 2021; 17:4154-4164. [PMID: 34803489 PMCID: PMC8579455 DOI: 10.7150/ijbs.65066] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/19/2021] [Indexed: 12/13/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common clinical disease associated with upper gastrointestinal motility disorders. Recently, with improvements in living standards and changes in lifestyle and dietary habits, the incidence of GERD has been increasing yearly. However, the mechanism of GERD has not been fully elucidated due to its complex pathogenesis, and this had led to unsatisfactory therapeutic outcomes. Currently, the occurrence and development of GERD involve multiple factors. Its pathogenesis is mainly thought to be related to factors, such as lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, crural diaphragmatic dysfunction, hiatus hernia, and impaired esophageal clearance. Therefore, explaining the pathogenesis of GERD more clearly and systematically, exploring potential and effective therapeutic targets, and choosing the best treatment methods have gradually become the focus of scholars' attention. Herein, we reviewed current advancements in the dynamic mechanism of GERD to better counsel patients on possible treatment options.
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Affiliation(s)
- Zhi Zheng
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Yuxi Shang
- Department of Hematology, Fuxing Hospital, Eighth Clinical Medical College, Capital Medical University, Beijing, China
| | - Ning Wang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiaoye Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Chenglin Xin
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Xiaosheng Yan
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Yuhao Zhai
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Jie Yin
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Jun Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
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DeLay K, Pandolfino JE, Roman S, Gyawali CP, Savarino E, Tye M, Kaizer A, Yadlapati R. Diagnostic yield and reliability of post-prandial high-resolution manometry and impedance-ph for detecting rumination and supragastric belching in PPI non-responders. Neurogastroenterol Motil 2021; 33:e14106. [PMID: 33687131 PMCID: PMC8426416 DOI: 10.1111/nmo.14106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Supragastric belching (SGB) and rumination are behavioral disorders associated with proton pump inhibitor (PPI) non-response and can be diagnosed using multichannel intraluminal impedance-pH (MII-pH) and post-prandial high-resolution impedance manometry (PPHRIM). This pilot study compared diagnostic yield and inter-rater agreement for SGB and rumination using MII-pH and PPHRIM. METHODS Three esophageal physiologists performed blinded interpretations of MII-pH and PPHRIM in 22 PPI non-responders. Raters selected from 4 diagnostic impressions (normal, GERD, behavioral disorders, GERD+behavioral disorders) without clinical context. Primary outcomes were diagnostic impressions compared against clinical gold standard impression, between raters, and between test modalities. Following a 28-month wash-out period, raters re-interpreted MII-pH with clinical context and under consensus definition of diagnostic criteria. KEY RESULTS Compared to gold standard, rater accuracy for presence of behavioral disorders ranged from 45 to 77% on MII-pH and 45-59% on PPHRIM. On MII-pH, inter-rater agreement was fair for diagnosis (ĸ0.32, p < 0.01) and suboptimal for presence of behavioral disorders (ĸ0.13, p = 0.14). On PPHRIM, inter-rater agreement was suboptimal for both diagnosis (ĸ0.03, p = 0.34) and presence of a behavioral disorder (ĸ-0.22, p = 0.96). Inter-rater agreement improved in post hoc MII-pH interpretations. Rumination was more frequently identified on PPHRIM (23, 35%) compared to MII-pH (7, 11%). CONCLUSIONS AND INFERENCES Diagnostic accuracy and inter-rater agreement are higher for MII-pH than PPHRIM, and behavioral disorders are more frequently identified on PPHRIM. Identifying behavioral disorders on MII-pH and PPHRIM has implications for clinical evaluation of PPI non-response; clinical context is essential for accurate study interpretation. Further work is needed to standardize definitions and interpretations.
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Affiliation(s)
- Kelli DeLay
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sabine Roman
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, Lyon, France; Université de Lyon, Lyon I University, Digestive Physiology, Lyon, France; Université de Lyon, Inserm U1032, LabTAU, Lyon, France
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Division of Gastroenterology, University of Padua, Padova, Italy
| | - Michael Tye
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alexander Kaizer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA;,UCSD Center for Esophageal Diseases, Division of Gastroenterology, University of California San Diego, San Diego, California; USA
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Thalheimer A, Bueter M. Excess Body Weight and Gastroesophageal Reflux Disease. Visc Med 2021; 37:267-272. [PMID: 34540942 DOI: 10.1159/000516050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/22/2021] [Indexed: 12/20/2022] Open
Abstract
Background Gastroesophageal reflux disease (GERD) is strongly associated with excess body weight. Summary GERD is characterized by typical symptoms with or without mucosal damage because of retrograde flow of gastric content into the esophagus. An ineffective esophagogastric junction (EGJ) combined with anatomical abnormalities is considered to be causative. The incidence of GERD is strongly associated with excess body weight, reflecting the pathophysiological relevance of the abdominothoracic pressure gradient. Key Message Weight loss has been demonstrated to be an effective therapy for GERD combined with obesity. In cases in which surgical therapy is indicated, traditional antireflux surgery has led to equivocal results, advocating a proximal Roux-en-Y gastric bypass in these patients to correct both GERD and excess body weight.
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Affiliation(s)
- Andreas Thalheimer
- Department of Visceral and Transplant Surgery, University Hospital of Zürich, Zurich, Switzerland.,Department of Surgery, Spital Männedorf, Männedorf, Switzerland
| | - Marco Bueter
- Department of Visceral and Transplant Surgery, University Hospital of Zürich, Zurich, Switzerland.,Department of Surgery, Spital Männedorf, Männedorf, Switzerland
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12
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Iovino P, Theron B, Prew S, Menon S, Trudgill N. The mechanisms associated with reflux episodes in ambulant subjects with gastro-esophageal reflux disease. Neurogastroenterol Motil 2021; 33:e14023. [PMID: 33112052 DOI: 10.1111/nmo.14023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The mechanisms associated with gastro-esophageal reflux (GER) episodes were studied using combined High-resolution Impedance Manometry (HRIM) and pH monitoring in ambulant subjects with different patterns of GERD. METHODS Sixteen subjects with mild-moderate esophagitis (Los Angeles (LA) grade A&B) (group A) and 11 subjects with severe esophagitis (LA grade C&D) or Barrett's esophagus (BE) were studied before and after a meal, resting, while walking, and during standardized exercise, using a HRIM and a pH probe. KEY RESULTS Post-prandial acid GER episodes were more common in group B (median 10 range (3-18) vs A (6.5 (0-18), p = 0.048). Postprandial acid clearance time was much longer in group B (median 0.71( 0.07-2.66 min) vs A (0.17 (0.04-2.44 min), p = 0.02). Transient lower esophageal sphincter relaxation (TLESR) was the most frequent mechanism associated with GER episodes in both groups. Post-prandial TLESRs with GER were more common in group B (median 17 (9-24) vs A 13.5 (7-34), p = 0.014), particularly during exercise (B 8 (6-9) vs A 6 (5-6.8), p = 0.007). Post-prandially TLESR with acid reflux increased during exercise in both groups (A rest median 2.4 (0-6.4) per hour vs exercise 4.7 (0-17.3), p = 0.005 and B 4 (0.8-9.6) vs 5.3 (2.7-13.3) per hour, p = 0.045). CONCLUSIONS AND INFERENCES TLESR was the most common mechanism associated with reflux episodes in all subjects. Acid reflux episodes were more common in subjects with severe esophagitis or BE and esophageal acid clearance was much slower. Post-prandial exercise increased TLESR with acid reflux and GERD patients should be encouraged to avoid exercise immediately after a meal.
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Affiliation(s)
- Paola Iovino
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Byron Theron
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
| | - Sandra Prew
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
| | - Shyam Menon
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
| | - Nigel Trudgill
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
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13
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Shcherbynina MB, Gladun VM, Sarana V. Acoustic Myography as a Noninvasive Technique for Assessing Muscle Function: Historical Aspects and Possibilities for Application in Clinical Practice. NEUROPHYSIOLOGY+ 2021. [DOI: 10.1007/s11062-021-09885-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Abstract
The esophagogastric junction (EGJ) is a complex barrier between the thoracic and abdominal luminal gut compartments, comprised primarily of the lower esophageal sphincter (LES) and crural diaphragm. Although closed at rest, the EGJ relaxes to allow antegrade bolus transit and retrograde venting of air. Abnormal relaxation is the hallmark of achalasia spectrum disorders, while increased frequency of transient lower esophageal sphincter relaxations and/or EGJ disruption are seen in gastroesophageal reflux disease. High resolution manometry (HRM) is the modern day gold standard for assessment of EGJ morphology and function, with better performance characteristics compared with endoscopy and barium esophagography. Conventional LES metrics defining EGJ function include resting LES pressure as well as postswallow residual pressures. Newer HRM-based metrics include EGJ contractile integral, which measures static barrier function at rest, and EGJ morphology, which characterizes the relationship between LES and crural diaphragm. Provocative maneuvers assess dynamic EGJ function during physiological or pharmacologic stress. The most useful of these maneuvers, the rapid drink challenge, assesses for latent obstruction, while multiple rapid swallows evaluate adequacy of deglutitive inhibition. Amyl nitrate and cholecystokinin administration can segregate motor from structural obstruction. Newer provocative tests (straight leg raise maneuver, abdominal compression) and novel diagnostic tools (functional lumen imaging probe) complement HRM evaluation of the EGJ. Although current HRM metrics and maneuvers show promise in identifying clinically relevant EGJ abnormalities, future investigations evaluating management outcomes will improve segregation of normal from abnormal EGJ morphology and function.
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15
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Rengarajan A, Argüero J, Yazaki E, Kadirkamanthan SS, Siriwardana HPP, Brunt LM, Sifrim D, Gyawali CP. High-resolution manometry features of paraesophageal hernia. Neurogastroenterol Motil 2020; 32:e13947. [PMID: 33118680 DOI: 10.1111/nmo.13947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Paraesophageal hernias (PEH) can be associated with obstructive symptoms, but high-resolution manometry (HRM) characteristics have not been described in detail. METHODS HRM studies of confirmed PEH patients (n = 60, 66.3 ± 1.5 years, 76.7% F), axial hernias (n = 125, 56.1 ± 1.1 years, 58.4% F), and healthy controls (n = 20, 27.9 ± 0.7 years, 45% F) were analyzed. Axial hernias (type 1) were compared to PEH subtyped as isolated PEH (type 2), PEH with axial hernia (type 3), PEH with herniated abdominal organs (type 4), and unknown. Distal contractile integral (DCI), esophageal length, lower esophageal sphincter pressures (LESP), EGJ contractile integral (EGJ-CI), and integrated relaxation pressure (IRP) were extracted. Intra-luminal pressures were measured proximal (intrabolus pressure, IBP) and distal (intragastric pressure, IGP) to EGJ. Univariate and multivariate analyses were performed to characterize esophageal and EGJ motor physiology in PEH. KEY RESULTS PEH patients had LESP and EGJ-CI similar to controls; axial hernia patients had lower LESP. While IRP was within normal limits, PEH had elevated IBP and IGP, and shorter esophageal length compared to axial hernia and normal controls (P ≤ .0001 across groups). Short esophageal length was consistent across PEH subtypes (P = .06). On multivariate regression analysis, IBP remained an independent predictor of PEH (P < .0001). Within PEH subtypes, gastric pressure was higher when axial HH was also present, in contrast to isolated PEH (P = .03); other metrics did not differ. CONCLUSIONS & INFERENCES Luminal pressure increase both upstream and downstream of the EGJ on HRM likely represents obstructive phenomena in PEH, identification of which may support suspicion of PEH.
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Affiliation(s)
- Arvind Rengarajan
- Division of Gastroenterology, Washington University in St Louis, St Louis, MO, USA
| | - Julieta Argüero
- Barts and the London School of Medicine and Dentistry, Queen Mary Institute of London, London, UK
| | - Etsuro Yazaki
- Barts and the London School of Medicine and Dentistry, Queen Mary Institute of London, London, UK
| | | | | | - L Michael Brunt
- Section of Minimally Invasive Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary Institute of London, London, UK
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University in St Louis, St Louis, MO, USA
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16
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Saracco M, Savarino V, Bodini G, Saracco GM, Pellicano R. Gastroesophageal reflux disease: key messages for clinicians. Minerva Gastroenterol (Torino) 2020; 67:390-403. [PMID: 33103406 DOI: 10.23736/s2724-5985.20.02783-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a chronic common disorder for which patients often refer to specialists. In the last decades, numerous studies helped to clarify the pathophysiology and the natural history of this disease. Currently, in the clinical setting, GERD is defined by the presence of symptoms that, when endoscopic investigation is required, permit to distinguish between cases with or without associated esophageal mucosal injuries. These conditions are called erosive reflux disease and non-erosive reflux disease (NERD), respectively. The latter is the most common manifestation of GERD. Symptoms are defined typical, as heartburn and regurgitation, and atypical (also called extra-esophageal), as coughing and/or wheezing, hoarseness, sore throat, otitis media, and dental manifestations. In this context, it is crucial for clinicians to investigate the presence of features of suspected malignancy, as unexplained weight loss, anemia, dysphagia, persistent vomiting, familiar history of cancer, long history of GERD, and beginning of GERD symptoms after the age of 50 years. The presence of these risk factors should induce to perform an endoscopic examination. Particular attention should be given to functional conditions that can mimic GERD, such as functional heartburn and hypersensitive esophagus as well as, more rarely, eosinophilic esophagitis. The former ones have different pathophysiology and this explains the frequent non-response to proton pump inhibitor drugs. This narrative review provides to clinicians a useful and practical overview of the state-of-the-art on advancements in the knowledge of GERD.
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Affiliation(s)
| | | | - Giorgia Bodini
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Giorgio M Saracco
- Department of Medical Sciences, University of Turin, Turin, Italy.,Unit of Gastroenterology, Molinette Hospital, Turin, Italy
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17
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Ribolsi M, de Carlo G, Balestrieri P, Guarino MPL, Cicala M. Understanding the relationship between esophageal motor disorders and reflux disease. Expert Rev Gastroenterol Hepatol 2020; 14:933-940. [PMID: 32658587 DOI: 10.1080/17474124.2020.1791703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The management of gastro-esophageal reflux disease (GERD) patients is often complex as the clinical presentation is heterogeneous and the mechanisms underlying symptoms are multifactorial. In the past decades, investigations conducted with conventional manometry and, above all, the more accurate high resolution manometry (HRM), helped us in exploring the field of esophageal motility and in understanding the link between motor features and GERD pathogenesis. AREAS COVERED Several studies carried out with conventional manometry and HRM have confirmed a relevant role of esophageal motor function in GERD pathogenesis. In particular, HRM studies have shown a direct correlation between impaired esophageal body motility, disruption of the esophagogastric junction and reflux burden. These findings impact the clinical and therapeutical management of GERD patients. Moreover, HRM findings might be helpful in evaluating patients with proton pump inhibitor (PPI) resistance and inconclusive evidences of GERD. EXPERT OPINION The relationship between esophageal motility and GERD pathogenesis needs to be further evaluated by multicenter outcome studies involving a large number of GERD patients and healthy controls. However, other more promising areas could be progressed.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University , Rome, Italy
| | - Giovanni de Carlo
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University , Rome, Italy
| | - Paola Balestrieri
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University , Rome, Italy
| | | | - Michele Cicala
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University , Rome, Italy
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18
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Felinska E, Billeter A, Nickel F, Contin P, Berlth F, Chand B, Grimminger P, Mikami D, Schoppmann SF, Müller-Stich B. Do we understand the pathophysiology of GERD after sleeve gastrectomy? Ann N Y Acad Sci 2020; 1482:26-35. [PMID: 32893342 DOI: 10.1111/nyas.14467] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD), a prevalent problem among obese individuals, is strongly associated with obesity and weight loss. Hence, bariatric surgery effectively improves GERD for many patients. Depending on the type of bariatric procedure, however, surgery can also worsen or even cause a new onset of GERD. As a consequence, GERD remains a relevant problem for many bariatric patients, and especially those who have undergone sleeve gastrectomy (SG). Affected patients report not only a decrease in physical functioning but also suffer from mental and emotional problems, resulting in poorer social functioning. The pathomechanism of GERD after SG is most likely multifactorial and triggered by the interaction of anatomical, physiological, and physical factors. Contributing factors include the shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia. In order to successfully treat post-sleeve gastrectomy GERD, the cause of the problem must first be identified. Therapeutic approaches include lifestyle changes, medication, interventional treatment, and/or revisional surgery.
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Affiliation(s)
- Eleni Felinska
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Adrian Billeter
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pietro Contin
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Bipan Chand
- Department of Surgery, Loyola University, Chicago, Illinois
| | - Peter Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Dean Mikami
- Department of Surgery, John A. Burton School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Sebastian F Schoppmann
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Beat Müller-Stich
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
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19
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Savarino E, Frazzoni M, Marabotto E, Zentilin P, Iovino P, Costantini M, Tolone S, Battaglia E, Cicala M, Usai-Satta P, de Bortoli N, Penagini R, Savarino V. A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring. Dig Liver Dis 2020; 52:966-980. [PMID: 32513632 DOI: 10.1016/j.dld.2020.04.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.
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Affiliation(s)
- Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Paola Iovino
- Gastroenterology Unit, University of Salerno, Salerno, Italy
| | - Mario Costantini
- Clinica Chirurgica III, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaja Hospital, Asti, Italy
| | - Michele Cicala
- Unit of Digestive Diseases, Campus Bio Medico University, Rome, Italy
| | | | - Nicola de Bortoli
- Gastrointestinal Unit-Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56124 Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit - Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico - University of Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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20
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Banting SP, Badgery HE, Read M, Mashimo H. Rethinking gastroesophageal reflux disorder. Ann N Y Acad Sci 2020; 1482:177-192. [PMID: 32875572 DOI: 10.1111/nyas.14478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/28/2020] [Accepted: 08/06/2020] [Indexed: 12/17/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common clinical condition for which our understanding has evolved over the past decades. It is now considered a cluster of phenotypes with numerous anatomical and physiological abnormalities contributing to its pathophysiology. As such, it is important to first understand the underlying mechanism of the disease process for each patient before embarking on therapeutic interventions. The aim of our paper is to highlight the mechanisms contributing to GERD and review investigations and interpretation of these results. Finally, the paper reviews the available treatment modalities for this condition, ranging from medical intervention, endoscopic options through to surgery and its various techniques.
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Affiliation(s)
- Samuel P Banting
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Henry E Badgery
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Matthew Read
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, the University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Hiroshi Mashimo
- Department of Medicine, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
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21
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Rogers BD, Gyawali CP. Enhancing High-Resolution Esophageal Manometry: Use of Ancillary Techniques and Maneuvers. Gastroenterol Clin North Am 2020; 49:411-426. [PMID: 32718561 DOI: 10.1016/j.gtc.2020.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
High-resolution manometry evaluates esophageal motor function using 10 supine water swallows. Superimposing impedance over high-resolution manometry pressure topography assesses the relationship between contraction and bolus propulsion and identifies inadequate clearance. Ancillary techniques and maneuvers augment the standard supine high-resolution manometry evaluation by challenging peristaltic function. Increasing bolus volume (rapid drink challenge) and altering bolus consistency (standardized test meal, solid swallows) enhance identification of esophageal outflow obstruction syndromes. Physiologic maneuvers (multiple rapid swallows, abdominal compression) address the ability of the esophageal smooth muscle to augment contraction vigor. Pharmacologic challenge is less commonly used clinically, and elucidates pathophysiology of esophageal motor disorders.
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Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO 63110, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO 63110, USA.
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22
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Lottrup C, Khan A, Rangan V, Clarke JO. Esophageal physiology-an overview of esophageal disorders from a pathophysiological point of view. Ann N Y Acad Sci 2020; 1481:182-197. [PMID: 32648992 DOI: 10.1111/nyas.14417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 11/30/2022]
Abstract
The esophagus serves the principal purpose of transporting food from the pharynx into the stomach. A complex interplay between nerves and muscle fibers ensures that swallowing takes place as a finely coordinated event. Esophageal function can be tested by a variety of methods, endoscopy, manometry, and reflux monitoring being some of the most important. Regarding pathophysiology, motor disorders, such as achalasia, often cause dysphagia and/or chest pain. Functional esophageal disorders are a heterogeneous group with hypersensitivity as a dominant pathophysiological factor. Gastroesophageal reflux disease often causes symptoms, such as heartburn and regurgitation, and a spectrum of disease, ranging from minimal mucosal damage visible only in the microscope to esophageal ulcers and strictures in the most severe cases. Eosinophilic esophagitis is an immune-mediated condition that can result in significant dysphagia and associated luminal narrowing. In the following, we will provide an overview of the most common esophageal disorders from a combined pathophysiological and clinical view.
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Affiliation(s)
- Christian Lottrup
- Department of Medicine, Aalborg University Hospital, Hobro, Denmark.,Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Abraham Khan
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Vikram Rangan
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John O Clarke
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California
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23
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Rogers B, Hasak S, Hansalia V, Gyawali CP. Trans-esophagogastric junction pressure gradients during straight leg raise maneuver on high-resolution manometry associate with large hiatus hernias. Neurogastroenterol Motil 2020; 32:e13836. [PMID: 32163648 DOI: 10.1111/nmo.13836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/17/2020] [Accepted: 02/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Straight leg raise (SLR) while supine increases intra-abdominal pressure. We hypothesized that elevations in intra-abdominal pressure would transmit into the thoracic cavity if the esophagogastric junction (EGJ) was disrupted. METHODS Consecutive patients undergoing esophageal HRM were included if they had adequate SLR (hip flexion with knees extended for ≥ 5 seconds while supine). EGJ morphology was subtyped based on lower esophageal sphincter (LES) and crural diaphragm (CD) location (type 1: LES and CD overlap; type 2: separation of < 3 cm; type 3: separation of ≥ 3 cm). EGJ tone was assessed using EGJ contractile integral (EGJ-CI). HRM studies were analyzed according to Chicago Classification v3.0. Mean and peak intra-thoracic and abdominal pressures were measured at baseline and during SLR using on-screen software tools. Trans-EGJ gradients were compared, and pressure gradient < 1 mmHg denoted the equalization of pressures. KEY RESULTS Of 430 patients, 248 (57.5 ± 0.9 years, 69.4% F) completed SLR. EGJ morphology was type 1 in 122 (49.2%), type 2 in 56 (22.6%) and type 3 in 40 (16.1%). In types 1 and 2 EGJ, neither the mean nor peak trans-EGJ pressure gradient changed with SLR (P ≥ .17 for each). In contrast, in type 3 EGJ, peak pressure gradient decreased significantly following SLR (3.5 ± 1.8 mmHg vs. -8.6 ± 4.8 mmHg, P = .01). More type 3 EGJ patients equalized peak (65%) pressures across EGJ compared with types 1 and 2 (27%, P < .001). CONCLUSIONS AND INFERENCES The evaluation of intra-abdominal and intra-thoracic pressures with SLR during esophageal HRM can provide evidence of physiological disruption of the EGJ barrier.
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Affiliation(s)
- Benjamin Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Stephen Hasak
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Vivek Hansalia
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
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24
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Ghisa M, Barberio B, Savarino V, Marabotto E, Ribolsi M, Bodini G, Zingone F, Frazzoni M, Savarino E. The Lyon Consensus: Does It Differ From the Previous Ones? J Neurogastroenterol Motil 2020; 26:311-321. [PMID: 32606254 PMCID: PMC7329153 DOI: 10.5056/jnm20046] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is a complex disorder with heterogeneous symptoms and a multifaceted pathogenetic basis, which prevent a simple diagnostic algorithm or any categorical classification. Clinical history, questionnaires and response to proton pump inhibitor (PPI) therapy are insufficient tools to make a conclusive diagnosis of GERD and further investigations are frequently required. The Lyon Consensus goes beyond the previous classifications and defines endoscopic and functional parameters able to establish the presence of GERD. Evidences for reflux include high-grade erosive esophagitis, Barrett’s esophagus, and peptic strictures at endoscopy as well as esophageal acid exposure time > 6% on pH-metry or combined pH-impedance monitoring. Even if a normal endoscopy does not exclude GERD, its combination with distal acid exposure time < 4% on off-PPI pH-impedance monitoring provides sufficient evidence refuting this diagnosis. Reflux-symptom association on pH-monitoring provides supportive evidence for reflux-triggered symptoms and may predict a better treatment outcome, when present. Also recommendations to perform pH-impedance “on” or “off” PPI are well depicted. When endoscopy and pH-metry or combined pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (eg, microscopic esophagitis), high-resolution manometry (ie, ineffective esophagogastric barrier and esophageal body hypomotility), and novel impedance metrics, such as mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index, can contribute to better identify patients with GERD. Definition of individual patient phenotype, based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the esophagogastric junction, and clinical presentation, will lead to manage GERD patients with a tailored approach chosen among different types of therapy.
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Affiliation(s)
- Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology, Campus Bio-Medico University, Rome, Italy
| | - Giorgia Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Ang D, Lee Y, Clarke JO, Lynch K, Guillaume A, Onyimba F, Kamal A, Gyawali CP. Diagnosis of gastroesophageal reflux: an update on current and emerging modalities. Ann N Y Acad Sci 2020; 1481:154-169. [DOI: 10.1111/nyas.14369] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Daphne Ang
- Department of Gastroenterology Changi General Hospital Singapore Singapore
| | - Yeong‐Yeh Lee
- Department of Gastroenterology, Hepatology and Internal Medicine, School of Medical Sciences Universiti Sains Malaysia Kota Bharu Malaysia
- Gut Research Group, Faculty of Medicine National University of Malaysia Kuala Lumpur Malaysia
- St George and Sutherland Clinical School University of New South Wales Sydney New South Wales Australia
| | - John O. Clarke
- Division of Gastroenterology and Hepatology Stanford University Stanford California
| | - Kristle Lynch
- Division of Gastroenterology, Department of Medicine Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania
| | - Alexandra Guillaume
- Division of Gastroenterology and Hepatology, Stony Brook Medicine Stony Brook University Hospital Stony Brook New York
| | - Frances Onyimba
- Division of Gastroenterology and Hepatology University of Maryland School of Medicine Baltimore Maryland
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology Stanford University Stanford California
| | - C. Prakash Gyawali
- Division of Gastroenterology Washington University School of Medicine St. Louis Missouri
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26
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Zachariah RA, Goo T, Lee RH. Mechanism and Pathophysiology of Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:209-226. [PMID: 32146942 DOI: 10.1016/j.giec.2019.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroesophageal reflux (GER) describes a process in which gastric contents travel retrograde into the esophagus. GER can be either a physiologic phenomenon that occurs in asymptomatic individuals or can potentially cause symptoms. When the latter occurs, this represents GER disease (GERD). The process by which GER transforms into GERD begins at the esophagogastric junction. Impaired clearance of the refluxate also contributes to GERD. Reflux causes degradation of esophageal mucosal defense. The refluxate triggers sensory afferents leading to symptom generation.
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Affiliation(s)
- Robin A Zachariah
- H.H. Chao Comprehensive Digestive Disease Center, 333 City Boulevard West, Suite 400, Room 459, Orange, CA 92868, USA
| | - Tyralee Goo
- Tibor Rubin Veterans' Affairs Medical Center, 5901 E. Seventh Street, Long Beach, CA 90822, USA
| | - Robert H Lee
- H.H. Chao Comprehensive Digestive Disease Center, 333 City Boulevard West, Suite 400, Room 459, Orange, CA 92868, USA; Tibor Rubin Veterans' Affairs Medical Center, 5901 E. Seventh Street, Long Beach, CA 90822, USA.
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27
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Yadlapati R, Pandolfino JE. Personalized Approach in the Work-up and Management of Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:227-238. [PMID: 32146943 PMCID: PMC7083512 DOI: 10.1016/j.giec.2019.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with gastroesophageal reflux disease (GERD) present with heterogeneous symptoms, response to treatment, and physiologic profiles, requiring distinct and personalized management. This article provides a stepwise framework to phenotype GERD beginning with (1) characterization of symptom profile and response to acid suppression; (2) endoscopic evaluation of mucosal and anatomic integrity; (3) ambulatory reflux monitoring to characterize reflux burden and sensitivity; and (4) esophageal physiologic testing to assess gastroesophageal reflux mechanism and effectors of reflux clearance, and evaluate for alternate causes.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, 9500 Gilman Drive MC 0956, La Jolla, CA 92093, USA.
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Chicago, IL 60611, USA
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28
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Impact of Gastroesophageal Reflux Disease on Mucosal Immunity and Atopic Disorders. Clin Rev Allergy Immunol 2020; 57:213-225. [PMID: 30206783 DOI: 10.1007/s12016-018-8701-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Atopic disorders and gastroesophageal reflux disease (GERD) are some of the most common medical conditions treated by primary care physicians and specialists alike. The observation that atopic disorders, like asthma, allergic rhinitis and sinusitis, food allergies, atopic dermatitis, contact dermatitis, and eosinophilic esophagitis are common comorbidities in patients with GERD raises the question of the nature of the relationship that may exist between GERD and atopic disorders. In this article, we review the pathophysiology of GERD, its effect on the immune system, the effect of acid-blocking medications on allergic responses, as well as several common atopic conditions that have been associated with GERD including asthma, chronic rhinosinusitis (CRS), allergic rhinitis (AR), atopic dermatitis (AD), contact dermatitis (CD), food allergies, proton pump inhibitor (PPI)-responsive esophageal eosinophilia (PPI-REE), and eosinophilic esophagitis (EoE). In each condition, the evidence of a causal link is not definitive. Although the relationship between asthma and GERD remains controversial, evidence suggests that a subset of asthma patients with documented GERD may experience improved asthma control following appropriate treatment of GERD. The relationship of GERD to allergic rhinitis and chronic sinusitis is weak; however, studies support the concept that treatment of frequent episodes of GERD can have a positive effect on rhinitis and sinusitis overall. The relationship between allergic sensitization and GERD is likely bidirectional. GERD may induce changes in the mucosal immune system that may favor the development of food allergy and allergic sensitization to aeroallergens; however, the underlying mechanisms have not been established.
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Geysen H, Gielis E, Deloose E, Vanuytsel T, Tack J, Biesiekierski JR, Pauwels A. Acute administration of fructans increases the number of transient lower esophageal sphincter relaxations in healthy volunteers. Neurogastroenterol Motil 2020; 32:e13727. [PMID: 31633262 DOI: 10.1111/nmo.13727] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/22/2019] [Accepted: 09/04/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Dietary measures are often advised to patients with gastro-esophageal reflux disease (GERD). Fermentable Oligo-, Di-, Mono-saccharides and Polyols (FODMAPs) induce lower gastrointestinal (GI) symptoms. However, their effects on esophageal motility, including transient lower esophageal sphincter relaxations (TLESRs), reflux events and GERD symptoms are unknown. We investigated the effect of acute administration of two FODMAPs, fructose, and fructans, on the number of TLESRs, reflux episodes and symptom perception in healthy volunteers (HVs). MATERIALS After an overnight fast, 20 HVs (10 males; 32.6 ± 2.8 years) underwent a high-resolution impedance manometry. The number of TLESRs and reflux episodes was quantified during five hours after consumption of a high-caloric meal (740 kcal) enriched with 40 g of either fructose, fructans or glucose (as placebo). Results were analyzed using mixed models. RESULTS There was a trend for a change in the number of TLESRs between the three conditions (P = .06). Post hoc analysis revealed a trend toward a higher number of TLESRs in the fructan condition compared with placebo (Pcorr = .06). Acute administration of fructose did not influence the number of TLESRs. The total number of reflux events was not affected by either FODMAP condition. Lower esophageal sphincter (LES) pressures dropped significantly in the first postprandial hour to recover slowly back to baseline values (P < .0001), without any difference in LES pressure between the three conditions. CONCLUSION Ingestion of fructans increased the number of TLESRs slightly compared with placebo. The effect of FODMAPs such as fructans or a low FODMAP diet on reflux parameters in GERD patients remains to be investigated.
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Affiliation(s)
- Hannelore Geysen
- Translational Research Center for Gastrointestinal Disease, KU Leuven, Leuven, Belgium
| | - Eva Gielis
- Translational Research Center for Gastrointestinal Disease, KU Leuven, Leuven, Belgium
| | - Eveline Deloose
- Translational Research Center for Gastrointestinal Disease, KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disease, KU Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disease, KU Leuven, Leuven, Belgium
| | - Jessica R Biesiekierski
- Translational Research Center for Gastrointestinal Disease, KU Leuven, Leuven, Belgium.,Department of Dietetics, Nutrition & Sport, La Trobe University, Melbourne, Vic., Australia
| | - Ans Pauwels
- Translational Research Center for Gastrointestinal Disease, KU Leuven, Leuven, Belgium
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30
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Lin S, Li H, Fang X. Esophageal Motor Dysfunctions in Gastroesophageal Reflux Disease and Therapeutic Perspectives. J Neurogastroenterol Motil 2019; 25:499-507. [PMID: 31587540 PMCID: PMC6786454 DOI: 10.5056/jnm19081] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/20/2019] [Indexed: 01/01/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a very common disease, and the prevalence in the general population has recently increased. GERD is a chronic relapsing disease associated with motility disorders of the upper gastrointestinal tract. Several factors are implicated in GERD, including hypotensive lower esophageal sphincter, frequent transient lower esophageal sphincter relaxation, esophageal hypersensitivity, reduced resistance of the esophageal mucosa against the refluxed contents, ineffective esophageal motility, abnormal bolus transport, deficits initiating secondary peristalsis, abnormal response to multiple rapid swallowing, and hiatal hernia. One or more of these mechanisms result in the reflux of stomach contents into the esophagus, delayed clearance of the refluxate, and the development of symptoms and/or complications. New techniques, such as 24-hour pH and multichannel intraluminal impedance monitoring, multichannel intraluminal impedance and esophageal manometry, high-resolution manometry, 3-dimensional high-resolution manometry, enoscopic functional luminal imaging probe, and 24-hour dynamic esophageal manometry, provide more information on esophageal motility and have clarified the pathophysiology of GERD. Proton pump inhibitors remain the preferred pharmaceutical option to treat GERD. The ideal target of GERD treatment is to restore esophageal motility and reconstruct the anti-reflux mechanism. This review focuses on current advances in esophageal motor dysfunction in patients with GERD and the influence of these developments on GERD treatment.
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Affiliation(s)
- Sihui Lin
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical Colleg e, Beijing, China.,Department of Gastroenterology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian Province, China
| | - Hua Li
- Department of Gastroenterology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian Province, China
| | - Xiucai Fang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical Colleg e, Beijing, China
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Ghisa M, Marinelli C, Savarino V, Savarino E. Idiopathic pulmonary fibrosis and GERD: links and risks. Ther Clin Risk Manag 2019; 15:1081-1093. [PMID: 31564886 PMCID: PMC6733342 DOI: 10.2147/tcrm.s184291] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/11/2019] [Indexed: 01/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) and idiopathic pulmonary fibrosis (IPF) are two pathological conditions often strictly related, even if a clear relationship of causality has not been demonstrated. GERD is a frequent comorbidity in IPF patients, as demonstrated using combined multichannel intraluminal impedance-pH, despite being mostly clinically silent. According to that, it has been hypothesized that microaspiration of gastric material may play a fundamental role in the fibrotic transformation of pulmonary parenchyma. In contrast, it cannot be excluded that IPF may favor GERD by increasing the negative intrathoracic pressure. Therefore, this relationship is uncertain as well as not univocal. Nevertheless, the latest international guidelines recommend the use of proton pump inhibitors (PPIs) in IPF based on several data showing that PPIs can stabilize lung function, reduce disease flares and hospitalizations. On the contrary, recent studies not only question the relevance of these results, but also associate the use of PPIs with an increased risk of lung infections and a negative prognostic outcome. The aim of this review is to analyze the possible links between GERD and IPF and their possible therapeutic implications, trying to translate this scientific evidence into useful information for clinical practice.
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Affiliation(s)
- Matteo Ghisa
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Carla Marinelli
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Ghisa M, Della Coletta M, Barbuscio I, Marabotto E, Barberio B, Frazzoni M, De Bortoli N, Zentilin P, Tolone S, Ottonello A, Lorenzon G, Savarino V, Savarino E. Updates in the field of non-esophageal gastroesophageal reflux disorder. Expert Rev Gastroenterol Hepatol 2019; 13:827-838. [PMID: 31322443 DOI: 10.1080/17474124.2019.1645593] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.
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Affiliation(s)
- Matteo Ghisa
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Marco Della Coletta
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Ilenia Barbuscio
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Brigida Barberio
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | | | - Nicola De Bortoli
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa , Pisa , Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Salvatore Tolone
- Surgery Unit, Department of Surgery, University of Campania Luigi Vanvitelli , Caserta , Italy
| | - Andrea Ottonello
- Department of Surgical Science and Integrated Diagnostics, University of Genoa , Genoa , Italy
| | - Greta Lorenzon
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
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Manolakis AC, Broers C, Geysen H, Goelen N, Van Houtte B, Rommel N, Vanuytsel T, Tack J, Pauwels A. Effect of citalopram on esophageal motility in healthy subjects-Implications for reflux episodes, dysphagia, and globus. Neurogastroenterol Motil 2019; 31:e13632. [PMID: 31121087 DOI: 10.1111/nmo.13632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Drugs such as citalopram, "targeting" the serotonin pathway, can alter esophageal mechano-chemical sensitivity and gastrointestinal motility. The aim of this study was to clarify the effect of citalopram on esophageal motility and sphincter function, transient lower esophageal sphincter relaxations (TLESRs), and reflux events. METHODS Sixteen healthy volunteers (HV) receiving 20 mg citalopram or placebo intravenously, in a randomized cross-over fashion, underwent two high-resolution impedance manometry studies involving liquid swallows and a high-fat, high-caloric meal. Manometric, reflux, and symptom-related parameters were studied. KEY RESULTS A lower distal contractile integral was recorded under citalopram, compared with placebo (P = 0.026). Upper esophageal sphincter (UES) resting pressure was significantly higher after citalopram administration throughout the study (P < 0.05, all periods). Similarly, the UES postswallow mean and maximum pressures were higher in the citalopram condition (P < 0.0001, in both cases) and this was also the case for the 0.2 s integrated relaxation pressure (P = 0.04). Esophagogastric junction resting pressures in the citalopram visit were significantly higher during swallow protocol, preprandial period, and the first postprandial hour (P < 0.05, in all cases). TLESRs and total reflux events were both reduced after citalopram infusion (P = 0.01, in both cases). During treatment with citalopram, five participants complained about globus sensation (P = 0.06). This citalopram-induced globus was associated with higher UES postswallow mean and maximum pressure values (P = 0.01 and P = 0.04, respectively). CONCLUSIONS AND INFERENCES Administration of citalopram exerts a diversified response on esophageal motility and sphincter function, linked to clinically relevant phenomena: a reduction in postprandial TLESRs and the induction of drug-induced globus.
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Affiliation(s)
- Anastassios C Manolakis
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium.,Department of Gastroenterology, University Hospital of Larissa, Larissa, Greece
| | - Charlotte Broers
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Hannelore Geysen
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Nick Goelen
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Brecht Van Houtte
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Nathalie Rommel
- Experimental Oto-Rhino-Laryngology, Department of Neurosciences, Deglutology, KU Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Ans Pauwels
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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The relationship between gastroesophageal junction integrity and symptomatic fundoplication outcomes. Surg Endosc 2019; 34:1387-1392. [DOI: 10.1007/s00464-019-06921-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/12/2019] [Indexed: 12/14/2022]
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35
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Savarino E, Marabotto E, Bodini G, Furnari M, Della Coletta M, Ghisa M, Barberio B, Frazzoni M, De Bortoli N, Zentilin P, Pellegatta G, Tolone S, Ottonello A, Savarino V. Advancements in the use of manometry and impedance testing for esophageal functional disorders. Expert Rev Gastroenterol Hepatol 2019; 13:425-435. [PMID: 30896306 DOI: 10.1080/17474124.2019.1595587] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The utilization of high-resolution manometry (HRM) has enhanced our understanding and assessment of esophageal motor disorders. Moreover, the combination of impedance technology with HRM (HRIM) has further improved our knowledge of esophageal physiology and the clinical evaluation of dysmotility, thanks to the addition of accurate measurement of bolus transit. Areas covered. This paper provides an overview of current knowledge in the use of HRIM for the study of esophageal functional disorders by reporting mainly the results of many publications and several systematic reviews in this field. Expert opinion. HRIM has represented a relevant improvement in the assessment of esophageal motility and has required the development of new metrics, such as the esophageal impedance integral ratio, the bolus flow time, the nadir impedance pressure and the impedance bolus height, which increase the evaluation of esophageal bolus transit. An extension of impedance is represented by functional lumen imaging probe (FLIP), which determines the biophysical properties and the distensibility of the esophagus and permits to detect contractility patterns not seen on HRM alone. We eagerly wait for a new and fruitful iteration of the Chicago Classification, now in version 3.0, which can cover the ongoing clinical experience of HRIM.
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Affiliation(s)
- Edoardo Savarino
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Elisa Marabotto
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Giorgia Bodini
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Manuele Furnari
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Marco Della Coletta
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Matteo Ghisa
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Brigida Barberio
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Marzio Frazzoni
- c Digestiva Pathophysiology Unit , Baggiovara Hospital , Modena , Italy
| | - Nicola De Bortoli
- d Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery , University of Pisa , Pisa , Italy
| | - Patrizia Zentilin
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Gaia Pellegatta
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Salvatore Tolone
- e Surgery Unit, Department of Surgery , University of Campania Luigi Vanvitelli , Caserta , Italy
| | - Andrea Ottonello
- f Department of Surgical Science and Integrated Diagnostics , University of Genoa , Genoa , Italy
| | - Vincenzo Savarino
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
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He S, Jell A, Hüser N, Kohn N, Feussner H. 24-hour monitoring of transient lower esophageal sphincter relaxation events by long-term high-resolution impedance manometry in normal volunteers: The "mirror phenomenon". Neurogastroenterol Motil 2019; 31:e13530. [PMID: 30676686 DOI: 10.1111/nmo.13530] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/30/2018] [Accepted: 11/27/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The aim of this study was to investigate the frequency and circadian changes in transient lower esophageal sphincter relaxations (TLESRs) in normal volunteers using 24-hour high-resolution impedance manometry (HRIM). METHODS Fifteen volunteers underwent HRIM. TLESRs were recorded during the mealtime, 2-hour postprandial, daytime, and supine periods. The catheter was firmly secured to the nose, and subjects went home, ate normal meals, and continued routine daily activities. KEY RESULTS Successful recordings were obtained in 11 volunteers. Overall, 1083 TLESRs were documented; the average occurrence was 4.2/h, and the duration was 21.0 ± 5.2 seconds. The majority of the TLESRs occurred during the 2-hour postprandial (42.7%) and daytime (31.5%) periods, while 10.2% and 15.6% occurred during the mealtime and supine periods, respectively. Eight hundred and eighty-six (81.8%) TLESRs were associated with reflux. Overall, 25.5% of TLESRs were preceded by partial secondary peristalsis (PSP), while 74.5% were preceded by nothing. Terminating events included primary peristalsis (PP; 40.3%), PSP (42.8%), full secondary peristalsis (FSP; 8.2%), or nothing (8.7%). Both preceding and terminating events periodically changed throughout the four periods. One hundred and twelve (10.3%) TLESRs with both preceding and terminating events of PSP, presenting as a "mirror phenomenon," were documented. The majority of these TLESRs occurred during the supine (70.5%). CONCLUSIONS & INFERENCES Transient lower esophageal sphincter relaxations are common physiological motor events in normal volunteers; these events have certain circadian rhythms, as do the events that precede and terminate TLESR events. A special "mirror phenomenon" is observed when both the preceding and terminating events are PSP.
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Affiliation(s)
- Suyu He
- The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, China
| | - Alissa Jell
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Norbert Hüser
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nils Kohn
- Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hubertus Feussner
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Yadlapati R, Furuta GT, Menard-Katcher P. New Developments in Esophageal Motility Testing. ACTA ACUST UNITED AC 2019; 17:76-88. [DOI: 10.1007/s11938-019-00218-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) is defined by the presence of troublesome GERD symptoms despite PPI optimization for at least 8 weeks in the setting of ongoing documented pathologic gastroesophageal reflux. It arises from a dysfunction in protective systems to prevent reflux and as propagation of physiologic reflux events. Treatment possibilities include pharmacologic options, invasive management strategies, and endoluminal therapies. Management strategy should be personalized to the patient's needs and mechanistic dysfunction. This article reviews the definition, mechanisms, and management options for PPI-refractory GERD.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue B158, Aurora, CO 80045, USA.
| | - Kelli DeLay
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue B158, Aurora, CO 80045, USA
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Bardou M, Fortinsky KJ, Chapelle N, Luu M, Barkun A. An update on the latest chemical therapies for reflux esophagitis in children. Expert Opin Pharmacother 2018; 20:231-239. [DOI: 10.1080/14656566.2018.1549224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Marc Bardou
- Centre d’Investigations Cliniques CIC1432, CHU de Dijon, Dijon Cedex, France
- Gastroenterology Department, CHU de Dijon, Dijon Cedex, France
| | - Kyle J. Fortinsky
- Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Maxime Luu
- Centre d’Investigations Cliniques CIC1432, CHU de Dijon, Dijon Cedex, France
| | - Alan Barkun
- Gastroenterology department, McGill University Health Centre, Montréal, Québec, Canada
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40
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Clinical measurement of gastrointestinal motility and function: who, when and which test? Nat Rev Gastroenterol Hepatol 2018; 15:568-579. [PMID: 29872118 DOI: 10.1038/s41575-018-0030-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Symptoms related to abnormal gastrointestinal motility and function are common. Oropharyngeal and oesophageal dysphagia, heartburn, bloating, abdominal pain and alterations in bowel habits are among the most frequent reasons for seeking medical attention from internists or general practitioners and are also common reasons for referral to gastroenterologists and colorectal surgeons. However, the nonspecific nature of gastrointestinal symptoms, the absence of a definitive diagnosis on routine investigations (such as endoscopy, radiology or blood tests) and the lack of specific treatments make disease management challenging. Advances in technology have driven progress in the understanding of many of these conditions. This Review serves as an introduction to a series of Consensus Statements on the clinical measurements of gastrointestinal motility, function and sensitivity. A structured, evidence-based approach to the initial assessment and empirical treatment of patients presenting with gastrointestinal symptoms is discussed, followed by an outline of the contribution of modern physiological measurement on the management of patients in whom the cause of symptoms has not been identified with other tests. Discussions include the indications for and utility of high-resolution manometry, ambulatory pH-impedance monitoring, gastric emptying studies, breath tests and investigations of anorectal structure and function in day-to-day practice and clinical management.
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41
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Biasutto D, Roman S, Garros A, Mion F. Esophageal shortening after rapid drink test during esophageal high-resolution manometry: A relevant finding? United European Gastroenterol J 2018; 6:1323-1330. [PMID: 30386605 DOI: 10.1177/2050640618796752] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/30/2018] [Indexed: 12/20/2022] Open
Abstract
Background Esophageal shortening (ES) might be observed during high-resolution manometry (HRM), in particular after the rapid drink test (RDT). We aimed to assess its diagnostic value in patients referred for HRM. Methods HRM of patients without previous esophagogastric surgery or endoscopic treatment was retrospectively reviewed using the Chicago Classification v3.0. ES and pan-esophageal pressurization were analyzed during the RDT (200-ml free drinking in a sitting position). Results A total of 2141 cases (1291 females, mean age 54 years) were reviewed. During the RDT, ES occurred in 4% and pan-esophageal pressurization in 14% of patients. ES was almost exclusively encountered in patients with impaired esophagogastric junction relaxation or major disorders of peristalsis. Among 31 patients with ES and no definite diagnosis of achalasia, 19 had follow-up and 13 (68%) changed diagnostic category: two adenocarcinoma of the cardia, and 11 cases of atypical achalasia. The positive predictive value of ES for a significant esophageal disorder was 95%. Conclusion ES is rarely observed during the RDT. When present, it is associated with major motility disorders, especially achalasia. When the diagnostic criteria for achalasia are not fulfilled, further complementary examinations should be performed to rule out incomplete forms of achalasia or an infiltrative process of the cardia.
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Affiliation(s)
| | - Sabine Roman
- Digestive Physiology, Université de Lyon, France.,Digestive Physiology, Hôpital E Herriot, Hospices Civils de Lyon, France.,Inserm U1032, LabTAU, Université de Lyon, France
| | - Aurelien Garros
- Digestive Physiology, Hôpital E Herriot, Hospices Civils de Lyon, France
| | - Francois Mion
- Digestive Physiology, Université de Lyon, France.,Digestive Physiology, Hôpital E Herriot, Hospices Civils de Lyon, France.,Inserm U1032, LabTAU, Université de Lyon, France
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DEL GRANDE LM, HERBELLA FAM, KATAYAMA RC, SCHLOTTMANN F, PATTI MG. THE ROLE OF THE TRANSDIAPHRAGMATIC PRESSURE GRADIENT IN THE PATHOPHYSIOLOGY OF GASTROESOPHAGEAL REFLUX DISEASE. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55Suppl 1:13-17. [DOI: 10.1590/s0004-2803.201800000-39] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
Abstract
ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.
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43
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Herbella FAM, Schlottmann F, Patti MG. Pathophysiology of gastroesophageal reflux disease: how an antireflux procedure works (or does not work). Updates Surg 2018; 70:343-347. [DOI: 10.1007/s13304-018-0562-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/04/2018] [Indexed: 12/31/2022]
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44
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Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout AJPM, Vaezi M, Sifrim D, Fox MR, Vela MF, Tutuian R, Tack J, Bredenoord AJ, Pandolfino J, Roman S. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018; 67:1351-1362. [PMID: 29437910 PMCID: PMC6031267 DOI: 10.1136/gutjnl-2017-314722] [Citation(s) in RCA: 780] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/11/2018] [Accepted: 01/14/2018] [Indexed: 12/12/2022]
Abstract
Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Peter J Kahrilas
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Francois Mion
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark R Fox
- Gastroenterology, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland,Zürich Neurogastroenterology and Motility Research Group, Clinic for Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Radu Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Jan Tack
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - John Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
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45
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Keller J. What Is the Impact of High-Resolution Manometry in the Functional Diagnostic Workup of Gastroesophageal Reflux Disease? Visc Med 2018; 34:101-108. [PMID: 29888238 DOI: 10.1159/000486883] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
International guidelines agree that high-resolution esophageal manometry (HRM) is an integral part of the diagnostic evaluation of patients with refractory reflux symptoms and should be performed before antireflux surgery. Its most important goal is to explore differential diagnoses, in particular major esophageal motility disturbances, that may be responsible for symptoms. HRM additionally provides insights into all relevant pathomechanisms of gastroesophageal reflux disease (GERD): It can reveal important information on the morphology and function of the esophagogastric junction (EGJ), the presence of a hiatus hernia, transient lower esophageal sphincter relaxations, and dysmotility of the esophageal body. To obtain this information, a 3-step hierarchical system has been proposed for the algorithmic characterization of esophageal motor function. The first step is to investigate the morphology and contractility of the EGJ, the second to monitor esophageal body motor patterns in response to water swallows, and the third to determine the contraction reserve in patients with abnormal esophageal motor function using provocation tests. Observations made with HRM can not only explain the cause of symptoms in GERD patients but may also have the potential to direct specific treatment.
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Affiliation(s)
- Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
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46
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Zhao J, McMahon B, Fox M, Gregersen H. The esophagiome: integrated anatomical, mechanical, and physiological analysis of the esophago-gastric segment. Ann N Y Acad Sci 2018; 1434:5-20. [DOI: 10.1111/nyas.13869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/27/2018] [Accepted: 05/04/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Jingbo Zhao
- GIOME Academy, Department of Clinical Medicine; Aarhus University; Aarhus Denmark
| | - Barry McMahon
- Trinity Academic Gastroenterology Group; Tallaght Hospital and Trinity College; Dublin Ireland
| | - Mark Fox
- Abdominal Center: Gastroenterology; St. Claraspital Basel Switzerland
- Neurogastroenterology and Motility Research Group; University Hospital Zürich; Zürich Switzerland
| | - Hans Gregersen
- GIOME, Department of Surgery; Prince of Wales Hospital and Chinese University of Hong Kong; Shatin Hong Kong SAR
- California Medical Innovations Institute; San Diego California
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Biasutto D, Mion F, Garros A, Roman S. Rapid drink challenge test during esophageal high resolution manometry in patients with esophago-gastric junction outflow obstruction. Neurogastroenterol Motil 2018; 30:e13293. [PMID: 29356303 DOI: 10.1111/nmo.13293] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/21/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophago-gastric junction (EGJ) outflow obstruction is of unclear significance. Rapid drink challenge (RDC) test is easy to perform during esophageal high resolution manometry. We aimed to assess the yield of RDC test in patients with EGJ outflow obstruction. METHODS Manometry studies of patients with EGJ outflow obstruction according to the Chicago Classification v3.0 were retrospectively reviewed. Pan-esophageal pressurization (PEP), esophageal shortening, and pressure gradient across the EGJ were analyzed during RDC test (200-mL free drinking in sitting position) and compared according to the causes of EGJ outflow obstruction determined by charts review. KEY RESULTS Seventy-five patients (29 males, mean age 62 years) were included. Causes of EGJ outflow obstruction were previous esophago-gastric surgery (40%), incomplete form of achalasia (7%), mediastinal neoplasia (7%), other associated conditions (21%), and undetermined (25%). Rapid drink challenge test was successfully performed in 70 patients and associated with PEP and shortening in 41% and 13%, respectively. The causes of EGJ outflow obstruction were similarly distributed in patients with and without PEP during RDC test. Esophageal shortening tended to be more likely in patients with definitive findings of obstruction (achalasia, previous surgery, neoplasia) than in the others. Dysphagia was more severe in patients with PEP and/or shortening during RDC test compared to those without. CONCLUSIONS & INFERENCES Pan-esophageal pressurization and esophageal shortening were associated with symptoms severity but did not predict the cause of this disorder. Further prospective studies are necessary to determine if RDC test could help to select patients who might benefit from treatment.
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Affiliation(s)
- D Biasutto
- Hopital E Herriot, Digestive Physiology, Hospices Civils de Lyon, Université de Lyon, Lyon, France.,Digestive Physiology, Lyon I University, Université de Lyon, Lyon, France
| | - F Mion
- Hopital E Herriot, Digestive Physiology, Hospices Civils de Lyon, Université de Lyon, Lyon, France.,Digestive Physiology, Lyon I University, Université de Lyon, Lyon, France.,LabTAU, Inserm U1032, Université de Lyon, Lyon, France
| | - A Garros
- Hopital E Herriot, Digestive Physiology, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - S Roman
- Hopital E Herriot, Digestive Physiology, Hospices Civils de Lyon, Université de Lyon, Lyon, France.,Digestive Physiology, Lyon I University, Université de Lyon, Lyon, France.,LabTAU, Inserm U1032, Université de Lyon, Lyon, France
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48
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Rengarajan A, Bolkhir A, Gor P, Wang D, Munigala S, Gyawali CP. Esophagogastric junction and esophageal body contraction metrics on high-resolution manometry predict esophageal acid burden. Neurogastroenterol Motil 2018; 30:e13267. [PMID: 29266647 DOI: 10.1111/nmo.13267] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/27/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Distal contractile integral (DCI) and esophagogastric junction contractile integral (EGJ-CI) are high-resolution manometry (HRM) software metrics assessing esophageal motor function in gastroesophageal reflux disease (GERD). METHODS Patients undergoing HRM and ambulatory pH monitoring off antisecretory therapy prospectively completed symptom questionnaires assessing symptom burden and a global symptom score (GSS) at baseline and after GERD therapy. DCI<450 mm Hg/cm/s in ≥5 swallows diagnosed ineffective esophageal motility (IEM); proportions of failed (DCI<100 mm Hg/cm/s) and weak (DCI 100-450 mm Hg/cm/s) sequences were separately assessed. EGJ-CI assessed vigor of the EGJ barrier. Univariate and multivariate analyses addressed performance of esophageal body and EGJ metrics in predicting abnormal esophageal reflux burden, and symptom outcome from antireflux therapy. KEY RESULTS Of 188 patients (55.2 ± 0.9 year, 64% F), 42.6% had low EGJ-CI, and 25.0% had IEM. While low EGJ-CI was associated with abnormal reflux burden (P = 0.003), IEM alone was not (P = 0.2). Increasing proportions of failed swallows predicted abnormal AET better than the current IEM definition. Combined low EGJ-CI and IEM segregated abnormal total and supine acid burden compared to patients with normal EGJ-CI and no IEM (P ≤ 0.007 for each comparison). Medical therapy and surgical antireflux therapy were similarly effective in improving symptom burden; surgery resulted in better outcomes with low EGJ-CI (P ≤ 0.04), especially with intact esophageal body motor function (P = 0.02). CONCLUSIONS & INFERENCES While abnormal EGJ and esophageal body metrics are collectively associated with elevated esophageal reflux burden, increasing proportions of failed swallows are better predictors of reflux burden and outcome compared to the current IEM definition.
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Affiliation(s)
- A Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - A Bolkhir
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - P Gor
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - D Wang
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - S Munigala
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
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Vegetal and Animal Food Proteins Have a Different Impact in the First Postprandial Hour of Impedance-pH Analysis in Patients with Heartburn. Gastroenterol Res Pract 2018; 2018:7572430. [PMID: 29849599 PMCID: PMC5933063 DOI: 10.1155/2018/7572430] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 01/15/2018] [Indexed: 01/11/2023] Open
Abstract
Background and Aims By means of 24 h impedance-pH monitoring, we aimed to evaluate the effect of two different meals with a bromatological balanced composition: one with a prevailing component of animal proteins and the other with vegetable proteins. Patients and Methods We enrolled 165 patients with heartburn and negative endoscopy, who underwent impedance-pH monitoring off therapy. Patients were allocated to receive a Mediterranean diet with a total caloric intake of about 1694 kcal, divided into two meals: one with a prevailing component of animal proteins and the other with vegetable proteins. We evaluated the total reflux number, acid exposure time (AET), and symptom-reflux association with impedance-pH analysis. Moreover, during the first postprandial hour (at lunch and dinner), we evaluated the total reflux number, number of acid and weakly acidic refluxes, AET, and presence of symptoms. Results The male/female ratio was 80/85. Mean age was 51.9 ± 12.1 years. Impedance-pH analysis showed that 55/165 patients had pathological AET or a number of refluxes (nonerosive reflux disease (NERD)), 49/165 had normal AET and a number of refluxes but positive symptom-reflux association (hypersensitive esophagus (HE)), and 61/165 had normal AET and a number of refluxes with negative symptom-reflux association (functional heartburn (FH)). The overall first postprandial hour analysis showed a higher total reflux number, acid reflux number, and AET after the animal protein meal than after the vegetable protein meal. Moreover, more symptoms were reported after the animal protein meal. Similar results have been observed in the three different subcategories of patients (NERD, HE, and FH). Conclusions Vegetable proteins are associated with a lower number of refluxes, particularly acid refluxes, and with a reduced number of symptoms during the first postprandial hour. This is a pilot study and future investigations are warranted to confirm these results.
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50
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Babaei A, Szabo A, Yorio SD, Massey MD BT. Pressure exposure and catheter impingement affect the recorded pressure in the Manoscan 360™ system. Neurogastroenterol Motil 2018; 30:10.1111/nmo.13329. [PMID: 29520927 PMCID: PMC6129441 DOI: 10.1111/nmo.13329] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/06/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND The accuracy of pressure measurements by Manoscan high-resolution manometry (HRM) system is affected by pressure drift (PD). The PD is partly related to temperature and study duration, but other factors that contribute to errant pressure recording have not been systematically evaluated. The aim of this study was to investigate and quantify contributing factors to pressure recording error. METHODS In total, 660 in vitro experiments were conducted on seven HRM catheters to determine the effects of sustained pressure exposure, catheter impingement, temperature, duration of study, and immersion in saline or acid on recorded pressure and PD. KEY RESULTS At room temperature and without application of pressure, the PD was negligible. Application of sustained pressure significantly increased PD and catheter impingement of even 15° produced remarkable increases in the recorded pressure as well as post-recording PD. There was significant variability across sensors in their propensity to develop PD with temperature. Body (37°C) and freezing (0°C) temperatures resulted in significantly higher absolute value of PD in the opposite algebraic direction, respectively (for individual sensors). Although the overall trend was for higher PD with increasing temperature, some of the pressure sensors demonstrated inherently negative PD at body temperature. CONCLUSIONS AND INFERENCES In addition to the known effects of temperature, both sustained pressure exposure and catheter impingement significantly affect the recorded pressure and the magnitude of the PD observed at the end of the recording. These effects can be substantial enough to result in erroneous manometric diagnoses.
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Affiliation(s)
- Arash Babaei
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Institute for Health and Society, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steven Daniel Yorio
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T. Massey MD
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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