Smoking and gastro-oesophageal reflux

Secondhand smoke is associated with peptic ulcer disease and gastroesophageal reflux disease in non-smokers in a large Taiwanese population study

Background

Active smokers are known to be at an increased risk of both gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD), however the role of passive smoking remains unclear. In this study, we aimed to examine whether secondhand smoke (SHS) is associated with PUD and GERD.

Methods

In this population-based study, we conducted a large-scale analysis with 88,297 never-smokers (male: 18,595; female: 69,702; mean age 50.1 ± 11.0 years) from the Taiwan Biobank. The exposure group was comprised of those who had been exposed to SHS, and the no exposure group as those without SHS exposure. According to the frequency of exposure, we further divided the participants into "no exposure," "<1 h per week," and "≥1 h per week" groups. A cutoff point of 1 h per week was chosen according to the median exposure time in our participants. Associations between SHS and SHS frequency with PUD and GERD were assessed.

Results

Of the 88,297 enrolled participants, 11,909 (13.5%) had PUD and 76,388 (86.5%) did not. In addition, 11,758 (13.3%) had GERD and 76,539 (86.7%) did not. Multivariable analysis showed a significant association between SHS with PUD (odds ratio [OR] = 1.166; 95% confidence interval [CI] = 1.084-1.254; p < 0.001), and GERD (OR = 1.131; 95% CI = 1.053-1.216; p = 0.001). Furthermore, those exposed to SHS ≥ 1 h per week (vs. no exposure) were associated with higher risks of PUD (OR = 1.232; 95% CI = 1.121-1.355; p < 0.001) and GERD (OR = 1.200; 95% CI = 1.093-1.319; p < 0.001).

Conclusion

SHS was significantly associated with PUD and GERD. Furthermore, exposure to SHS ≥ 1 h per week (vs. no exposure) was associated with a 1.23-fold higher risk of PUD and 1.20-fold higher risk of GERD. This study represents the largest population-based investigation to explore the association between SHS with PUD and GERD in Taiwanese never-smokers.

Einfluss des Rauchens auf den Gastrointestinaltrakt

Hintergrund

Nikotin ist ein hochwirksames Suchtgift, das bei regelmäßiger Einnahme chronische oder unheilbare Erkrankungen und somit eine eingeschränkte Lebensqualität zur Folge haben kann.

Fragestellung

Das Ziel dieser Übersichtsarbeit besteht darin, mögliche gesundheitliche Folgen des Rauchens auf den Gastrointestinaltrakt aufzuzeigen und einen Überblick über raucherassoziierte neoplastische und nichtneoplastische gastrointestinale Erkrankungen zu geben.

Material und Methode

Anhand einer ausführlichen Literaturrecherche wird der aktuelle Wissensstand zu raucherassoziierten Folgen auf den Gastrointestinaltrakt dargestellt.

Ergebnisse

Rauchen ist ein wesentlicher Risikofaktor für die Entstehung neoplastischer und nichtneoplastischer Erkrankungen des gesamten Gastrointestinaltrakts. Diese weisen in der radiologischen Bildgebung allerdings keine spezifischen, raucherassoziierten Merkmale auf.

Schlussfolgerung

Die Kenntnis einer Raucheranamnese sowie möglicher Auswirkungen von Nikotin auf den Gastrointestinaltrakt können in der radiologischen Bildinterpretation hilfreich sein sowie die diagnostische Entscheidungsfähigkeit und Genauigkeit verbessern.

Non-Acid Fluid Exposure and Esophageal Squamous Cell Carcinoma

Esophageal squamous cell carcinoma (ESCC) accounts for the large majority of esophageal cancer cases worldwide. In this review, we examine the potential role of non-acidic fluid (NAF) exposure in ESCC carcinogenesis. Esophageal NAF consists of a mixture of salivary, esophageal, gastric, and duodenal fluids, containing inflammatory constituents such as digestive enzymes and bile acids that induce DNA damage, as well as known carcinogens such as acetaldehyde and N-nitrosamines. Exposure to NAF can occur in the setting of increased non-acid reflux, decreased gastric acidity, and decreased esophageal fluid clearance. Non-acid reflux has been associated with ESCC in small observational studies, and in animal models bile reflux can promote the development of ESCC. Associations have been found between increased ESCC risk and atrophic gastritis, a history of partial gastrectomy, and proton pump inhibitor use, all of which raise the pH of refluxate. Additionally, a minimally or non-acidic gastric environment contains an altered microbiome that can increase the production of acetaldehyde and N-nitrosamines. Esophageal motility disorders such as achalasia and opioid-induced esophageal dysfunction result in increased stasis and exposure to these potentially proinflammatory constituents of NAF. NAF may promote the development of ESCC via multiple mechanisms and is an understudied area of research.

Relationship between Helicobacter pylori infection and GERD

Gastroesophageal reflux disease (GERD) is due to the chronic exposure of the esophageal mucosa to acid secretion from the stomach. Helicobacter pylori (H.p.) infection, is a risk factor for the development of peptic ulcer, atrophic gastritis and gastric cancer, and causes various effects on gastric function. The relationship between GERD and H.pylori infection is still subject of debate. Background and aim: In literature no clear causal relationship has been established between GERD and H. pylori infection, although some papers support the onset of esophagitis in patients in whom the infection has been cured. Aim of this work is to review the most recent literature data about the relationship between reflux disease and H. pylori infection. Methods: Articles reviewed were found through literature searches on PubMed, Google Scholar using keywords such as gastroesophageal reflux disease, Helicobacter pylori, acid-related disorders, GERD and esophagitis.

Tobacco smoking, alcohol consumption and gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) develops when reflux of gastric content causes troublesome symptoms or complications. The main symptoms are heartburn and acid regurgitation and complications include oesophagitis, strictures, Barrett's oesophagus and oesophageal adenocarcinoma. In addition to hereditary influence, GORD is associated with lifestyle factors, mainly obesity. Tobacco smoking is regarded as an aetiological factor of GORD, while alcohol consumption is considered a triggering factor of reflux episodes and not a causal factor. Yet, both tobacco smoking and alcohol consumption can reduce the lower oesophageal sphincter pressure, facilitating reflux. In addition, tobacco smoking reduces the production of saliva rich in bicarbonate, which is important for buffering and clearance of acid in the oesophagus. Alcohol also has a direct noxious effect on the oesophageal mucosa, which predisposes to acidic injury. Tobacco smoking cessation reduces the risk of GORD symptoms and avoidance of alcohol is encouraged in individuals where alcohol consumption triggers reflux.

Smoking status and prevalence of upper gastrointestinal disorders

BACKGROUND

Lifestyle and environmental factors affecting upper gastrointestinal (GI) disorders are different in developing countries than those in developed nations.

OBJECTIVE

This study aimed to examine the association between smoking status and upper GI disorders among a large group of the Iranian adult population.

METHODS

This cross-sectional study was conducted among 1,933 adult men in Isfahan, Iran. Smoking status was assessed by a self-administered questionnaire. Required information on GI health was collected through the use of the validated ROME III questionnaire. Individuals who reported having heartburn sometimes, often, or always in the last 3 months were considered as having epidemiologic gastroesophageal reflux disease (GERD), and those who reported having heartburn often or always were considered as having clinical GERD. Subjects who reported having functional dyspepsia (FD) symptoms (based on the ROME III criteria) sometimes, often, or always in the last 3 months were considered as having epidemiologic FD, and those who reported having these disorders often or always were considered as having clinical FD.

RESULTS

Smoking was prevalent among 7.8% of the study population. FD and GERD was prevalent among 12.6% (n = 244) and 22.3% (n = 432), respectively. Smoking was not associated with GERD by either the epidemiologic or clinical definition. Although the association between smoking and FD (epidemiologic definition) was not statistically significant, smokers had an 83% higher risk of suffering from clinical FD compared with nonsmokers after taking potential confounders into account [odds ratio (OR) = 1.83, 95% CI: 1.12-3.00; p = 0.01]. Smokers had a 57% higher risk for epidemiologic postprandial fullness (OR = 1.57, 95% CI: 1.05-2.33; p = 0.02) and a 92% higher risk for clinical epigastric pain compared with nonsmokers (OR = 1.92, 95% CI: 1.02-3.62; p = 0.04). We found no significant association between smoking and severity of upper GI disorders.

CONCLUSION

This large population-based study indicated that smoking was not associated with GERD and epidemiologic FD. However, smoking was significantly associated with clinical FD, postprandial fullness, and epigastric pain.

Lifestyle measures in the management of gastro-oesophageal reflux disease: clinical and pathophysiological considerations

Several lifestyle and dietary factors are commonly cited as risk factors for gastro-oesophageal reflux disease (GORD) and modification of these factors has been advocated as first-line measures for the management of GORD. We performed a systematic review of the literature from 2005 to the present relating to the effect of these factors and their modification on GORD symptoms, physiological parameters of reflux as well as endoscopic appearances. Conflicting results existed for the association between smoking, alcohol and various dietary factors in the development of GORD. These equivocal findings are partly due to methodology problems. There is recent good evidence that weight reduction and smoking cessation are beneficial in reducing GORD symptoms. Clinical and physiological studies also suggest that some physical measures as well as modification of meal size and timing can also be beneficial. However, there is limited evidence for the role of avoiding alcohol and certain dietary ingredients including carbonated drinks, caffeine, fat, spicy foods, chocolate and mint.

Tobacco smoking cessation and improved gastroesophageal reflux: a prospective population-based cohort study: the HUNT study

OBJECTIVES

Tobacco smoking increases the risk of gastroesophageal reflux symptoms (GERS), but whether tobacco smoking cessation improves GERS is unclear. The aim of this study was to clarify if tobacco smoking cessation improves GERS.

METHODS

The study was based on the Nord-Trøndelag health study (the HUNT study), a prospective population-based cohort study conducted from 1995-1997 to 2006-2009 in Nord-Trøndelag County, Norway. All residents of the county from 20 years of age were invited. The study included 29,610 individuals (61% response rate) who reported whether they had heartburn or acid regurgitation. The association between tobacco smoking cessation and improvement in GERS was assessed by logistic regression, providing odds ratios (ORs) with 95% confidence intervals (CIs). The analyses were stratified by antireflux medication, and the results were adjusted for sex, age, body mass index (BMI), alcohol consumption, education, and physical exercise. Subgroup analyses were also stratified by BMI.

RESULTS

Among individuals using antireflux medication at least weekly, cessation of daily tobacco smoking was associated with improvement in GERS from severe to no or minor complaints (adjusted OR 1.78; 95% CI: 1.07-2.97), compared with persistent daily smoking. This association was present among individuals within the normal range of BMI (OR 5.67; 95% CI: 1.36-23.64), but not among overweight individuals. There was no association between tobacco smoking cessation and GERS status among individuals with minor GERS or individuals using antireflux medication less than weekly.

CONCLUSIONS

Tobacco smoking cessation was associated with improvement in severe GERS only in individuals of normal BMI using antireflux medication at least weekly, but not in other individual with GERS.

Vegetarianism as a protective factor for reflux esophagitis: a retrospective, cross-sectional study between Buddhist priests and general population

BACKGROUND/AIMS

Several risk factors for reflux esophagitis, such as smoking, alcohol consumption, obesity, and metabolic syndrome, are recognized. But vegetarianism as a protective factor for reflux esophagitis has not been reported. The aim of this study is to elucidate the protective effect of vegetarianism for reflux esophagitis.

METHODS

This is a cross-sectional study that compared the prevalence of reflux esophagitis of 148 Buddhist priests, who are obligatory vegetarians with that of age- and sex-matched controls who underwent health checkups in a health promotion center.

RESULTS

The prevalence of reflux esophagitis was higher in the control group than in the Buddhist priest group (21.6 vs 12.2 %). Weight, body mass index, waist circumference, waist-to-hip ratio, and abdominal adipose tissue area were higher and high density lipoprotein (HDL) cholesterol and total cholesterol were lower in the Buddhist priest group. The prevalence of metabolic syndrome was higher in the Buddhist priest group than the control group (30.4 vs 17.6 %). In univariate analysis, male sex (odds ratio [OR] = 3.325; 95 % confidence interval [CI], 1.659-6.666), current smoking (OR = 3.37; 95 % CI, 1.439-7.881), alcohol consumption (OR = 2.75; 95 % CI, 1.375-5.481), waist circumference (OR = 1.99; 95 % CI, 1.062-3.739), negative for Helicobacter pylori IgG antibody (OR = 1.89; 95 % CI, 1.018-3.491) and non-vegetarianism (OR = 1.99; 95 % CI, 1.062-3.739) were associated with reflux esophagitis. According to multivariate analysis, male sex (OR = 3.44; 95 % CI, 1.698-6.970), non-vegetarianism (OR = 2.08; 95 % CI, 1.086-3.974) and negative H. pylori IgG antibody (OR = 1.96; 95 % CI, 1.039-3.712) were significantly associated with reflux esophagitis.

CONCLUSIONS

A non-vegetarian diet is associated with reflux esophagitis.

Protective role of aerodigestive reflexes against aspiration: study on subjects with impaired and preserved reflexes

BACKGROUND & AIMS

Direct evidence to support the airway protective function of aerodigestive reflexes triggered by pharyngeal stimulation was previously demonstrated by abolishing these reflexes by topical pharyngeal anesthesia in normal subjects. Studies have also shown that these reflexes deteriorate in cigarette smokers. Aim of this study was to determine the influence of defective pharyngeal aerodigestive reflexes on airway protection in cigarette smokers.

METHODS

Pharyngoglottal Closure reflex; PGCR, Pharyngo-UES Contractile reflex; PUCR, and Reflexive Pharyngeal Swallow; RPS were studied in 15 healthy non-smokers (24.2±3.3 SD y, 7 males) and 15 healthy chronic smokers (27.3±8.1, 7 males). To elicit these reflexes and to evaluate aspiration, colored water was perfused into the hypopharynx at the rate of 1 mL/min. Maximum volume of water that can safely dwell in the hypopharynx before spilling into the larynx (Hypopharyngeal Safe Volume; HPSV) and the threshold volume to elicit PGCR, PUCR, and RPS were determined in smokers and results compared with non-smokers.

RESULTS

At baseline, RPS was elicited in all non-smokers (100%) and in only 3 of 15 smokers (20%; P<.001). None of the non-smokers showed evidence of laryngeal spillage of water, whereas 12 of 15 smokers with absent RPS had laryngeal spillage. Pharyngeal anesthesia abolished RPS reflex in all non-smokers resulting in laryngeal spillage. The HPSV was 0.61±0.06 mL and 0.76±0.06 mL in non-smokers and smokers respectively (P=.1).

CONCLUSIONS

Deteriorated reflexive pharyngeal swallow in chronic cigarette smokers predispose them to risks of aspiration and similarly, abolishing this reflex in non-smokers also results in laryngeal spillage. These observations directly demonstrate the airway protective function of RPS.

Effect of systemic alcohol and nicotine on airway protective reflexes

OBJECTIVES

Injection of water into the pharynx induces contraction of the upper esophageal sphincter (UES), triggers the pharyngo-UES contractile reflex (PUCR), and at a higher volume, triggers an irrepressible swallow, the reflexive pharyngeal swallow (RPS). These aerodigestive reflexes have been proposed to reduce the risks of aspiration. Alcohol ingestion can predispose to aspiration and previous studies have shown that cigarette smoking can adversely affect these reflexes. It is not known whether this is a local effect of smoking on the pharynx or a systemic effect of nicotine. The aim of this study was to elucidate the effect of systemic alcohol and nicotine on PUCR and RPS.

METHODS

Ten healthy non-smoking subjects (8 men, 2 women; mean age: 32+/-3 s.d. years) and 10 healthy chronic smokers (7 men, 3 women; 34+/-8 years) with no history of alcohol abuse were studied. Using previously described techniques, the above reflexes were elicited by rapid and slow water injections into the pharynx, before and after an intravenous injection of 5% alcohol (breath alcohol level of 0.1%), before and after smoking, and before and after a nicotine patch was applied. Blood nicotine levels were measured.

RESULTS

During rapid and slow water injections, alcohol significantly increased the threshold volume (ml) to trigger PUCR and RPS (rapid: PUCR: baseline 0.2+/-0.05, alcohol 0.4+/-0.09; P=0.022; RPS: baseline 0.5+/-0.17, alcohol 0.8+/-0.19; P=0.01, slow: PUCR: baseline 0.2+/-0.03, alcohol 0.4+/-0.08; P=0.012; RPS: baseline 3.0+/-0.3, alcohol 4.6+/-0.5; P=0.028). During rapid water injections, acute smoking increased the threshold volume to trigger PUCR and RPS (PUCR: baseline 0.4+/-0.06, smoking 0.67+/-0.09; P=0.03; RPS: baseline 0.7+/-0.03, smoking 1.1+/-0.1; P=0.001). No similar increases were noted after a nicotine patch was applied.

CONCLUSIONS

Acute systemic alcohol exposure inhibits the elicitation PUCR and RPS. Unlike cigarette smoking, systemic nicotine does not alter the elicitation of these reflexes.

Body weight, lifestyle, dietary habits and gastroesophageal reflux disease

While lifestyle modifications are currently used as first-line treatment for subjects with gastroesophageal reflux disease (GERD), the pathogenetic role of lifestyle factors and consequently, the efficacy of lifestyle measures is controversial. Our aim was to systematically review the pathogenetic link between overweight/obesity, dietary habits, physical activity and GERD, and the beneficial effect of specific recommended changes, by means of the available literature from the 1999 to the present. Obesity, in particular, abdominal obesity, plays a key role in determining GERD symptoms and complications through mechanical and metabolic effects. Controlled weight loss (by diet or surgery) is effective in improving GERD symptoms. No definitive data exist regarding the role of diet and, in particular, of specific foods or drinks, in influencing GERD clinical manifestations. Moderate physical activity seems to be beneficial for GERD, while vigorous activity may be dangerous in predisposed individuals. In conclusion, being obese/overweight and GERD-specific symptoms and endoscopic features are related, and weight loss significantly improves GERD clinical-endoscopic manifestations. The role of dietary behavior, mainly in terms of specific dietary components, remains controversial. Mild routine physical activity in association with diet modifications, i.e. a diet rich in fiber and low in fat, is advisable in preventing reflux symptoms.

Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey

OBJECTIVE

The prevalence and natural history of gastroesophageal reflux in infants have been poorly documented. The aim of this study was to evaluate the prevalence and natural history of infant regurgitation in Italian children during the first 2 years of life.

METHODS

A detailed questionnaire, according to the Rome II criteria, was completed by 59 primary care pediatricians to assess infant regurgitation in consecutive patients seen in their office over a 3-month period. A total of 2642 patients aged 0 to 12 months were prospectively enrolled during this 3-month period. Follow-up was performed at 6, 12, 18, and 24 months of age.

RESULTS

A total of 313 children (12%; 147 girls) received the diagnosis of infant regurgitation. Vomiting was present in 34 of 313 patients. Their score for the Infant Gastroesophageal Reflux Questionnaire was 8.51 +/- 4.75 (mean +/- SD). Follow-up visits were conducted to the end in 210 of 313 subjects. Regurgitation had disappeared in 56 of 210 infants by the first 6 months of age, in 128 by the first 12 months, in 23 at 18 months, and in 3 patients by the first 24 months. At follow-up, 1 of 210 patients had developed a gastroesophageal reflux disease with esophagitis, proven endoscopically and histologically; another patient received a diagnosis of cow milk protein intolerance. The Infant Gastroesophageal Reflux Questionnaire score reached 0 after 8.2 +/- 3.9 months in breastfed infants (89 of 210) and after 9.6 +/- 4.1 months in artificially fed infants.

CONCLUSIONS

We found that 12% of Italian infants satisfied the Rome II criteria for infant regurgitation. Eighty-eight percent of 210 infants who had completed a 24-month follow-up period had improved at the age of 12 months. Only 1 patient later turned out to have gastroesophageal reflux disease. Use of breast milk was associated with a shorter time necessary to reach an Infant Gastroesophageal Reflux Questionnaire score of 0.

Aerophagia and gastroesophageal reflux disease in patients using continuous positive airway pressure: a preliminary observation

STUDY OBJECTIVES

Aerophagia is a complication of continuous positive airway pressure (CPAP) therapy for sleep disordered breathing (SDB), whereupon air is forced into the stomach and bowel. Associated discomfort can result in CPAP discontinuation. We hypothesize that aerophagia is associated with gastroesophageal reflux disease (GERD) via mechanisms involving GERD related lower esophageal sphincter (LES) compromise.

METHODS

Twenty-two subjects with aerophagia and 22 controls, matched for age, gender, and body mass index, who were being treated with CPAP for SDB were compared in regard to clinical aspects of GERD, GERD associated habits, SDB severity as measured by polysomnography, and mean CPAP pressure.

RESULTS

More subjects with aerophagia had symptoms of GERD (77.3% vs. 36.4%; p < 0.01) and were on GERD related medications (45.5% vs. 18.2%, p < 0.05) than controls. Regarding polysomnography, mean oxygen saturation percentages were lower in the aerophagia group than controls (95.0% vs. 96.5%, p < 0.05). No other differences were observed, including mean CPAP pressures. No one in the aerophagia group (vs. 27.3% of the control group) was a current tobacco user (p < 0.01). There was no difference in caffeine or alcohol use between the 2 groups.

CONCLUSIONS

These results imply aerophagia is associated with GERD symptoms and GERD related medication use. This finding suggests a relationship between GERD related LES pathophysiology and the development of aerophagia in patients with SDB treated with CPAP.

Environmental factors in the etiology of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is currently one of the most common health problems in the Western world, affecting up to 20% of the adult population weekly and 50% monthly. It generates substantial suffering among patients as well as significant costs to both patients and society in general. GERD can further result in serious complications such as esophageal strictures, Barrett's esophagus and esophageal adenocarcinoma. This review discusses the current knowledge on risk factors and potential protective factors in the development of GERD.

Risk factors for Barrett’s oesophagus and oesophageal adenocarcinoma: Results from the FINBAR study

AIM: To investigate risk factors associated with Barrett’s oesophagus and oesophageal adenocarcinoma.

METHODS: This all-Ireland population-based case-control study recruited 224 Barrett’s oesophagus patients, 227 oesophageal adenocarcinoma patients and 260 controls. All participants underwent a structured interview with information obtained about potential lifestyle and environmental risk factors.

RESULTS: Gastro-oesophageal reflux was associated with Barrett’s [OR 12.0 (95% CI 7.64-18.7)] and oesophageal adenocarcinoma [OR 3.48 (95% CI 2.25-5.41)]. Oesophageal adenocarcinoma patients were more likely than controls to be ex- or current smokers [OR 1.72 (95% CI 1.06-2.81) and OR 4.84 (95% CI 2.72-8.61) respectively] and to have a high body mass index [OR 2.69 (95% CI 1.62-4.46)]. No significant associations were observed between these risk factors and Barrett's oesophagus. Fruit but not vegetables were negatively associated with oesophageal adenocarcinoma [OR 0.50 (95% CI 0.30-0.86)].

CONCLUSION: A high body mass index, a diet low in fruit and cigarette smoking may be involved in the progression from Barrett’s oesophagus to oesophageal adenocarcinoma.

Bases científicas del tratamiento médico referente a dieta, hábitos y postura en pacientes con síndrome de reflujo gastroesofágico crónico

In most patients with chronic gastroesophageal reflux disease, treatment is medical. Among the main elements involved in treatment are general dietary measures, lifestyle habits, and patients' attitudes to symptom control. The present article summarizes the scientific foundations that support these measures: head elevation during nighttime sleep, smoking cessation, losing weight, avoiding rigorous exercise, and reducing or eliminating alcohol consumption. Dietary therapy is mainly based on avoiding fatty foods, chocolate, coffee, mint, and irritating fizzy drinks. Although each patient's response to these measures is highly individual, the mechanisms through which symptoms are reproduced is gradually becoming clearer: a large percentage of patients with uncomplicated gastroesophageal reflux disease will gain considerable relief simply by eliminating some of these habits.

Das präoperative „Rauchverbot“

For decades it has been assumed, that smoking within 6 hours of anesthesia and surgery raises the incidence of perioperative cardiopulmonary complications (PPC) including aspiration. Therefore, every patient is advised to stop smoking at the day before surgery, and not to smoke at all at the day of surgery. If the patient does not follow this advice, this will result in a postponement of anesthesia and surgery. The present article aims at re-investigating the scientific basis of this dogma in anesthesia, which virtually forbids smoking at short-term prior to surgery. The influence of short-term (6 h) abstinence from smoking on the perioperative pulmonary morbidity has not been systematically investigated. Interestingly, giving up smoking less than two months prior to surgery does not significantly decrease, but rather may increase the incidence of PPC. With respect to the risk of aspiration, smoking does not increase either the volume or the acidity of gastric juices. A short-lived reduction in the tone of the lower esophageal sphincter is reversible within minutes after termination of smoking. While the emptying of liquid gastric juices is not influenced by smoking, there is a certain delay in the propulgation of solid food. This effect, however, is probably of no clinical relevance in patients, who had their last solid meal the evening before surgery. Hence, we conclude that the anesthesia dogma, which rules out smoking shortly prior to anesthesia, cannot be based on an otherwise increased incidence of pulmonary aspiration or other pulmonary morbidity. However, acute smoking (probably by an increase in COHb) may increase the incidence of myocardial ischemia during exercise and anesthesia. With reference to this possible cardiac complication it still seems reasonable to discourage smoking at least 12 to 48 hours prior to surgery in patients with elevated cardiac risk.

Managing dyspepsia without alarm signs in primary care: new national guidance for England and Wales

AIM

To report new recommendations for the primary care management of dyspepsia without alarm signs in England and Wales.

METHOD

An independent, representative group of health care professionals, patient representatives and researchers developed the guideline using evidence-based and small group-working principles, and incorporated extensive peer-reviewing and feedback from stakeholder organizations.

RESULTS

Referral to investigate dyspepsia should be made for alarm signs and not on the basis of age alone, reflecting the balance of benefit and harm from endoscopy. Empirical management without formal diagnosis is appropriate for most patients: reviewing patient history, lifestyle, over-the-counter medicines, and providing a course of proton-pump inhibitors and/or Helicobacter pylori test and treatment. Patients with ongoing symptoms require at least annual review to discuss symptoms and lifestyle, and as appropriate, encourage stepping down prescribed medication and returning to self-care. A new strategy included in the step down process is the use of therapies 'on-demand'.

CONCLUSION

The guideline provides structured and supported recommendations for both undiagnosed and endoscopically investigated dyspepsia. Some favour increased investigation to detect Barrett's oesophagus and carcinoma. However, there is inconclusive evidence that patients without alarm signs will benefit subsequently from endoscopy, while investigation involves a small but real risk of harm.

Differences in clinical characteristics between patients with endoscopy-negative reflux disease and erosive esophagitis in Japan

OBJECTIVE

Helicobacter pylori infection and atrophic gastritis are inversely related to erosive esophagitis. Whether these factors affect the pathogenesis of endoscopy-negative reflux disease is not clear. We aimed to elucidate the differences in clinical characteristics between endoscopy-negative erosive disease and erosive esophagitis.

METHODS

253 subjects (89 with endoscopy-negative reflux disease and 164 with erosive esophagitis) were studied. Gastric atrophy was assessed by measurement of serum pepsinogen. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (CI) of endoscopy-negative reflux disease compared with erosive esophagitis.

RESULTS

Among GERD patients, female gender (OR = 2.27, 95% CI, 1.25-4.10), smoking (OR = 0.45, 95% CI, 0.22-0.91), and the presence of hiatal hernia (OR = 0.30, 95% CI, 0.17-0.56) were significantly associated with endoscopy-negative reflux disease compared with male gender, not smoking, and absence of hiatal hernia, respectively. Body mass index (BMI) was also significantly associated with a decreased OR for endoscopy-negative reflux disease. Although H. pylori infection and gastric atrophy were significantly more common in patients with endoscopy-negative reflux disease, these associations did not persist in a multiple-adjustment model. After adjustment for gender, BMI, smoking, and hiatal hernia, a decrease in serum pepsinogen I/II ratio was significantly associated with an increased OR for endoscopy-negative reflux disease (p for trend = 0.018).

CONCLUSIONS

Female gender, low BMI, not smoking, absence of hiatal hernia, and severity of gastric atrophy were positively associated with endoscopy-negative reflux disease compared with erosive esophagitis among Japanese patients.

Smoking and systemic disease

Cigarette smoking is associated with a number of adverse health effects, including well-established links to cardiopulmonary disease and several cancers. Some of the other important systemic diseases associated with smoking are the subjects of this article, such as diabetes mellitus and insulin resistance and thyroid diseases. Also reviewed here is the negative impact of smoking on male and female infertility, on selected dermatologic conditions, and on gastrointestinal diseases including peptic ulcer and inflammatory bowel diseases.

The role of the hiatus hernia in gastro-oesophageal reflux disease

A sliding hiatus hernia disrupts both the anatomy and physiology of the normal antireflux mechanism. It reduces lower oesophageal sphincter length and pressure, and impairs the augmenting effects of the diaphragmatic crus. It is associated with decreased oesophageal peristalsis, increases the cross-sectional area of the oesophago-gastric junction, and acts as a reservoir allowing reflux from the hernia sac into the oesophagus during swallowing. The overall effect is that of increased oesophageal acid exposure. The presence of a hiatus hernia is associated with symptoms of gastro-oesophageal reflux, increased prevalence and severity of reflux oesophagitis, as well as Barrett's oesophagus and oesophageal adenocarcinoma. The efficacy of treatment with proton pump inhibitors is reduced. Our view on the significance of the sliding hiatus hernia in gastro-oesophageal reflux disease has changed enormously in recent decades. It was initially thought that a hiatus hernia had to be present for reflux oesophagitis to occur. Subsequently, the hiatus hernia was considered an incidental finding of little consequence. We now appreciate that the hiatus hernia has major patho-physiological effects favouring gastro-oesophageal reflux and hence contributing to oesophageal mucosal injury, particularly in patients with severe gastro-oesophageal reflux disease.

Management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic condition requiring long-term treatment. Simple lifestyle modifications are the first methods employed by patients and, because of their low cost and simplicity, should be continued even when more potent therapies are initiated. Potent acid-suppressive therapy is currently the most important and successful medical therapy. Whereas healing of the esophageal mucosa is achieved with a single dose of any proton pump inhibitor (PPI) in more than 80% of cases, symptoms are more difficult to control. Patients with persistent symptoms on therapy should be tested (preferably with combined multichannel intraluminal impedance and pH) for association of symptoms with acid, nonacid, or no GER. Long-term follow-up studies indicate that PPIs are efficacious, tolerable, and safe medication. So far, promotility agents have shown limited efficacy, and their side-effect profile outweighs their benefits. Antireflux surgery in carefully selected patients (ie, young, typical GERD symptoms, abnormal pH study, and good response to PPI) is as effective as PPI therapy and should be offered to these patients as an alternative to medication. Still, patients should be informed about the risks of antireflux surgery (ie, risk of postoperative dysphagia; decreased ability to belch, possibly leading to bloating; increased flatulence). Endoscopic antireflux procedures are recommended only in selected patients and given the relative short experience with these techniques, patients treated with endoscopic procedures should be enrolled in a rigorous follow-up program.

Effect of chronic and acute cigarette smoking on the pharyngoglottal closure reflex

BACKGROUND

Injection of water into the pharynx at a threshold volume induces vocal cord adduction--the pharyngoglottal closure reflex (PGCR). This reflex together with other supraoesophageal reflexes may be helpful in preventing aspiration. Cigarette smoking has an adverse affect on the pharyngo-upper oesophageal sphincter contractile reflex and reflexive pharyngeal swallow. The effect of smoking on PGCR has not been studied previously.

AIMS

To elucidate the effect of chronic and acute cigarette smoking on PGCR.

SUBJECTS

We studied 10 chronic smokers and 10 non-smokers before and after real/simulated smoking, respectively.

METHODS

Using concurrent recordings, glottal function was monitored by video endoscopy, swallowing by electromyography, and PGCR was triggered by rapid and slow pharyngeal water injections.

RESULTS

The threshold volume to trigger PGCR during rapid injection was significantly higher in chronic smokers (non-smoker 0.20 (SEM 0.02) ml, smoker 0.36 (0.02) ml; p<0.001). In six of 10 smokers, acute smoking abolished this reflex during slow water injection.

CONCLUSIONS

Smoking adversely affects stimulation of PGCR. This finding may have implications in the development of reflux related respiratory complications in smokers.

The role of gastroesophageal reflux in the pathogenesis of laryngeal carcinoma

Gastroesophageal reflux (GER) has been strongly associated with carcinogenesis of the lower esophagus and development of several otolaryngologic disorders. Epidemiologic studies support concept that the malignant transformation of laryngeal mucosal surfaces is due to GER-initiated chronic laryngeal inflammation. However, large clinical studies with matched control groups and further experimental investigations are necessary to ascertain the relationship between reflux and laryngeal carcinoma. This review stresses that early diagnosis of GER disease, based on clinical suspicion, ambulatory 24-hour double-probe pH monitoring, and endoscopic examination, as well as effective treatment of reflux, are considered the keys for relief of symptomatology and preventing the chronic irritation of the laryngeal mucosa that may contribute to the development of laryngeal carcinoma.

The role of acid and alkaline reflux in laryngeal squamous cell carcinoma

HYPOTHESIS

At present, main factors considered responsible for the onset of squamous cell carcinoma are tobacco smoking, alcohol abuse, and exposure to viral and toxic agents. In last years, great interest has been focused on gastroesophageal reflux as independent carcinogenic factor and co-carcinogen in association with smoking and alcohol assumption.

STUDY DESIGN

Initially, the aim of this study was to objectively evaluate the presence of distal and proximal esophageal reflux with multielectrode pH measurement in patients with cancer of the larynx and/or hypopharynx (group A). However, in the course of the study, pharyngolaryngeal cancer was also observed in 4 patients with achlorhydria; therefore, the hypothesis that alkaline reflux might be involved in the onset of laryngeal cancer was tested (group B).

METHODS

Twenty-one consecutive patients with laryngeal or hypopharyngolaryngeal squamous cell carcinoma (group A) entered the study. Twenty-one patients without laryngo-pharyngeal diseases were used as control subjects. A validated questionnaire of the clinical history was completed by all patients who underwent 24-hour pH monitoring. Group B included 40 consecutive gastrectomized patients (28 males and 12 females) in whom biliary or alkaline reflux was directly consequent to Billroth I or Billroth II operation. The control group was composed of 40 non-gastrectomized dyspeptic patients. The clinical history was controlled and obtained; EDGS and ENT examination with videolaryngoscopy was performed in all patients.

RESULTS

In group A, pH measurement showed pathological reflux in 80.9% (17 of 21) of patients with no typical symptoms in 63.7% of them. The difference was significant with respect to the control group. In group B, 6 of 40 (15%) had preneoplastic lesions or a history of laryngeal tumor. The difference was significant with respect to the control group. A total of 7.5% of group B patients had previously undergone CO2 laser cordectomy for laryngeal squamous cell carcinoma and 7.5% had leukoplakia. We found a significantly higher incidence (<.05) of neoplastic and preneoplastic disease of the larynx in patients undergoing Billroth II and total gastrectomy than in those undergoing Billroth I and Roux-en-Y resection. We also found a significant increase (<.01) in ENT lesions in the group of patients who had undergone gastrectomy more than 20 years previously.

CONCLUSIONS

In agreement with literature reports, results obtained in group A confirmed that gastroesophageal reflux is often present in patients with neoplastic lesions of the pharynx and larynx. Furthermore, gastric resection is indicated for the first time as an additional risk factor or cofactor of precancerosis and squamous cell carcinoma of the pharynx or larynx. Further studies are necessary to establish the cause and effect relationship between biliary reflux and pharyngo-laryngeal tumors.

Natural history and familial relationships of infant spilling to 9 years of age

OBJECTIVES

To determine the natural history of infant spilling (regurgitation/vomiting) during the first 2 years of life and to determine the relationship between infant spilling and gastroesophageal reflux (GER) symptoms at 9 years of age.

METHODS

A prospective birth cohort was followed with daily symptom diaries during the first 2 years of life and reviewed at 9 years of age (range: 8-11 years). The prevalence of infant spilling during the first 2 years of life, the prevalence of GER symptoms between 8 and 11 years of age (mean age: 9.7 years), relative risk of infant spilling predisposing to GER symptoms at 9 years of age, and prevalence of maternal GER symptoms and relationship with infant spilling and GER at 9 years of age were measured.

RESULTS

A total of 693 children who represented 83% of an original sample of 836 children and were followed for 2 years from birth with daily symptom diaries were contacted at 9 (8-11) years of age. Spilling of most feeds each day was common in infancy and reached a peak prevalence of 41% between 3 and 4 months of age and thereafter declined to < 5% between 13 and 14 months of age. Infants with spilling on 90 days or more during the first 2 years of life (classified as frequent spilling) were more likely to have GER symptoms at 9 years of age. Children with frequent infant spilling, compared with those with no spilling, had a relative risk of 2.3 (95% confidence interval [CI]: 1.3-4.0) of 1 or more GER symptoms at 9 years of age, 4.6 (95% CI: 1.5-13.8) for heartburn, 2.7 (95% CI: 1.4-5.5) for vomiting, and 4.7 (95% CI: 1.6-14.0) for acid regurgitation. Gender, breastfeeding, and environmental tobacco smoke exposure were not significant factors related to infant spilling. Prepregnancy smoking and smoking in the same room as the child at the 9-month and 18-month follow-ups had a significant effect on GER symptoms at 9 years of age. Infant spilling and GER at 9 years of age were significantly related to maternal GER symptoms but not to paternal GER symptoms.

CONCLUSIONS

Spilling in infancy is very common, but the majority of children settle by 13 to 14 months of age. However, those with frequent spilling (>90 days) are more likely to have GER symptoms at 9 years of age. In addition, a maternal history of GER was significantly related both to infant spilling and to GER at 9 years, suggesting that a genetic component may be involved. Physicians should consider studying children with a history of frequent infant spilling to determine whether this group is at increased risk for GER disease.

Association of laryngopharyngeal symptoms with gastroesophageal reflux disease

OBJECTIVES

The prevalence of gastroesophageal reflux disease (GERD) in patients with laryngopharyngeal disorders is probably greater than realized.

STUDY DESIGN

Prospective study.

METHODS

To investigate the incidence of gastroenterological diseases including GERD in patients complaining of nonspecific laryngopharyngeal symptoms, laryngological examinations and gastroenterological evaluation with esophagogastroduodenoscopy were performed in 30 patients who refused to undergo 24-hour pH monitoring. Therapeutic intervention by behavioural and dietary modifications, antireflux medication, and eradication of Helicobacter pylori were assessed for changes in laryngeal findings and relief of symptoms.

RESULTS

Posterior laryngitis was present in 26 patients and in 19 of them was accompanied by erythema and edema of the interarytenoid region. Gastroenterological diseases such as GERD (43%), hiatal hernia (43%), and Helicobacter pylori-positive antrum gastritis (23%) were confirmed in 22 (73%) cases by esophagogastroduodenoscopy and histological examination of biopsy specimens. Medical antireflux treatment and eradication of Helicobacter pylori resulted in a remarkably therapeutic success rate of 90% because there was resolution of laryngopharyngeal symptoms and laryngeal findings in 20 of 22 patients with gastroenterological diseases for the mean follow-up period of 8 months.

CONCLUSIONS

Laryngopharyngeal symptoms can be predictors of gastroesophageal diseases and GERD because the most frequent underlying cause is supposed to be associated with posterior laryngitis. Medical antireflux treatment is effective for relief of symptoms and mucosal healing of posterior laryngitis.

Effect of cigarette smoking on gastropharyngeal and gastroesophageal reflux

Gastropharyngeal reflux appears to be associated with various otolaryngological complaints. Cigarette smoking is known to affect adversely the defense mechanisms against reflux of acid gastric contents into the esophagus. To study the relationship between gastropharyngeal, as well as gastroesophageal, reflux and cigarette smoking, 15 subjects underwent 24-hour double-probe pH monitoring while smoking their daily amount of cigarettes. The percentage of time the pH was below 4 during the smoking period was significantly higher than the percentage of time the pH was below 4 during the nonsmoking period, proximal, at the level of the upper esophageal sphincter, as well as distal, above the lower esophageal sphincter. These findings demonstrate that smoking increases gastropharyngeal and gastroesophageal reflux. Smokers with complaints and disorders caused by reflux should therefore be advised to stop smoking in order to reduce reflux.

Risk factors for erosive reflux esophagitis: a case-control study

OBJECTIVES

It is presently not fully understood which risk factors contribute to the occurrence of reflux esophagitis and how such factors might influence the severity of the disease. The aim of this study was to delineate the clinical epidemiology of erosive reflux esophagitis.

METHODS

Outpatients from a medicine and gastroenterology clinic who underwent upper GI endoscopy were recruited into a case-control study. A total of 1,533 patients with and 3,428 patients without endoscopically diagnosed reflux esophagitis were categorized as case and control subjects, respectively. Using multivariate logistic regressions for statistical analysis, the presence of esophageal erosions, ulcers or strictures, served as three separate outcome variables. Demographic characteristics, intake of nonsteroidal anti-inflammatory drugs (NSAIDs), consumption of alcohol and cigarettes, and the presence of hiatus hernia or peptic ulcer served as predictor variables.

RESULTS

Erosive reflux esophagitis tended to occur more frequently in Caucasian male patients. Hiatus hernia was associated with a strong risk for developing esophageal erosions, ulcers, and strictures. Although statistical significance was demonstrated only for esophageal erosions, in all grades of reflux esophagitis alike, gastric and duodenal ulcer exerted a protective influence. Consumption of NSAIDs increased the risk for esophageal ulcers only. Smoking and alcohol were not associated with an increased risk of developing any type of erosive reflux esophagitis.

CONCLUSIONS

The results stress the critical role played by hiatus hernia in all grades of erosive reflux esophagitis. NSAIDs may act through a mechanism of topically induced esophageal injury. Our data also suggest that the presence of either gastric or duodenal ulcer exerts a protective influence against the development of reflux disease.

Acute effect of nicotine patch on gastric emptying of liquid and solid contents in healthy subjects

The effect of nicotine on gastric emptying remains controversial. Gastric emptying is delayed in chronic smokers after smoking high-dose nicotine cigarettes, but it is unchanged after chewing nicotine gums. No information is available on the effect of transdermal nicotine patches on the gastric emptying of solid and liquid contents in healthy nonsmokers. Our objective was to prospectively evaluate the effect of the nicotine patch on gastric emptying of liquid and solid contents in healthy nonsmokers. Ten healthy nonsmoking volunteers underwent a baseline dual-isotope gastric scintigraphy with [111In]-diethylenetriaminepantaacetic acid (DTPA) and [99mTc]sulfur colloid isotopes to evaluate prospectively the gastric emptying of liquid and solid contents, respectively. The gastric scintigraphy was repeated after placing a transdermal nicotine patch (Habitrol) for 12 hr designed to deliver 14 mg of nicotine per day. Plasma nicotine level was measured prior to baseline gastric scintigraphy and after 12 hr placing the nicotine patch. Plasma nicotine was absent in all subjects at baseline and but was significantly elevated after 12 hr of nicotine patch (P < 0.009). The mean half-emptying times (T1/2) for the gastric emptying of liquids before and after nicotine patch placement were 31.2+/-23.3 and 25.6+/-8.4 min, respectively (P = 0.498). The mean T1/2s for the gastric emptying of solids before and after nicotine patch placement were 70.1+/-34.0 and 59.7+/-31.4 min, respectively (P = 0.202). There was no correlation between the plasma nicotine level and gastric emptying of liquid and solid contents (correlation coefficient = -0.23 and -0.01, respectively). In conclusion, acute transdermal delivery of nicotine does not affect the gastric emptying of solid and liquid contents in healthy nonsmoking subjects.

Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I Epidemiologic Followup Study. First National Health and Nutrition Examination Survey

PURPOSE

Gastroesophageal reflux disease is an important and increasingly common condition. Both overweight and high fat food consumption have been implicated as causes of reflux disease. We examined the relationship of overweight, high dietary fat intake, and other factors with reflux disease hospitalization.

METHODS

We studied participants in the first National Health and Nutrition Examination Survey, a population-based sample examined in 1971-75 and followed through 1992-93. Persons with a physician-diagnosed hiatal hernia at baseline or reflux disease hospitalization within the first five years of study were excluded. A second analysis included follow-up of 9851 participants free of reflux disease in 1982-84. Ninety-six percent of the baseline cohort were recontacted. Reflux disease cases were persons hospitalized with a diagnosis of esophagitis or uncomplicated hiatal hernia. Hazard rate ratios for reflux disease hospitalization according to body mass index (BMI) (kg/m2), total daily servings of high fat foods and other factors were calculated using Cox proportional hazards analysis.

RESULTS

A total of 12,349 persons were followed for a median of 18.5 years (range 5.0-22.1). Cumulative incidence of reflux disease hospitalization was 5.2% at 20 years. Multivariate survival analysis revealed higher reflux disease hospitalization rates with higher BMI (5 kg/m2) [hazard ratio (HR) = 1.22, 95% confidence interval (CI) = 1.13-1.32]. No relationship was found between higher fat intake and reflux disease hospitalization. Other factors associated with reflux disease hospitalization included age, low recreational activity, and history of doctor-diagnosed arthritis.

CONCLUSIONS

Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization.

Risk factors associated with symptoms of gastroesophageal reflux

BACKGROUND

Although patients with gastroesophageal reflux are often instructed to change their lifestyle, population-based data on the risk factors for reflux in the United States are lacking.

METHODS

We performed a cross-sectional study in an age- and gender-stratified random sample of the population of Olmsted County, Minnesota. Residents aged 25 to 74 years were mailed a valid self-report questionnaire that measured reflux symptoms and potential risk factors. Logistic regression was used to estimate the odds ratios (OR) with 95% confidence intervals (CI) for reflux symptoms (heartburn or acid regurgitation) associated with potential risk factors.

RESULTS

Overall, 1,524 (72%) of 2,118 eligible subjects responded. A body mass index >30 kg/m2 (OR = 2.8; CI, 1.7 to 4.5), reporting an immediate family member with heartburn or disease of the esophagus or stomach (OR = 2.6; CI, 1.8 to 3.7), a past history of smoking (OR = 1.6; CI, 1.1 to 2.3), consuming more than seven drinks per week (OR = 1.9; Cl, 1.1 to 3.3), and a higher psychosomatic symptom checklist score (OR per 5 units = 1.4; CI, 1.3 to 1.6) were independently associated with frequent (at least weekly) reflux symptoms.

CONCLUSION

Obesity is a strong risk factor for gastroesophageal reflux, although the value of weight reduction remains to be proven. That family history was also a risk factor suggests that there may be a genetic component to the disorder.

Familial clustering of reflux symptoms

OBJECTIVE

A number of case reports describe multiple family members with gastroesophageal reflux disease and Barrett' s esophagus. The wider importance of familial factors in gastroesophageal reflux disease has not been established. Therefore, we have studied the prevalence of reflux symptoms and medication use among relatives of patients with documented gastroesophageal reflux disease.

METHODS

A postal questionnaire study of the first degree relatives of six groups of matched patients. The groups comprised patients with 1) no dyspeptic symptoms; 2) reflux symptoms and a normal pH study; 3) reflux symptoms, an abnormal pH study, and a lower esophageal sphincter (LOS) pressure more than 10 mm Hg; 4) reflux symptoms, an abnormal pH study, and a LOS pressure less than 10 mm Hg; 5) Barrett's esophagus; and 6) peptic stricture.

RESULTS

Four hundred eighteen subjects replied (78% response). Infrequent reflux symptoms were equally common in all groups of relatives. Frequent reflux symptoms, however, were more common among relatives of patients with an abnormal pH study and normal (26%, p = 0.007) or low LOS pressure (27%, p = 0.01) or Barrett's esophagus (30%, p = 0.003), compared with relatives of nondyspeptic patients (9%). Frequent reflux symptoms were no more common among relatives of patients with a normal pH study (16%) or peptic stricture (18%). Reflux medication use showed a similar pattern.

CONCLUSIONS

Familial clustering of reflux symptoms is seen in relatives of patients with reflux symptoms and increased esophageal acid exposure and in relatives of patients with Barrett's esophagus.

Effect of chronic and acute cigarette smoking on the pharyngo-upper oesophageal sphincter contractile reflex and reflexive pharyngeal swallow

BACKGROUND

Cigarette smoking is known to affect adversely the defence mechanisms against gastro-oesophageal reflux. The effect of smoking on the supraoesophageal reflexes that prevent aspiration of gastric contents has not been previously studied.

AIMS

To elucidate the effect of cigarette smoking on two of the supraoesophageal reflexes: the pharyngo-upper oesophageal sphincter (UOS) contractile reflex; and the reflexive pharyngeal swallow.

METHODS

Ten chronic smokers and 10 non-smokers were studied, before and 10 minutes after real or simulated smoking, respectively. UOS pressure and threshold volume for the reflexes were determined using a UOS sleeve assembly. Two modes of fluid delivery into the pharynx were tested: rapid injection and slow injection.

RESULTS

For both rapid and slow injections, the threshold volume for triggering the pharyngo-UOS contractile reflex was significantly higher in smokers than in non-smokers (rapid: smokers 0.42 (SE 0.07) ml, non-smokers 0.16 (0. 04) ml; slow: smokers 0.86 (0.06) ml, non-smokers 0.38 (0.1) ml; p<0. 05). During rapid injection, the threshold volume for reflexive pharyngeal swallow was higher in smokers (smokers 0.94 (0.09) ml, non-smokers 0.46 (0.05) ml; p<0.05). Acute smoking further increased the threshold volume for the pharyngo-UOS contractile reflex and reflexive pharyngeal swallow during rapid injection.

CONCLUSIONS

Smoking adversely affects stimulation of the pharyngo-UOS contractile reflex and pharyngeal reflexive swallow. These findings may have implications in the development of reflux related respiratory complications among smokers.

Effect of transdermal application of nicotine on colonic transit in healthy nonsmoking volunteers

The radio-opaque marker technique (ROMT) is a safe and noninvasive method to determine total colonic (TCTT) and segmental colonic transit times (SCTT). Previous results have shown that smoking volunteers had significantly longer TCTT than nonsmokers, but the underlying mechanism was not clear. We investigated the effect of transdermal nicotine application in two different doses in a non-blind randomized experiment involving three distinct phases. In phase 1 baseline transit times were determined with an abdominal X-ray after a 6-day period of marker ingestion and again after the following bowel movement to study the influence of a bowel movement just before the X-ray. TCTT was nearly twice as high before than after defaecation (42.6 h vs. 25.1 h, P < 0.05). The main acceleration was found in the rectosigmoid (RS) (18.6 h vs 7.1 h, P < 0.05) with no significant changes in right (RC) and left colon (LC). In phase 2 and 3 nicotine was applied in two doses of 17.5 mg day-1 and 35 mg day-1 in random order. Both doses resulted in a significant decrease of TCTT compared to the predefaecation baseline (42.6 h vs 32.2 h/28.2 h, respectively, P < 0.05). Again the main effect was located in the RS (18.6 h vs 9.9 h/7.6 h, P < 0.05). Short-term application nicotine results in a decrease of TCTT which is due to an accelerated transit in the RS.

Effect of smoking on the results of esophageal pH measurement in clinical routine

Because data on the effects of smoking on gastroesophageal reflux are controversial, we evaluated the effect of smoking on the results of esophageal 24-hour pH-metry in clinical routine. Participants were 280 consecutive patients with symptoms suggestive of reflux disease, 78 smokers, and 202 nonsmokers. Of the smokers, 45 actually smoked during the pH measurement and 33 abstained from smoking. The frequency of reflux episodes, the fraction of time pH was < 4, and the percentage of abnormal 24-hour pH-metry results were compared among actual smokers, abstaining smokers, and nonsmokers. In actual smokers, the effect of smoking on gastroesophageal reflux was further analyzed by comparing the reflux frequency and the fraction of time that pH was < 4 for a 10-minute period before, during, and after smoking. We found no difference in reflux frequency and fraction of time that pH was < 4 among actual smokers, abstaining smokers, and nonsmokers, regardless of a normal or an abnormal pH-metry result. The percentage of patients with a pH-metry result indicating disease was similar in the three groups, at 53%, 52%, and 50%, respectively. Gastroesophageal reflux was not increased during smoking a cigarette or in the postsmoking period compared with the presmoking period. Neither being a smoker nor actually smoking a cigarette had a negative influence on gastroesophageal reflux. Thus smoking or abstaining from smoking does not modify the results of pH-metry in clinical routine.

Prognostic factors influencing relapse of oesophagitis during maintenance therapy with antisecretory drugs: a meta-analysis of long-term omeprazole trials

BACKGROUND

This meta-analysis investigated factors that may affect the risk of relapse of oesophagitis, and evaluated the predictive value of symptoms for the presence of relapse during long-term treatment.

METHODS

Individual data from 1154 patients included in five independently conducted, randomized, long-term clinical trials of the efficacy of different dosage regimens of omeprazole, standard ranitidine treatment and placebo for the prevention of relapse of oesophagitis were pooled for this meta-analysis. The therapeutic regimens studied were omeprazole 20 mg o.m. (OME20) in 366 patients, omeprazole 10 mg o.m. (OME10) in 225 patients, omeprazole 20 mg weekends (OMEW) in 235 patients, ranitidine 150 mg b.d. (RAN) in 179 patients, or placebo (PLA) in 149 patients.

RESULTS

OME20 maintained 82.4% (95% CI: 78.2-86.6%) of patients in endoscopic remission over the 6-month period compared to 71.9% (95% CI: 65.5-78.3%) for OME10, 52.3% (95% CI: 44.4-60.1%) for RAN, 42.7% (95% CI: 35.8-49.5%) for OMEW, and 10.6% (95% CI: 5.0-16.3%) for PLA. A Cox's regression analysis of time to recurrence of oesophagitis showed that four factors were associated with a higher relapse rate during placebo and active maintenance therapy: (a) pre-treatment severity of oesophagitis (P < 0.0001), (b) young age (P = 0.01), (c) non-smoking (P = 0.02) and (d) moderate/severe regurgitation before entry into the trials (P = 0.03). Asymptomatic relapse of oesophagitis was uncommon, being found in only 8.6% of the patients.

CONCLUSIONS

Maintenance treatment with omeprazole 10 and 20 mg daily is superior to all other regimens tested, and is only marginally influenced by the pretreatment severity of oesophagitis. Age contributes to the factors that influence the outcome during long-term treatment with omeprazole. Symptom relief is highly predictive for the maintenance of healing.