Modern diagnosis of GERD: the Lyon Consensus

Evidence summary on management strategies for gastroesophageal reflux symptoms in patients following esophageal cancer surgery

Objective

This study aimed to summarize evidence-based strategies for the self-management of gastroesophageal reflux symptoms (GERS) at home among patients who have undergone esophageal cancer surgery, providing practical references for clinical practice.

Methods

A systematic evidence summary was conducted based on the reporting standards of the Fudan University Center for Evidence-based Nursing. Literature was retrieved from international and Chinese databases, including guidelines, expert consensus, systematic reviews, and original studies. The search covered the period from the inception of the databases to June 30, 2024. Two independent reviewers appraised the quality of evidence and synthesized recommendations across six domains: reflux symptoms, assessment, treatment, health education, follow-up, and outcome indicators.

Results

A total of 25 high-quality studies were included, comprising 10 guidelines, 10 expert consensus documents, two systematic reviews, and three original studies. Thirty-four evidence items were synthesized, emphasizing a combination of pharmacological treatments, lifestyle modifications, and health education to improve self-management outcomes.

Conclusions

This evidence synthesis highlights effective strategies for home-based self-management of GERS after esophageal cancer surgery. Future research should focus on culturally tailored interventions and large-scale studies to further enhance the applicability and reliability of these findings.

Trial registration

This study was registered at the Fudan University Center for Evidence-Based Nursing (Registration No. ES202446701).

Predictive Value of Digestive Enzymes in Patients With Reflux-Induced Chronic Cough

OBJECTIVE

To investigate the presence and clinical value of salivary elastase, pepsin, trypsin, cholesterol, and bile salts in the development of laryngopharyngeal reflux disease-related chronic cough (LPRD-CC).

STUDY DESIGN

Prospective controlled study.

SETTING

University hospital study.

METHODS

Patients with LPRD at the 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring were recruited from two European hospitals. Symptoms and findings were evaluated with the reflux symptom score (RSS), quality-of-life RSS (QoL-RSS), and the reflux sign assessment (RSA) at baseline and following 3 months of treatment. Pepsin, trypsin, elastase, cholesterol, and bile acids were measured in the saliva of patients. Clinical presentation and enzyme patterns were compared between patients with LPRD-CC versus patients without chronic cough. Predictive values of digestive enzymes on clinical patterns were assessed.

RESULTS

Of the 104 recruited patients, 54 had LPRD-CC and 50 did not. Patients with chronic cough demonstrated significantly lower pharyngeal upright reflux events but higher RSS compared to those without chronic cough. The CC group demonstrated significant reduction of RSS (164.4 ± 104.5 vs 105.1 ± 103.2) and RSA (27.7 ± 6.6 vs 21.6 ± 8.1) following treatment. RSS (78.4 ± 51.3 vs 50.2 ± 49.7) and RSA (24.8 ± 7.9 vs 21.5 ± 10.3) were similarly reduced in the non-CC group. The chronic cough group maintained significantly higher scores in otolaryngological RSS (P = .033), respiratory RSS (P = .036), overall RSS (P = .035), and RSS quality of life (RSS-QoL) (P = .007). Salivary elastase demonstrated moderate correlation with both chronic cough presence (rs = 0.325) and RSS (rs = 0.353), while salivary bile salts correlated strongly with RSS-QoL (rs = 0.564). In patients with chronic cough, esophageal acid exposure time showed a significant negative correlation with salivary pH (rs = -0.443).

CONCLUSION

LPRD patients with chronic cough demonstrated higher symptom severity than those without, with salivary elastase and bile salts as potential predictors of clinical findings.

Good clinical practice recommendations for proton pump inhibitor prescription and deprescription. A review by experts from the AMG

INTRODUCTION AND AIM

Proton pump inhibitors (PPIs) are widely known drugs that are used quite frequently and indicated in both the short and long terms, in numerous acid-related diseases. Our aim was to produce an expert review that establishes recommendations for the adequate prescription and deprescription of PPIs.

METHODS

A group of experts in PPI use that are members of the Asociación Mexicana de Gastroenterología (AMG), after extensively reviewing the published literature and discussing each recommendation at a face-to-face meeting, prepared the present document of good clinical practice recommendations. This document is not intended to be a clinical practice guideline or utilize the methodology said format requires.

RESULTS

Eighteen experts on PPI use developed 22 good clinical practice recommendations for prescribing short-term, long-term, and on-demand PPIs, recognizing adverse events, and lastly, deprescribing PPIs, in acid-related diseases.

CONCLUSIONS

At present, there is scientific evidence on PPI use in numerous diseases, some in the short term (4-8 weeks), others on-demand (for short periods until symptoms improve), or in the long term (without suspending). Numerous adverse effects have been attributed to PPIs, but the majority have no well-established causal association. Nevertheless, PPIs should be suspended when there is no clear indication for their use. These recommendations aim to aid general physicians and specialists, with respect to PPI prescription and deprescription.

Esophageal Hypervigilance and Mucosal Integrity Predict Symptom Outcomes in Reflux Patients With Normal Acid Exposure

BACKGROUND

Managing esophageal symptoms with normal acid exposure is challenging, requiring focus on both physiological and psychological factors. However, no studies have explored how patients perceive symptom changes after using alginates or proton-pump inhibitors (PPIs) in this context. This study examines the interrelationships among changes in reflux symptom severity, esophageal hypervigilance, and psychological distress in patients with normal esophageal acid exposure treated with either alginate suspension or PPIs.

METHODS

We conducted a 2-year prospective, randomized, open-label study with patients displaying typical reflux symptoms but normal acid exposure, confirmed via ambulatory pH-impedance monitoring. Participants completed validated questionnaires assessing esophageal hypervigilance and anxiety (EHAS), symptom severity, sleep quality, and depression at baseline and follow-up to evaluate symptom changes and predictors between treatments.

RESULTS

Among 146 patients (mean age: 47.9, 63% female), 75 received alginate and 71 PPI therapy. Improvements in questionnaire scores were significant across both treatments (p < 0.001), with no differences between groups. However, only a few patients in both groups achieved a > 50% reduction in gastro-esophageal reflux disease questionnaire (GERDQ) and global symptom severity (GSS) after treatment. Multivariable regression revealed that the reduction in esophageal hypervigilance and lower mean nocturnal baseline impedance (MNBI) were significant predictors of symptom improvement.

CONCLUSION

In reflux patients with normal acid exposure, neither PPIs nor alginates alone effectively improved symptoms, but reducing esophageal hypervigilance and anxiety led to better outcomes. Mucosal integrity and EHAS scores are independent predictors of treatment response. The EHAS is a useful tool for assessing treatment impact and guiding personalized care. A comprehensive approach addressing both psychological and physiological factors is essential, especially for those with normal acid levels.

Diagnosis and Management of Gastroesophageal Reflux Disease: A Concise Review for Clinicians

Gastroesophageal reflux disease (GERD) is a clinical condition seen frequently by both primary care providers and gastroenterologists. Although it is incredibly common, the diagnosis and management of GERD are not always straightforward. In this review, we summarize the symptoms, pathophysiologic process, and risk factors for GERD. We outline a stepwise approach for the diagnosis of GERD, accounting for the presence of typical and atypical symptoms, in the context of alarm symptoms and comorbid conditions. We also outline an approach to management of GERD based on the results of diagnostic work-up, including the presence or absence of GERD-related complications, symptom severity, and response to recommended medical therapy. On completion of this article, clinicians should be able to select the appropriate diagnostic and treatment pathways for patients with GERD. Clinicians should also be able to properly identify when to refer a patient with GERD to a gastroenterologist.

Diagnostic value of combining ultrafast cine MRI and morphological measurements on gastroesophageal reflux disease

PURPOSE

To evaluate the diagnostic performance of combining ultrafast real-time cine MRI with morphological measurements on gastroesophageal reflux disease (GERD).

METHODS

In the prospective study, 40 healthy volunteers and 30 GERD patients underwent real-time cine MRI using an undersampled low-angle gradient echo sequence (50 ms/frame) with deep-learning reconstruction, to monitor the gastroesophageal junction (GEJ) and observe the reflux of the contrast agent during the Valsalva maneuver. The width of the lower esophagus, the length of the lower esophageal sphincter (LES), the end-expiratory and post Valsalva maneuver His angle were measured.

RESULTS

There were no statistical differences between the two group either in lower esophageal width (14.06 ± 1.50 mm vs. 14.75 ± 1.57 mm, P > 0.05) or LES length (25.20 ± 1.46 mm vs. 24.39 ± 1.68 mm, P > 0.05). The end-expiratory His angle (84.45 ± 18.67°) and post Valsalva maneuver His angle (101.53 ± 19.22°), and the differences between them (17.08 ± 5.65°) in the GERD group were greater than those in the healthy volunteers (71.51 ± 18.01°, 86.09 ± 18.24°, 14.57 ± 3.88° respectively, P < 0.05). Reflux was induced in 8 cases of GERD group including 4 cases with hiatus hernia and not observed in healthy volunteers. The AUC for diagnosing GERD were 0.702, 0.737 and 0.634 for end-expiratory, post Valsalva maneuver His angle and their differences, when combined with real-time MRI was 0.823, with a sensitivity of 86.67% and a specificity of 67.50%.

CONCLUSION

Real-time MRI can display dynamic swallowing and reflux at the GEJ. The His angle can serve as a morphological indicator for diagnosing GERD with MRI.

Is gastroesophageal reflux disease a comorbidity of burning mouth syndrome? A cross-sectional, real-world study

BackgroundThe etiology of burning mouth syndrome (BMS) patients remains unclear and systemic conditions concurrently with BMS are viewed with greater scrutiny. The present study aimed to reveal whether gastroesophageal reflux disease (GERD) is the possible comorbidity of BMS.MethodsIn our study, a real-world design was employed, enrolling BMS patients from an oral medicine clinic and capturing data in a non-interventional, cross-sectional setting. Endoscopy and the Gastroesophageal Reflux Disease Questionnaire (GERDQ) were used to assess the potential GERD patients. Demographics, clinical symptoms and signs were compared between both the GERD and non-GERD groups, and GERDQ ≥8 and <8 groups. Meanwhile, GERDQ items were assessed to determine predictive value.ResultsIn total, 124 BMS patients with GERDQ scores were enrolled, of whom 84 patients were screened by endoscopy. GERD were confirmed by endoscopy in 30.95% (26/84) of patients with BMS, whereas 69.05% (58/84) showed no definite evidence of GERD. When GERDQ with a cutoff score of 8 was utilized for screening all 124 BMS patients, 25.8% (32/124) had GERDQ scores ≥8. When considering the endoscopic diagnosis as the golden standard due to the low availability of 24-h pH monitoring, the specificity and sensitivity were 79.2% and 46.2% respectively. Clinically, altered taste (p = 0.022) and thickened tongue coating (p = 0.001) were significantly more common in the GERDQ ≥8 group, whereas no significant difference was revealed between endoscopy approved GERD and non-GERD groups.ConclusionsGERD may represent a potential systemic comorbidity in BMS patients and GERDQ might serve as the screening tool assisting healthcare professionals. Altered taste and thickened tongue coating might be suggestive for potential GERD symptoms in BMS patients. Further research is desired to elucidate the mechanisms linking such conditions.

An indication-based analysis of the yield and findings of esophageal high-resolution manometry

BACKGROUND

High-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. While studies have previously reported on HRM findings in patients with dysphagia and/or chest pain, we sought to compare the yield and findings of HRM based on different indications for motility testing.

METHODS

A retrospective study was performed including all successful HRM studies performed at two tertiary medical centers between 2018 and 2023. The indication was categorized as either: (1) dysphagia; (2) GERD evaluation; (3) non-cardiac chest pain; (4) epigastric pain; (5) regurgitation/vomiting; or (6) prior to esophageal surgery. Motility disorders were diagnosed as per the Chicago Classification, version 4.0.

RESULTS

A total of 768 patients were included (mean age 55.5 +/- 17.3; 56.2% female). The most common indications were dysphagia (368, 47.9%) and prior to reflux testing (267, 34.8%). Normal motility was found in 417 (54.3%) patients while a motility disorder was diagnosed in 351 (45.7%) subjects. A major motility disorder was found in 178 (23.2%) cases, with achalasia in 82 (10.7%) patients. HRM diagnoses significantly differed based on the indication for testing (p < 0.001), with major motility disorders and achalasia being most commonly diagnosed when performed for dysphagia and recurrent regurgitation/vomiting. The indication affected the likelihood of having any motility disorder (p = 0.010), a major motility disorder (p < 0.001), a disorder of EGJ Outflow (p < 0.001), and achalasia (p < 0.001).

CONCLUSIONS

The indication for HRM testing affects the likelihood of having a motility disorder including achalasia. The highest yield is in patients being evaluated for dysphagia and regurgitation/vomiting.

Long-term efficacy of on-demand vonoprazan treatment for mild reflux esophagitis: success rates and predictors of treatment failure

BACKGROUND

Concerns surrounding long-term proton pump inhibitor use have prompted the exploration of alternative treatments for reflux esophagitis (RE). We previously demonstrated that 24 weeks of on-demand treatment with vonoprazan, a potassium-competitive acid blocker, effectively managed mild RE (Los Angeles classification grade A/B) in more than 80% of patients. However, its long-term efficacy remains unknown. Therefore, the present study investigated sustained effectiveness.

METHODS

We conducted a retrospective observational study on 30 participants with mild RE from our previous research. Participants with recurrent RE or symptom exacerbation were excluded and considered as treatment failure. Participants with the remission of RE and reflux symptoms under on-demand treatment until the clinic visit between October 2023 and February 2024 were regarded as treatment success. Predictors of treatment failure were analyzed.

RESULTS

During the observation period, 5 participants failed treatment due to symptom exacerbation and 6 due to recurrent RE. Five participants were excluded from analyses due to non-GERD causes. Fourteen participants (56.0%) successfully continued on-demand treatment for 91.5 months [89.3-92.8]. Age > 67 years significantly predicted treatment failure with a sensitivity of 72.7% and specificity of 85.7%. Although none of the patients with RE grade A had recurrent RE, it was not a significant difference.

CONCLUSIONS

Approximately 50% of patients with mild RE successfully continued on-demand treatment for more than 7 years. Age > 67 years was identified as a predictor of treatment failure. Prospective multi-center studies are warranted to validate these results.

Mucosal integrity and acid sensitivity predict proton pump inhibitor response in patients with heartburn and normal acid exposure

BACKGROUND

Patients with typical reflux symptoms and normal acid exposure time (AET) are classified as either reflux hypersensitivity (RH) or functional heartburn (FH), some of whom respond to proton pump inhibitors (PPIs). We determined if esophageal psychophysiological parameters predict PPI response in symptomatic RH and FH patients.

METHODS

We prospectively recruited adults with heartburn diagnosed with RH or FH on 24-h impedance-pH monitoring off PPI. Mucosal integrity was evaluated using mean nocturnal baseline impedance (MNBI). Symptom response required ≥50 % reduction in global symptom severity. Infusion of hydrochloric acid (0.1 N) into the mid-esophagus evaluated acid sensitivity, using time to initial typical symptom perception (lag time) and intensity rating. Factors influencing PPI response were identified using logistic regression.

RESULTS

Of 102 study participants (age 21-64 years, 69.6 % women, 54 RH, 48 FH), 37.3 % demonstrated PPI response (RH: 44.4 %, FH: 29.2 %, p = NS). On multivariable logistic regression, lower MNBI correlated with PPI response in both RH and FH, shorter lag time also correlated in RH. The optimal MNBI threshold for predicting PPI response was 2500 ohms.

CONCLUSIONS

Lower MNBI indicating mucosal acid damage, and esophageal acid sensitivity prompting early symptom reporting are physiomarkers of PPIs response in RH and FH patients.

Primary Peristalsis Is the Dominant Mechanism of Refluxate Clearance Following Gastroesophageal Reflux

BACKGROUND

Refluxate volume and pH drop following gastroesophageal reflux are mostly cleared by peristalsis. We evaluated the roles of primary volume clearing peristaltic wave (VCPW), secondary VCPW, post-reflux swallow-induced peristaltic wave (PSPW), and late primary peristaltic wave (LPPW) in refluxate clearance.

METHODS

We retrospectively analyzed pH-impedance studies performed off therapy in 40 patients with typical esophageal symptoms. Mechanism of refluxate clearance was evaluated for each reflux episode (primary VCPW vs. secondary VCPW vs. none), as well as presence of PSPW, LPPW when PSPW was absent, and pH recovery with each mechanism. Per-episode and per-patient analyses determined the dominant mechanism of refluxate clearance and pH recovery.

RESULTS

Of 958 reflux episodes, 88% were acidic. A primary VCPW was the dominant mechanism for volume clearance (48.4% acid, 47.8% non-acid reflux episodes), and ≥ 50% pH recovery (58.7%). Of reflux episodes lacking pH recovery, PSPW resulted in ≥ 50% pH recovery in 40.2%, and LPPW in 60.9%. In logistic regression models, primary peristaltic wave (primary VCPW, PSPW, or LPPW) had the highest likelihood of pH recovery in per-episode analysis (OR 2.1, CI 1.3-3.0, p < 0.001), and in per-patient analysis (OR 11.0, CI 1.5-20.5, p = 0.025), among which primary VCPW was the most effective (OR 3.4, CI 1.5-7.7, p = 0.003).

CONCLUSIONS

A primary peristaltic wave from a swallow, either in the form of a VCPW, PSPW, or LPPW, is the dominant mechanism of pH recovery after gastroesophageal reflux. When a primary VCPW does not correct pH drop, PSPW, and LPPW are equivalent salvage mechanisms for pH recovery.

Clinical Relevance and Therapeutic Findings of Chronic Cough Related to Laryngopharyngeal Reflux Disease

OBJECTIVE

To investigate clinical significance of chronic cough in patients with laryngopharyngeal reflux disease (LPRD) and evaluate the potential of cough as a predictor for clinical findings and treatment outcomes.

METHODS

Data of patients with a positive diagnosis of LPRD at the 24-hour hypopharyngeal-esophageal multi-channel intraluminal impedance-pH monitoring (HEMII-pH) prospectively followed at the European Reflux Clinic and Elsan Hospital from January 2017 to August 2024 were retrieved. Four study groups were established based on chronic cough severity. Between-group analysis included HEMII-pH parameters (number and pH of pharyngeal reflux events), pretreatment and post treatment reflux symptom scores (RSS), reflux sign assessment (RSA), and gastrointestinal endoscopy findings.

RESULTS

The study included 523 patients [303 females (57.9%) and 220 males (42.1%)]. Of the 523 patients with LPRD, 326 (62.3%) had mild-to-severe chronic cough. The mean ages of patients ranged from 50.3 to 52.7 years. The cough severity score was associated with the severity of otolaryngological, digestive, and non-cough respiratory symptoms, with the mildest presentations in patients without chronic cough. The magnitude of pretreatment to post treatment changes in RSS and RSA decreased as cough severity increased. Patients with chronic cough demonstrated higher post therapeutic otolaryngological and non-cough respiratory symptom scores, while there were no significant differences across groups for digestive symptoms. The therapeutic response rate was 75.1%, without demonstrating significant differences between patients with chronic cough (75.9%) and those without (73.8%). The cough severity score was a predictor of the post treatment RSS (rs = 0.222; P = 0.001).

CONCLUSION

Chronic cough is a predominant symptom in LPRD with a prevalence of 62.3%. At baseline presentation, chronic cough severity is suggestive of a significant prognostic indicator of LPRD RSS severity.

Is Height a Contributing Factor of Laryngopharyngeal Reflux Disease? A Case-Series of 463 Patients

OBJECTIVE

To investigate the influence of height on pharyngeal reflux characteristics, clinical presentation, and therapeutic outcomes in patients with laryngopharyngeal reflux disease (LPRD).

METHODS

Data of patients with a positive diagnosis of LPRD at the 24-hour hypopharyngeal-esophageal multi-channel intraluminal impedance-pH monitoring (HEMII-pH) were collected from the European Reflux Clinic and Elsan Hospital from January 2017 to October 2024. Analysis included HEMII-pH parameters (number and pH of pharyngeal reflux events), pretreatment and post treatment reflux symptom scores (RSS), reflux sign assessment (RSA), and gastrointestinal endoscopy findings stratified by patient height.

RESULTS

The study included 463 patients (257 females (55.5%) and 206 males (44.5%). The mean ages of females and males were 51.7 ± 15.4 and 50.4 ± 16.1, respectively. Females demonstrated higher frequency of weakly acidic pharyngeal reflux events and RSS compared to males. Height did not influence HEMII-pH parameters or endoscopic findings in either sex. However, shortest females reported higher baseline digestive symptoms and demonstrated higher 3-month post treatment RSA scores. In males, therapeutic response varied by height, with significant RSS improvements observed in groups <171 cm and 171-180 cm, while the tallest group showed no significant improvement.

CONCLUSION

Height does not influence objective HEMII-pH findings. RSS did not differ across height-stratified cohorts, either at baseline or 3 months post treatment. Future studies should investigate the role of physiological, anatomical, and behavioral factors in height-related therapeutic variations.

A novel ingredients recipe derived from Shugan-Hewei Formula targeting chemical carcinogenesis-ROS signaling pathway treated gastroesophageal reflux disease

ETHNOPHARMACOLOGICAL RELEVANCE

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disease Shugan-Hewei (SGHW) formula is an extensively used traditional herbal decoction for treating GERD, which can significantly improve the clinical symptoms, quality of life, anxiety and depression status, etc. AIM OF THE STUDY: To elucidate the potential targets and pathways of SGHW in treating GERD by employing an integrative approach involving transcriptomics-based analysis combined with accurate network pharmacology.

MATERIALS AND METHODS

First, we conducted animal experiments to investigate the effect of SGHW on GERD. Then, transcriptome sequencing was used to reveal the differentially expressed genes (DEGs). Meanwhile, the main ingredients of SGHW were identified by UPLC/Q-TOF MS, and the compound-target network was constructed. We integrated the DEGs with the compound-target network to identify core DEGs, which were used to establish a protein-protein interaction (PPI) network and GO/KEGG pathways. After that, we mapped the core PPI network and the core pathway to pinpoint the critical targets. Similarly, we mapped the critical targets and the compound-target network to discover core compound-target pairs and employed molecular docking techniques to elucidate the interactions between these pairs. Finally, key signaling pathways and their targets were validated by immunoblotting and immunofluorescence.

RESULTS

The application of the SGHW resulted in a notable enhancement of the phenotype in the mixed reflux rat model. Transcriptomic analysis revealed a total of 1388 DEGs, among which 801 were upregulated and 587 were downregulated. According to Lipinski's "rule of 5", 45 compounds were extracted from the SGHW samples using UPLC/Q-TOF MS. Through online database searches, we identified 1131 potential targets for the active compounds and constructed a compound-target network based on these potential targets. Subsequently, we mapped the DEGs associated with the compound-target network, identifying 29 compounds targeting 119 core DEGs. KEGG pathway analysis of these core DEGs highlighted the chemical carcinogenesis-reactive oxygen species (ROS) signaling pathway as one of the most prominent pathways involved. We then established a PPI network based on these core DEGs and mapped the core PPI network alongside ROS pathway-related targets, identifying HMOX1 and CYP1A1 as the critical targets. Further analysis pinpointed key compound-target pairs, including Berberine targeting CYP1A1, and Honokiol, Tangeretin, α-Cyperone, 1-O-Acetylbritannilactone, Rotundine B, Cyperolone targeting HMOX1. These findings were validated through immunoblotting and immunofluorescence assays conducted in vivo.

CONCLUSION

In this study, we identified the monomers recipe derived from SGHW, including Berberine targeting CYP1A1, and Honokiol, Tangeretin, α-Cyperone, 1-O-Acetylbritannilactone, Rotundine B, Cyperolone targeting HMOX1 to regulate ROS signaling pathway in GERD treatment. Our findings offered a comprehensive insight into GERD treatment and herbal intervention, enhancing our understanding of accurate network pharmacology. It suggested that concentrating on a single pathway, specifically the ROS signaling pathway, could serve as a new therapeutic strategy for herbal medicine in GERD treatment.

Diagnostic Accuracy of Patient-Reported Outcome Measures and Finding Instruments in Laryngopharyngeal Reflux Disease

OBJECTIVE

To investigate the diagnostic accuracy of various combinations of patient-reported outcome measures (PROMs) and upper aerodigestive tract finding instruments dedicated to the clinical diagnosis of laryngopharyngeal reflux disease (LPRD).

STUDY DESIGN

Prospective, multicenter study.

SETTING

University hospital.

METHODS

Patients with LPRD at the 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring were recruited from three European hospitals. Asymptomatic individuals served as the control group. Participants completed the Reflux Symptom Index (RSI), Reflux Symptom Score (RSS), and Reflux Symptom Score-12 (RSS-12) at baseline and 3-month posttreatment. Clinical signs were evaluated with the Reflux Finding Score (RFS), Reflux Sign Assessment (RSA), and Reflux Sign Assessment-10 (RSA-10). Sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) were calculated for each instrument and their combinations.

RESULTS

A total of 542 LPRD patients and 204 healthy controls were included. The RSS was the PROM with the highest SE (95.4%), whereas RSS-12 reported the highest SP (94.7%). RSA had the highest SE (94.0%), and RSA-10 reported the highest SP (76.3%). The highest SE and SP of combination tools were found for RSS+RSA (90.4%) and RSS+RSA-10 (99.4%), respectively. RSS+RSA-10 achieved the highest PPV value (99.7%) and RSS+RSA had the highest NPV (79.3%). Overall, the RSS demonstrated the greatest diagnostic accuracy with an area under the curve (AUC) of 0.985. The combination RSS+RSA reported an AUC of 0.934.

CONCLUSION

The combination of RSS and RSA provided the most accurate diagnostic performance, maximizing SE, SP, PPV, and NPV. This combination offers enhanced utility for the preliminary diagnosis of LPRD.

Constructing an artificial intelligence-assisted system for the assessment of gastroesophageal valve function based on the hill classification (with video)

OBJECTIVE

In the functional assessment of the esophagogastric junction (EGJ), the endoscopic Hill classification plays a pivotal role in classifying the morphology of the gastroesophageal flap valve (GEFV). This study aims to develop an artificial intelligence model for Hill classification to assist endoscopists in diagnosis, covering the entire process from model development, testing, interpretability analysis, to multi-terminal deployment.

METHOD

The study collected four datasets, comprising a total of 1143 GEFV images and 17 gastroscopic videos, covering Hill grades I, II, III, and IV. The images were preprocessed and enhanced, followed by transfer learning using a pretrained model based on CNN and Transformer architectures. The model training utilized a cross-entropy loss function, combined with the Adam optimizer, and implemented a learning rate scheduling strategy. When assessing model performance, metrics such as accuracy, precision, recall, and F1 score were considered, and the diagnostic accuracy of the AI model was compared with that of endoscopists using McNemar's test, with a p-value < 0.05 indicating statistical significance. To enhance model transparency, various interpretability analysis techniques were used, including t-SNE, Grad-CAM, and SHAP. Finally, the model was converted into ONNX format and deployed on multiple device terminals.

RESULTS

Compared through performance metrics, the EfficientNet-Hill model surpassed other CNN and Transformer models, achieving an accuracy of 83.32% on the external test set, slightly lower than senior endoscopists (86.51%) but higher than junior endoscopists (75.82%). McNemar's test showed a significant difference in classification performance between the model and junior endoscopists (p < 0.05), but no significant difference between the model and senior endoscopists (p ≥ 0.05). Additionally, the model reached precision, recall, and F1 scores of 84.81%, 83.32%, and 83.95%, respectively. Despite its overall excellent performance, there were still misclassifications. Through interpretability analysis, key areas of model decision-making and reasons for misclassification were identified. Finally, the model achieved real-time automatic Hill classification at over 50fps on multiple platforms.

CONCLUSION

By employing deep learning to construct the EfficientNet-Hill AI model, automated Hill classification of GEFV morphology was achieved, aiding endoscopists in improving diagnostic efficiency and accuracy in endoscopic grading, and facilitating the integration of Hill classification into routine endoscopic reports and GERD assessments.

NMDAR2B/PKA/CREB signaling pathway contributes to esophageal neuropathic pain in gastroesophageal reflux disease

BACKGROUND

Esophageal hypersensitivity is an important cause of refractory gastroesophageal reflux disease, in which patients do not respond to standard acid-suppressive therapy and suffer from continuous noncardiac chest pain and regurgitation. The N-methyl-D-aspartate receptor (NMDAR) may play a crucial role in the development of visceral hypersensitivity in functional gastrointestinal disorders. However, the specific mechanisms of visceral hypersensitivity in upper digestive tract diseases remain poorly understood.

AIM

To investigate the role of the NMDAR2B/protein kinase A (PKA)/cAMP-response element binding protein (CREB) signaling pathway in the development of esophageal neuropathic pain associated with gastroesophageal reflux disease (GERD).

METHODS

Thirty-six 6-week-old specific pathogen free rats were randomly assigned to six groups: the control, model, model + NMDAR agonist, model + NMDAR antagonist, model + PKA antagonist, and model + NMDAR antagonist + PKA agonist groups, with six rats in each group. The model was induced via an intraperitoneal injection of ovalbumin for sensitization along with local esophageal stimulation. Immunohistochemistry and Western blotting were utilized to assess the expression levels of NMDAR2B signaling pathway-related proteins in the cingulate gyrus, dorsal thalamus, spinal dorsal horn, and peripheral esophageal tissues. RT-PCR was used to measure the corresponding mRNA expression, and ELISA was used to determine the serum brain-derived neurotrophic factor (BDNF) concentration. Behavioral scoring was performed during balloon distention and acid perfusion of the lower esophagus.

RESULTS

Compared with the control group, the model group presented significantly increased expression levels of the NMDAR2B, PKA, CREB, BDNF, substance P, and calcitonin gene-related peptide proteins and mRNAs in the cingulate gyrus, dorsal thalamus, spinal dorsal horn, and lower esophagus (P < 0.05). Compared with the model group, the model + NMDAR agonist group exhibited even higher expression levels of these proteins and mRNAs (P < 0.05), whereas the model + NMDAR antagonist and model + PKA antagonist groups presented lower expression levels (P < 0.05). The model + NMDAR antagonist + PKA agonist group presented higher expression levels than did the model + NMDAR antagonist group (P < 0.05). The changes in the serum BDNF concentration and behavioral score during balloon distention and acid perfusion were consistent with these changes in expression.

CONCLUSION

The NMDAR2B signaling pathway plays a critical role in the development of neuropathic pain in GERD through the PKA/CREB/BDNF pathway.

Differences in medical care satisfaction of patients with "functional" vs "organic" esophageal diseases, Italian validation of the PPRS SF questionnaire

Patient-physician relationship (PPR) plays a key role in modern healthcare, especially within gastrointestinal medical practice. In 2017 Kurlander et al. developed a Patient-Physician-Relationship-Scale (PPRS), a questionnaire used to assess the patients' medical care-satisfaction. The PPRS was later simplified by Drossman et al. in 2021 by creating a PPRS-SF (short form). This study aimed to validate the PPRS-SF in Italian and to administer it to patients with "functional" and "organic" esophageal diseases, to highlight the differences in the PPR between the two categories. The process of validation was carried out following a standardized forward-backward procedure and each step was overseen by a Rome foundation independent clinical monitor. The Italian version of the PPRS-SF was then administered to 50 Eosinophilic Esophagitis (EoE), 53 Achalasia, 48 Gastroesophageal Reflux Disease (GERD) and 44 esophageal disorders of gut brain interaction (eDGBI) patients. In eDGBI and GERD, the degree of patients' satisfaction was significantly lower. Between a score of -36 and + 36, the mean score for patients with EoE was 30.20 (± 9.78), for Achalasia 23.78 (± 19.9); for GERD 20.46 (± 16.03) and for esophageal DGBI 17.91 (± 18.41). Moreover, there was a negative significant correlation between the PPR and age (R=- 0.208). This study validated the Italian version of the PPRS-SF questionnaire and showed that the patients' diagnosis together with other factors such as their age, can affect the PPR. In particular, patients with DGBI and older patients reported lower scores than the ones with organic diseases and the younger ones, respectively.

The Los Angeles-B esophagitis is a conclusive diagnostic evidence for gastroesophageal reflux disease: the validation of Lyon Consensus 2.0

Background and Aims

Recently, Lyon Consensus 2.0 recommended Los Angeles (LA)-B esophagitis as conclusive evidence and LA-A esophagitis as borderline evidence for gastroesophageal reflux disease (GERD). This study aimed to investigate the diagnostic value of LA-B and LA-A esophagitis.

Methods

Patients with typical reflux symptoms who underwent endoscopy examination and received acid-suppressive therapy from two tertiary hospitals [the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, P. R. China) and the Third People's Hospital of Chengdu (Chengdu, P. R. China)] were retrospectively included. Acid-suppression response rates, endoscopy results, motility, and reflux parameters were compared between patients with different grades of esophagitis.

Results

In total, 401 patients were enrolled, among whom 254 were without reflux esophagitis (RE), 51 had LA-A esophagitis, 44 had LA-B esophagitis, and 52 had LA-C/D esophagitis. Patients with LA-B esophagitis and LA-C/D esophagitis had significantly higher acid-suppressive response rates than non-RE patients (P < 0.05), whereas no significant difference was found between patients with LA-A esophagitis and non-RE patients (non-RE vs LA-A vs LA-B vs LA-C/D: 52.4% vs 70.6% vs 75.0% vs 82.7%). Among patients with LA-A esophagitis, those with a number of reflux episodes that exceeded 80 per day (90.0% vs 52.4%, P = 0.044) or hypotensive esophagogastric junction (72.4% vs 52.4%, P = 0.040) had significantly higher acid-suppressive response rates than non-RE patients.

Conclusions

LA-B esophagitis can be regarded as conclusive evidence for GERD and initiate acid-suppressive therapy. LA-A esophagitis did not establish a definite GERD diagnosis alone. When combined with adjunctive or supportive evidence, the acid-suppressive therapy response rate of LA-A esophagitis improved.

Insight into global burden of gastroesophageal reflux disease: Understanding its reach and impact

The exact worldwide prevalence of gastroesophageal reflux disease (GERD) remains uncertain, despite its recognition as a common condition. This conundrum arises primarily from the lack of a standardized definition for GERD. The gold standard diagnostic tests for GERD, such as pH impedance testing and endoscopy, are cumbersome and impractical for assessing community prevalence. Consequently, most epidemiological studies rely on symptom-based screening tools. GERD symptoms can be both esophageal and extraesophageal, varying widely among individuals. This variability has led to multiple symptom-based definitions of GERD, with no consensus, resulting in prevalence estimates ranging from 5% to 25% worldwide. Most systematic reviews define GERD as experiencing heartburn and/or regurgitation at least once weekly, yielding a calculated prevalence of 13.98%. In 2017, the global age-standardized prevalence of GERD was estimated at 8819 per 100000 people (95% confidence interval: 7781-9863), a figure that has remained stable from 1990 to 2017. Prevalence increases with age, leading to more years lived with disability. GERD significantly impairs quality of life and can lead to multiple complications. Additionally, it imposes a severe economic burden, with the United States alone estimated to spend around 10 billion dollars annually on diagnosis and treatment. In summary, GERD prevalence varies greatly by region and even within different areas of the same province. Determining the exact prevalence is challenging due to inconsistent diagnostic criteria. However, it is well-documented that GERD poses a significant global burden, affecting the quality of life of individuals and creating a substantial healthcare cost.

Economic and treatment burden among newly diagnosed patients with erosive esophagitis in the US: a national retrospective cohort study

Erosive esophagitis (EE) is a common complication of gastroesophageal reflux disease. Guidelines support long-term proton pump inhibitor (PPI) therapy to relieve symptoms and maintain healing of EE. Ideally, patients remain on their first line of therapy (LOT) with an effective PPI. We aimed to measure how often patients receive PPI, persistence and cycling among LOTs, and resulting healthcare resource utilization and costs. We assessed administrative claims data of patients diagnosed with EE between 0 October 2016 and 31 December 2020 using the Optum Research Database. We assessed prescribing rates of the first PPI, persistence, and rate of cycling among LOTs, health care resource utilization, and overall costs. Of 281,087 patients with EE, 178,789 had endoscopy. Overall, 27% of EE-diagnosed patients and 21% of patients in the endoscopy subgroup did not receive a PPI prescription. Among patients that did receive PPI, cycling and switching among PPIs was common, with over 50% of those patients switching to another PPI or back to a previously-used PPI after a lapse in therapy. Average total all-cause costs per patient among endoscopy patients (including patients with no record of PPI fills) were $58,692.46, and average total EE-related costs were $4304.88. Patients with EE frequently cycle and switch among PPIs. About one-fifth of patients who underwent endoscopy did not receive prescription PPI. Health care resource utilization and costs in patients with EE are substantial. PPI cycling and high discontinuation rates to PPI therapy contribute to costs associated with EE and potential delays in effective therapy.

A Paper-Based Sensor for the Detection of Gastroesophageal Reflux Disease Utilizing a Cleavable Fluorescent Polymer

Nowadays, gastroesophageal reflux disease (GERD) has emerged as one of the major hazards to the health of the upper gastrointestinal tract, and there is an urgent need for a low-cost, user-friendly, and non-invasive detection method. Herein, a paper-based sensor (CP sensor) for the non-invasive screening of GERD is proposed. The sensor is structured as a specially shaped cellulose paper strip embedded with fluorescent colloids, which are self-assembled from a cleavable synthetic fluorescent polymer (P4). Benefiting from the introduction of amide bonds and the unique assembled structure of the nanocolloids, the pepsin in the sample solution will hydrolyze the water-soluble branches in the micellar shell during detection, resulting in a corresponding output of the fluorescent signal. This responsiveness, which can be observed by the naked eye, is so sensitive with a minimum detectable concentration for pepsin as low as 0.3 ng·mL-1. Clinical trials have further demonstrates that the designed paper sensor is capable of providing improved accuracy in the early diagnosis of GERD.

The relationship between intraoperative EndoFLIP™ distensibility index and manometry lower esophageal sphincter basal mean pressure in patients undergoing anti-reflux surgery

BACKGROUND

Decisions made for anti-reflux surgery can be guided by both EndoFLIP™ measurement of lower esophageal sphincter (LES) distensibility index (DI) and esophageal manometric measurement of lower esophageal function, but the exact nature of their relationship to one another is unknown despite serving similar purposes. The purpose of this study is to evaluate the relationship between pre-operative LES basal mean pressure with esophageal manometry and intraoperative gastroesophageal DI using EndoFLIP™ following crural dissection to aid in informing surgeons' decision-making during anti-reflux surgery.

METHODS

A retrospective chart review was conducted of patients with gastroesophageal reflux disease who underwent preoperative esophageal manometry evaluation and anti-reflux surgery with EndoFLIP™ intraoperatively between December 2020 and January 2024. Data collected included LES basal mean pressure from manometry and the logarithm of intraoperative EndoFLIP™ DI. Data analysis included descriptive statistics, Pearson's correlation coefficient, and independent sample t-tests.

RESULTS

A total of 147 patients were included in the study. Mean LES basal pressure was 20.3, and median DI after crural dissection was 4.6. There was a significant but weak to non-existent inverse correlation between LES basal mean pressure following crural dissection and logDI (r = - 0.243, p = 0.005). Mean LES pressures were compared with findings of significant differences at DI 5, 5.5, 6, 6,5, 7, 7.5, and 8 (p < 0.05 for all), thus, none of the analyzed DI cut-points could definitively be used to inform operative decision-making.

CONCLUSION

There is a significant but weak or non-existent inverse relationship between LES basal mean pressure measured on manometry and DI following crural dissection during anti-reflux surgery, but no specific DI can determine best fundoplication type of surgery based on LES pressures. Surgeons should take advantage of the distinct information gleaned from both manometry and EndoFLIP™, when possible, when planning and performing anti-reflux surgery.

Laryngopharyngeal Reflux Disease and Gastroesophageal Reflux Disease Can Mutually Influence

OBJECTIVE

To investigate the mutually relationship between gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPRD).

METHODS

All included patients completed simultaneous 24-hour hypopharyngeal intraluminal multichannel impedance pH monitoring (24h-MII-pH), Reflux Symptom Index (RSI), and Reflux Finding Score (RFS). The LPRD diagnosis was based on the occurrence of ≥1 acid or non-acid hypopharyngeal proximal reflux episode(HRE), GERD was defined as a length of time >4.0% of the 24-hour recording spent below pH 4.0 or a DeMeester score >14.72. Patients with both positive LPRD and GERD were classified as LPRD & GERD group, patients with positive LPRD and negative GERD were classified as ILPRD group, patients with negative LPRD and positive GERD were classified as IGERD group, and patients with both negative LPRD and GERD were classified as N group. The differences in clinical characteristics of reflux between the groups were statistically analyzed.

RESULTS

A total of 437 patients were included, including 248 (56.75%) in the ILPRD group, 98 (22.43%) in the LPRD & GERD group, 23 (5.26%) in the IGERD group, and 68 (15.56%) in the N group. There was no significant difference between the types of gastroesophageal reflux in patients with GERD. The number of weak acid/acid/gas/liquid HREs was significantly more in LPRD & GERD patients than in ILPRD patients (P < 0.01), and the number of distal acid reflux events and Longest distal acid clearance time were significantly higher in LPRD & GERD patients than in IGERD patients (P > 0.01).

CONCLUSION

GERD and LPRD are not the same disease but can mutually influence. Combined GERD increased all types of laryngopharyngeal reflux events in patients with LPRD, whereas combined LPRD only increased acidic distal reflux events and acid clearance time in patients with GERD.

Topical Protection of Esophageal Mucosa as a New Treatment of GERD

Among the various factors implicated in the pathogenesis of gastroesophageal reflux disease (GERD), visceral hypersensitivity and mucosal resistance have been recently re-evaluated in relation to the increasing phenomenon of proton pump inhibitor failure, particularly in patients with nonerosive reflux disease (NERD). Intensive research has allowed us to understand that noxious substances contained in the refluxate are able to interact with esophageal epithelium and to induce the elicitation of symptoms. The frequent evidence of microscopic esophagitis able to increase the permeability of the mucosa, the proximity of sensory afferent nerve fibers to the esophageal lumen favoring the higher sensitivity to noxious substances and the possible activation of inflammatory pathways interacting with sensory nerve endings are pathophysiological alterations confirming that mucosal resistance is impaired in GERD patients. Accordingly, the reinforcement of protective mechanisms of esophageal mucosa by topical therapies has become a novel treatment target. Alginate, the combination of hyaluronic acid+chondroitin sulphate and Poliprotect have been shown to adhere to esophageal mucosa and to have good protective properties. Several placebo-controlled clinical trials have shown that these compounds, given alone or as add-on therapy for short periods, enable to relieve symptoms and to improve the quality of life in NERD patients. Further studies are needed to confirm the above results and to find new mucosal protectants in order to improve the management of NERD patients.

American Foregut Society Cooperative White Paper on Mechanisms of Pathologic Reflux and Antireflux Surgery

Background:

Within the spectrum of gastroesophageal reflux disease (GERD), pathologic reflux applies to the subset of patients with either erosive esophagitis or abnormal esophageal acid exposure on pH-metry, consequences of a dysfunctional antireflux barrier (ARB).

Methods:

The American Foregut Society (AFS) tasked a 13-member working group of expert foregut surgeons and esophagologists (The ARB Cooperative) to develop a white paper on ARB function, dysfunction, and mechanisms of action of antireflux surgery through discussion of relevant literature summarized herein.

Results:

The ARB Cooperative concluded that pathologic reflux is a consequence of the interplay between progressive anatomical distortion of the ARB and physiology. Factors contributing to ARB dysfunction include (1) separation of crural diaphragm from the lower esophageal sphincter with widening of the hiatus and diminished crural diaphragm sphincteric function; (2) loss of the intra-abdominal lower esophageal sphincter segment with complete disabling of the flap valve component of the ARB; (3) axial hiatal hernia leading to reflux during swallow-induced lower esophageal sphincter (LES) relaxation, LES hypotension, inspiration related reflux, a lowered threshold for eliciting transient LES relaxations, and increased compliance of the gastroesophageal junction leading to greater diameter of sphincter opening during transient LES relaxations. With regard to antireflux surgery, the objectives include: (1) reduction of hiatal hernia and restoration of the intra-abdominal esophageal segment; (2) repair of the dilated hiatus; (3) restoring flap valve function by modifying gastroesophageal anatomy; and (4) restricting gastroesophageal junction opening during periods of relaxation.

Conclusions:

This ARB Cooperative white paper supports the concept of there being 3 major inter-related mechanisms promoting ARB competence: the LES as an intrinsic sphincter, the crural diaphragm as an extrinsic sphincter, and the gastroesophageal valve, a mechanical 1-way valve. Pathological reflux occurs with progressive anatomical disruption of the ARB which in turn leads to physiological dysfunction, the severity of which parallels the extent of anatomical disruption. The corollary of this is that the primary mechanism of antireflux surgery is to restore the ARB by eliminating or compensating for its anatomical disruption. It is the hope of the cooperative that understanding the proposed framework will help clinicians and researchers in improving antireflux procedures.

Isfahan Artificial Intelligence Event 2023: Reflux Detection Competition

Background

Gastroesophageal reflux disease (GERD) is a prevalent digestive disorder that impacts millions of individuals globally. Multichannel intraluminal impedance-pH (MII-pH) monitoring represents a novel technique and currently stands as the gold standard for diagnosing GERD. Accurately characterizing reflux events from MII data are crucial for GERD diagnosis. Despite the initial introduction of clinical literature toward software advancements several years ago, the reliable extraction of reflux events from MII data continues to pose a significant challenge. Achieving success necessitates the seamless collaboration of two key components: a reflux definition criteria protocol established by gastrointestinal experts and a comprehensive analysis of MII data for reflux detection.

Method

In an endeavor to address this challenge, our team assembled a dataset comprising 201 MII episodes. We meticulously crafted precise reflux episode definition criteria, establishing the gold standard and labels for MII data.

Result

A variety of signal-analyzing methods should be explored. The first Isfahan Artificial Intelligence Competition in 2023 featured formal assessments of alternative methodologies across six distinct domains, including MII data evaluations.

Discussion

This article outlines the datasets provided to participants and offers an overview of the competition results.

Reflux Seen on a Barium Swallow is Not a Substitute For Ambulatory Reflux Monitoring in Symptomatic Patients

OBJECTIVE

Gastroesophageal reflux (GER) is often reported in barium studies (GERB). We aimed to evaluate whether GERB associates with parameters defining conclusive reflux using Lyon criteria on esophageal physiological testing (GERpH).

METHODS

Adults who underwent both ambulatory reflux monitoring off antisecretory therapy and barium esophagogram between 2018 and 2023 were eligible for inclusion in this retrospective study. All reflux monitoring studies were independently reviewed to extract acid exposure time (AET) and number of reflux episodes. GERpH was diagnosed based on Lyon consensus criteria, and compared with GERB reported on barium esophagogram. Performance characteristics of GERB in predicting AET >6% and GERpH by Lyon criteria were calculated.

RESULTS

Of 182 patients (median age: 55.0 y, 69.8% females, median body mass index: 29.8 kg/m2), 61 had GERB and 101 had GERpH, whereas 58 had neither GERB nor GERpH. AET >6% was seen in 39.3% with GERB, and never with GERB without GERpH. The sensitivity and specificity of GERB in predicting AET >6% were 31.6% and 65.1%; corresponding values in predicting conclusive gastroesophageal reflux disease were 37.6% and 71.6%, respectively. A hiatus hernia (HH) was seen in 46.8% with GERB and was associated with higher median AET (6.0% vs 3.8% without HH, P = 0.003) and higher frequency of AET >6% (50.6% vs 32.5%, P = 0.032), but not higher reflux episodes (P ≥ 0.51).

CONCLUSIONS

In patients with symptoms suspicious of reflux disease, reflux seen on a barium esophagogram has suboptimal performance characteristics in predicting conclusive gastroesophageal reflux disease. HH identified on barium esophagography is associated with a higher reflux burden on reflux monitoring.

Spectrum of esophageal manometry and 24-h pH impedance findings in non-erosive gastroesophageal reflux disease and response to phenotype-based treatment-A prospective observational study

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is classified into erosive reflux disease (ERD) and non-erosive reflux disease (NERD). NERD includes three phenotypes: true NERD, functional heartburn (FH) and reflux hypersensitivity (RH). The management of these NERD phenotypes differs. We aimed at studying the spectrum of high-resolution manometry (HRM) and 24-hour impedance-pH findings in Indian patients with NERD, classifying the phenotypes and assessing the response to phenotype-based treatment.

METHODS

We prospectively studied the clinical characteristics, endoscopy, HRM, 24-hour impedance-pH findings, symptom association and response to phenotype-specific treatment in patients with NERD.

RESULTS

Of 53 patients with NERD, the following phenotypes were diagnosed namely: 35 (66%) true NERD, 12 (22.7%) RH and six (11.3%) FH. The esophagogastric junction-contractile integral (EGJ-CI) was low in 60.4% and ineffective esophageal motility (IEM) was present in 53% of patients. The respective median values for true NERD, RH and FH groups were as follows: proximal mean nocturnal baseline impedance (P-MNBI) 2250Ω, 2241Ω, 2550Ω, (p = 0.592), distal (D-MNBI) 1431Ω, 2887.5Ω, 2516Ω (p < 0.001), post-reflux swallow-induced peristaltic wave index (PSPWI) 11.1%, 16%, 18.7% (p = 0.127). Receiver operating characteristic (ROC) curve analyses showed that D-MNBI and PSPWI discriminated FH and RH from true NERD, respectively, with a cut-off of 2376.5Ω (area under curve [AUC]:0.919, p < 0.001), 22.6% (AUC:0.671, p = 0.184) and 2318Ω (AUC:0.919, p =  < 0.001), 16.2% (AUC:0.671, p = 0.079). The median P-MNBI was lower in patients with GERD-associated cough than other symptoms 1325 (1250, -). Fifty (94.3%) patients showed significant improvement in symptom severity scores (p < 0.001) following phenotype-specific treatment.

CONCLUSIONS

In NERD patients, EGJ-CI and IEM were low. D-MNBI and PSPWI could effectively discriminate true NERD from FH and RH, whereas P-MNBI could help diagnose GERD-associated cough. The phenotype-specific treatment provides better symptom relief for patients.

Management of Patients With Refractory Reflux-Like Symptoms Despite Proton Pump Inhibitor Therapy: Evidence-Based Consensus Statements

BACKGROUND

Many patients diagnosed with gastro-oesophageal reflux disease (GERD) have persistent symptoms despite proton pump inhibitor (PPI) therapy.

AIMS

The aim of this consensus is to provide evidence-based statements to guide clinicians caring for patients with refractory reflux-like symptoms (rRLS) or refractory GERD.

METHODS

This consensus was developed by the International Working Group for the Classification of Oesophagitis. The steering committee developed specific PICO questions pertaining to the management of PPI rRLS. Methodologists conducted systematic reviews of the literature. The quality of evidence and strength of recommendations were rated using the GRADE approach.

RESULTS

Consensus was reached on 13 of 17 statements on diagnosis and management. For rRLS, suggested diagnostic strategies included endoscopy, ambulatory reflux testing and oesophageal manometry. The group did not reach consensus on the role of oesophageal biopsies or the use of reflux-symptom association in patients undergoing reflux testing. The group suggested against increasing the PPI dose in patients who had received 8 weeks of a twice-daily PPI. Adjunctive alginate or antacid therapy was suggested. There was no consensus on the role of adjunctive prokinetics. There was little role for adjunctive transient lower oesophageal sphincter relaxation (TLESR) inhibitors or bile acid sequestrants. Endoscopic or surgical anti-reflux procedures should not be performed in patients with rRLS in the absence of objectively confirmed GERD.

CONCLUSIONS

The management of rRLS should be personalised, based on shared decision-making regarding the role of diagnostic testing to confirm or rule out GERD as a basis for treatment optimisation. Anti-reflux procedures should not be performed without objective confirmation of GERD.

Mean Nocturnal Baseline Impedance May Be Greater Than 2500 Ohms in Chinese Patients With GERD

BACKGROUND

According to the Lyon Consensus 2.0, mean nocturnal baseline impedance (MNBI) greater than 2500 Ω is considered evidence against gastroesophageal reflux disease (GERD). However, we have observed that a subset of GERD patients presents with MNBI exceeding 2500 Ω.

AIMS

To investigate MNBI characteristics in Chinese GERD patients, identify clinical features of those with normal MNBI, and examine factors influencing MNBI values.

METHODS

We retrospectively investigated 259 patients with typical reflux symptoms. Demographics, symptoms, proton pump inhibitor (PPI) response, esophageal motility parameters were compared between patients with different AET levels and MNBI levels.

RESULTS

Among the cohort, 38.2% had AET 4%-6%, and 37.5% had AET > 6%. Notably, 95.2% of patients with AET < 4%, 49.5% with AET 4%-6%, and 17.6% with AET > 6% had MNBI > 2500 Ω. Independent risk factors for MNBI > 2500 Ω included the number and duration of supine acid reflux and lower esophageal sphincter (LES) resting pressure. In GERD patients with heartburn, patients with MNBI ≤ 2500 Ω had higher PPI response than MNBI > 2500 Ω (81.1% vs. 55.6%, p = 0.009).

CONCLUSIONS

Approximately one-third of Chinese GERD patients have an MNBI > 2500 Ω. The thresholds of MNBI for supporting or ruling out GERD in the Chinese population should be adjusted. MNBI values are independently predicted by the severity of supine acid reflux and the LES resting pressure. GERD patients with mild supine acid reflux may still exhibit normal MNBI levels. Patients with lower MNBI values tend to show better responses to PPI therapy.

Short Versus Standard Peroral Endoscopic Myotomy for Esophageal Achalasia: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) has become the treatment of choice for achalasia. However, the impact of myotomy length on POEM outcomes remains unclear. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the outcomes of short versus standard-length myotomy in achalasia patients.

METHODS

We conducted a comprehensive search in PubMed, Embase, and Web of Science databases to identify all RCTs that compared POEM using short myotomy with standard myotomy. The primary outcomes were clinical success and post-operative gastroesophageal reflux disease (GERD). The secondary outcomes were procedural time, length of hospital stay, and intraprocedural complications. Pooled odds ratio (OR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were calculated.

RESULTS

Three RCTs with 365 achalasia patients treated with short (n = 179) or standard (n = 186) myotomy were included. Short and standard myotomies showed similar clinical success (OR 1.95, 95% CI 0.61-6.23, p = 0.26; I2 = 41%), reflux symptoms (OR 0.97, 95% CI 0.49-1.89, p = 0.92; I2 = 20%), pathologic acid exposure on pH monitoring (OR 0.70, 95% CI 0.33-1.50, p = 0.36; I2 = 58%), reflux esophagitis on upper endoscopy (OR 0.82, 95% CI 0.40-1.70, p = 0.59; I2 = 42%), intraprocedural complications (OR 1.22, 95% CI 0.53-2.79, p = 0.65; I2 = 0%), and length of hospital stay (MD - 0.01, 95% CI - 0.72 to 0.69, p = 0.97, I2 = 73%). Procedural time was shorter in short myotomy (MD - 16.11 min, 95% CI - 26.04 to - 6.19, p = 0.001; I2 = 84%).

CONCLUSIONS

POEM using short myotomy for achalasia is non-inferior to standard myotomy for efficacy, safety, and post-operative GERD but is associated with a shorter procedural time.

Exploring esophagogastric junction morphology and contractile integral: implications for refractory gastroesophageal reflux disease pathophysiology

BACKGROUND

Evaluate the clinical significance of esophagogastric junction (EGJ) morphology and esophagogastric junction contractile integral (EGJ-CI) in refractory gastroesophageal reflux disease (RGERD) patients.

METHODS

From June 2021 to June 2023, 144 RGERD patients underwent comprehensive evaluation, recording symptom scores, demographic data. GERD classification (NERD or RE, A-D) was based on endoscopic findings. Reflux was assessed through 24-hour pH-impedance monitoring, and high-resolution esophageal manometry(HREM) measured parameters including EGJ-CI.

RESULTS

HREM revealed EGJ morphologies (type I, II, III) in 80.6%, 13.9%, and 5.6% of subjects, respectively. As the separation between the lower esophageal sphincter(LES) and crural diaphragm(CD) increased, EGJ-CI decreased (p < 0.005). Subjects with EGJ morphology types II and III had significantly higher acid exposure times(AET), DeMeester scores, and impedance reflux times than type I (p < 0.05). There was no statistical difference between types II and III. Impedance reflux times in subjects with type III morphology were significantly higher than those with types I and II (p < 0.05). The optimal EGJ-CI cutoff for distinguishing pathological reflux was 24.8 mmHg·cm, with 68% sensitivity, 72.3% specificity, and an AUC of 0.693 (95% CI 0.609-0.768). Logistic regression analysis identified EGJ-CI <24.8 mmHg·cm (OR = 2.5, 95% CI 1.1-5.5, p = 0.022) and ineffective esophageal motility(IEM) (OR = 2.4, 95% CI 1.2-5.2, p = 0.027) as independent risk factors.

CONCLUSION

EGJ-CI is crucial for clinically assessing EGJ barrier function, predicting pathological reflux and selecting patients with persistent reflux symptoms for surgery.

Effectiveness of Changing Drug Classes in Patients With Refractory Laryngopharyngeal Reflux Disease

OBJECTIVE

To investigate the effectiveness of drug class changes in patients with refractory laryngopharyngeal reflux disease (LPRD).

STUDY DESIGN

Retrospective case series with prospective data.

SETTING

Multicenter study.

METHODS

The data of patients treated for a refractory LPRD from September 2017 to December 2023 were collected. The effectiveness of drug class changes was assessed through the reflux symptom score (RSS) change. Signs were evaluated with the Reflux Sign Assessment. The RSS reduction was used to categorize the therapeutic responses as mild (20%-40% RSS reduction), moderate (40.1%-60% RSS reduction), high (60.1%-80%), and complete (>80%).

RESULTS

Among the 334 medical records, 74 (22.2%) patients had refractory LPRD defined as no RSS change in the pre- to 3-month posttreatment. The mean age was 52.6 ± 15.5 years. Changing drug class was associated with significant 3- to 6-month posttreatment reductions of RSS and RSA. Thirty patients (39%) did not experience symptom reduction after changing drugs. Changing alginate to magaldrate and magaldrate to alginate was associated with the highest responder rate (76.9%). Changing PPI and alginate/magaldrate molecules led to a response rate of 62.5%. In patients initially treated with a combination of PPI and alginate or magaldrate, changing PPI without changing alginate/magaldrate led to a 37.5% response rate. The baseline RSS was predictive of the 3- and 6-month RSS (therapeutic response).

CONCLUSION

Changing drug class, especially alginate-to-magaldrate, may be an effective therapeutic approach for patients with a refractory LPRD.

Laparoscopic fundoplication improves esophageal motility in patients with gastroesophageal reflux disease: a high-volume single-center controlled study in the era of high-resolution manometry and 24-hour pH impedance

BACKGROUND

Most existing literature studies reported that laparoscopic fundoplication (LF) is safe in the setting of ineffective or weak peristalsis. However, the effect of the wrap on esophageal motility is still debated. This study aimed to assess how a functioning and effective fundoplication could affect esophageal motility in patients with gastroesophageal reflux disease (GERD).

METHODS

This study analyzed prospectively collected data on patients who underwent laparoscopic Nissen (LN) fundoplication or laparoscopic Toupet (LT) fundoplication for GERD at our department between 2010 and 2022. Demographic and clinical characteristics were recorded. Patients were evaluated using the Gastroesophageal Reflux Disease Questionnaire (GerdQ), barium swallow, endoscopy, high-resolution manometry (HRM), and 24-hour pH impedance (multichannel intraluminal impedance and pH monitoring [MII-pH]) before and after surgery. HRM was reviewed by 2 experts, following the criteria of the Chicago Classification (version 4.0). LF failure was objectively defined in case of abnormal postoperative MII-pH according to the Lyon 2.0 criteria with/without an abnormal GerdQ.

RESULTS

During the study period, 124 patients with GERD (89 males and 35 females) were recruited. Of note, 58 patients underwent LN fundoplication, and 66 patients underwent LT fundoplication. All procedures were completed laparoscopically, and the 90-day postoperative mortality was nil. At the postoperative MII-pH, good outcome was recorded in 103 patients, and failure was recorded in 21 patients. There was a significant association between a successful LF and the normalization of esophageal motility (P < .05).

CONCLUSION

Our data confirmed that LF is an effective treatment in patients with GERD, regardless of esophageal motility status. Moreover, our results indicate that LF could determine a normalization of motility abnormalities in patients with GERD.

Effect of Anti-reflux Mucosal Ablation on Esophageal Motility in Patients With Gastroesophageal Reflux Disease: A Study Based on High-resolution Impedance Manometry

Background/Aims

Anti-reflux mucosal ablation (ARMA) is a promising endoscopic intervention for proton pump inhibitor (PPI)-dependent gastroesophageal reflux disease (GERD). However, the effect of ARMA on esophageal motility remains unclear.

Methods

Twenty patients with PPI-dependent GERD receiving ARMA were prospectively enrolled. Comprehensive self-report symptom questionnaires, endoscopy, 24-hour impedance-pH monitoring, and high-resolution impedance manometry were performed and analyzed before and 3 months after ARMA.

Results

All ARMA procedures were performed successfully. Symptom scores, including GerdQ (11.16 ± 2.67 to 9.11 ± 2.64, P = 0.026) and reflux symptom index (11.63 ± 5.62 to 6.11 ± 3.86, P = 0.001), improved significantly, while 13 patients (65%) reported discontinuation of PPI. Total acid exposure time (5.84 ± 4.63% to 2.83 ± 3.41%, P = 0.024) and number of reflux episodes (73.05 ± 19.34 to 37.55 ± 22.71, P < 0.001) decreased significantly after ARMA. Improved esophagogastric junction (EGJ) barrier function, including increased lower esophageal sphincter resting pressure (13.89 ± 10.78 mmHg to 21.68 ± 11.5 mmHg, P = 0.034), 4-second integrated relaxation pressure (5.75 ± 6.42 mmHg to 9.99 ± 5.89 mmHg, P = 0.020), and EGJ-contractile integral (16.42 ± 16.93 mmHg·cm to 31.95 ± 21.25 mmHg·cm, P = 0.016), were observed. Esophageal body contractility also increased significantly (distal contractile integral, 966.85 ± 845.84 mmHg·s·cm to 1198.8 ± 811.74 mmHg·s·cm, P = 0.023). Patients with symptom improvement had better pre-AMRA esophageal body contractility.

Conclusions

ARMA effectively improves symptoms and reflux burden, EGJ barrier function, and esophageal body contractility in patients with PPIdependent GERD during short-term evaluation. Longer follow-up to clarify the sustainability of ARMA is needed.

Baseline Impedance via Manometry Predicts Pathological Mean Nocturnal Baseline Impedance in Isolated Laryngopharyngeal Reflux Symptoms

Background/Aims

Distal mean nocturnal baseline impedance (MNBI) measuring via pH-impedance may be valuable in diagnosing patients with suspected laryngopharyngeal reflux (LPR). However, its wide adoption is hindered by cost and invasiveness. This study investigates whether baseline impedance measured during high-resolution impedance manometry (HRIM-BI) can predict pathological MNBI.

Methods

A cross-sectional study in Taiwan included 74 subjects suspected of LPR, who underwent HRIM (MMS) and pH-impedance testing (Diversatek), after stopping proton pump inhibitors for more than 7 days. Subjects with grade C or D esophagitis or Barrett's esophagus were excluded. The cohort was divided into 2 groups: those with concomitant typical reflux symptoms (CTRS, n = 28) and those with isolated LPR symptoms (ILPRS, n = 46). HRIM-BI measurements focused on both distal and proximal esophagi. Pathological MNBI was identified as values below 2065 Ω, measured 3 cm above the lower esophageal sphincter.

Results

In all subjects, distal HRIM-BI values correlated weakly with distal MNBI(r = 0.34-0.39, P < 0.005). However, in patients with ILPRS, distal HRIM-BI corelated moderately with distal MNBI(r = 0.43-0.48, P < 0.005). The areas under the receiver operating characteristic curve was 0.78 (P = 0.001) with a sensitivity of 0.83 and a specificity of 0.68. No correlation exists between distal HRIM-BI and distal MNBI in patients with CTRS, and between proximal HRIM-BI and proximal MNBI in both groups.

Conclusions

Distal HRIM-BI from HRIM may potentially predict pathological MNBI in patients with ILPRS, but not in those with CTRS. Future outcome studies linked to the metric are warranted.

Is reflux hypersensitivity truly a functional gastrointestinal disorder? A retrospective cross-sectional study

BACKGROUND

According to Rome IV, reflux hypersensitivity (RH) represents a novel form of functional esophageal disorder. This study was designed to compare the clinical features of three types of endoscopic-negative heartburn: RH, nonerosive reflux disease (NERD), and functional heartburn (FH).

METHODS

Patients with heartburn in a medical center from 01/01/2017 to 10/31/2021 were included. This article presented a blinded retrospective analysis of 24 h MII-pH and HRM tracings from patients with NERD, RH, and FH to compare their clinical characteristics.

RESULTS

A total of 118 patients were included in the study. There were no significant differences in age, sex, BMI, smoking status, or drinking history among RH, NERD and FH. Functional dyspepsia (FD) symptoms were more prone to exist in FH than in NERD (P < 0.05), whereas hiatal hernia was more prevalent in NERD and RH than in FH (P < 0.05). The incidence of anxiety and depression gradually increased in the NERD, RH, and FH groups (P >  0.05). The distal MNBI and PSPW index of the NERD and RH groups were lower than those of the FH group (P < 0.05). The distal MNBI showed good diagnostic potential.

CONCLUSIONS

Clear pathological alterations, which are distinct from those of other FGIDs, are observable in RH. It might be inappropriate to categorize RHs within FGIDs.

Risk Factors for Symptoms in Patients With Heterotopic Gastric Mucosa in the Upper Esophagus

Goal: This study is aimed at comparing the clinical characteristics and histological types of symptomatic and asymptomatic patients with heterotopic gastric mucosa in the upper esophagus (HGMUE) and exploring the factors influencing the occurrence and severity of laryngopharyngeal reflux (LPR) symptoms in these patients. Background: HGMUE is a potential cause of LPR symptoms. Study: This retrospective analysis evaluated 70 patients with HGMUE using a detailed questionnaire. Clinical, histological, high-resolution manometry, and 24-h pH impedance monitoring data were compared between symptomatic (n = 49) and asymptomatic (n = 21) patients. Results: The diameter of HGMUE was significantly larger in the symptomatic group (p < 0.05), and the incidence of LPR symptoms increased with larger diameter grades; male patients were more likely to have LPR symptoms. The incidence of LPR symptoms varied significantly across histological classifications, being highest in patients with the fundic type (χ 2 = 6.64, p < 0.05). Binary logistic regression analysis identified sex and histological type as risk factors for LPR symptoms, with odds ratios of 8.996 (95% confidence interval (CI): 1.350-59.962) and 8.493 (95% CI: 1.486-48.522), respectively. The mean nocturnal baseline impedance (MNBI) in the upper esophagus was significantly lower in the symptomatic group (1676.82 ± 739.09 Ω vs. 2441.01 ± 604.11 Ω; p < 0.05). Clinical and demographic characteristics did not significantly affect the severity of LPR symptoms. Conclusion: The diameter, histological type, and sex of patients are risk factors for the occurrence of LPR symptoms in patients with HGMUE. More attention should be paid to patients with these factors. The MNBI is an effective indicator of the symptoms and treatment.

Unveiling the intricacies: Insight into gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) poses a substantial global health challenge, with prevalence rates exhibiting geographical variation. Despite its widespread recognition, the exact prevalence and associated risk factors remain elusive. This article comprehensively analyzed the global burden of GERD, shedding light on its risk factors, underlying pathophysiological mechanisms, current diagnostic modalities, evolving management strategies tailored to diverse patient profiles, and complex determinants contributing to treatment failures. A deeper comprehension of GERD is achieved by dissecting these intricate facets, paving the way for enhanced clinical management and improved patient outcomes.

Distribution of esophageal inflammation in patients with eosinophilic esophagitis and its impact on diagnosis and outcome

BACKGROUND

This study aimed to assess the distribution of esophageal inflammation in patients with eosinophilic esophagitis (EoE) and its impact on diagnosis and outcome.

AIMS AND METHODS

Data from consecutive adult EoE patients who were followed-up at four Italian referral centers from October 2022 to October 2023 were retrospectively collected.

RESULTS

One hundred forty-nine patients were included. Proximal EoE was observed in 8.1 % of patients; distal EoE in 27.5 %; and diffuse EoE in 64.4 %. Allergic rhinitis was more prevalent in distal and diffuse than proximal EoE (72.5 % vs. 61.5 % vs 33.3 %; P = 0.049). The prevalence of asthma, atopic dermatitis, oral allergy syndrome, and gastroesophageal reflux disease was not significantly different among the three EoE extent groups. Endoscopic inflammatory features at diagnosis were more prevalent in proximal EoE (91.7 % vs. 53.8 % distal [P = 0.01] vs. 66 % diffuse[P = 0.05]). No significant differences in fibrotic features and esophageal stenoses were observed. The clinical and histological remission rates after first-line therapy were comparable in all groups.

CONCLUSION

Esophageal inflammation in EoE more frequently involves the entire esophagus, followed by isolated distal and proximal involvement. No clear correlation was observed between the histological extent of EoE at diagnosis and comorbidities or treatment response.

How preoperative upper gastrointestinal investigations affect the management of bariatric patients: results of a cohort study of 897 patients

INTRODUCTION

Preoperative diagnostic protocols vary worldwide, some prioritizing safety while others question routine procedures. Building on prior research, this study explores the impact of diverse preoperative findings on bariatric management and procedure selection.

METHODS

In a retrospective analysis of prospective data of over 1000 bariatric surgery patients from January 2017 to December 2022 undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) were analyzed. Preoperative assessment included upper endoscopy, upper GI series, and esophageal manometry. Sonography data were excluded. The primary endpoint examined the influence of preoperative exams on procedure selection, the secondary endpoint evaluated their therapeutic impact.

RESULTS

897 patients (741 RYGB, 156 SG) were included. All underwent upper endoscopy, revealing common findings such as type C gastritis and reflux esophagitis. Upper endoscopy prompted a therapeutic consequence in 216 patients (24.3%), resulting in a number needed to screen (NNS) of 4.1. Upper GI series and manometry were more frequently performed before LSG. Upper GI series detected hiatal hernias and motility disorders but did not result in any change of procedures. Esophageal manometry found pathologies in 37 (25.3%) patients rising to 41.5% if symptoms were present. Overall, 16 (1.8%) patients experienced a change in the planned procedure, with 14 changes prompted by preoperative findings and two by technical difficulties.

CONCLUSION

We advise routine upper endoscopies for all patients undergoing LRYGB or LSG, while reserving upper GI series only for selected cases. Manometry should be exclusively performed on symptomatic patients undergoing LSG, ensuring a balanced and individualized preoperative assessment.

Scintigraphic Imaging of Extra-Esophageal Manifestation of Gastresophageal Reflux Disease

OBJECTIVES

There is currently no reference standard test for the detection of the extra-esophageal manifestations of gastroesophageal reflux disease (GERD). The current suite of diagnostic tests principally assesses reflux events in the esophagus. A new scintigraphic technique has been developed and validated against reference standards. It allows direct visualization of refluxate in the laryngopharynx and lungs.

METHODS

Fifty patients were assessed by scintigraphy before and after fundoplication at a single nuclear medicine facility. Standardized reflux symptom indices (RSIs) were obtained from each patient before and after surgery. Patients were scanned after oral 99 m technetium Fyton administration with early dynamic images and delayed SPECT/CT images of the head, neck, and lungs. ANOVA, Spearman correlation, and the Student's t-test were utilized for analysis.

RESULTS

The study population (35F, 15 M) had a mean age of 63.9 years. Mean BMI was 26.8 with 67% being overweight or obese. All patients had significant reflux. SPECT/CT showed LPR events in 45/50 and pulmonary micro-aspiration (PMA) in 45/50 preoperatively and in 36/50 and 20/50 postoperatively, respectively. The RSI, cough, and throat clearing indices showed a significant fall postoperatively (p < 0.001). Frequency of scintigraphic reflux events was reduced from a mean of 4.5 in 30 min to 2.9 (t = 9.1, p = 0.004).

CONCLUSION

The novel scintigraphic test detects esophageal and extra-esophageal reflux events and permits direct visualization of refluxate in the head and neck structures and lungs. It correlates well with symptoms of reflux in the esophagus and extra-esophageal structures and the response to therapy.

LEVEL OF EVIDENCE

Although prospective, the study did not randomize patients and in effect each patient became their own control following an intervention (fundoplication). Thus, the study is Level 3 evidence Laryngoscope, 135:73-79, 2025.

Rebound of Reflux-Related Symptoms After Helicobacter pylori Eradication in Patients With Gastroesophageal Reflux Disease: A Prospective Randomized Study

BACKGROUND/PURPOSE

We aimed to assess the effects of Helicobacter pylori (H. pylori) eradication on the rebound of reflux-related symptoms among gastroesophageal reflux disease (GERD) patients.

METHODS

This prospective randomized study recruited patients with typical reflux symptoms and reflux esophagitis on esophagogastroduodenoscopy (NCT02934152). Patients positive for H. pylori via a urea breath test (UBT) were randomly assigned to receive bacterial eradication with triple therapy for 2 weeks either before or after proton-pump inhibitor (PPI) treatment for 4 weeks. Follow-up was implemented with serial GerdQ evaluation and a subsequent UBT. The primary outcome was the incidence rates of symptom rebound between patients with and without H. pylori infection. The secondary outcomes included the severity of symptom rebound, incidence rates of symptom rebound, and successful eradication rates between the early and late eradication groups.

RESULTS

A total of 248 patients were enrolled, of whom 107 (43.1%) tested positive for H. pylori infection. All patients with and without concurrent H. pylori infection had significant symptom improvement over the entire treatment. Patients with H. pylori infection had significantly lower rates of symptom rebound (19.8% vs. 34.2%, p = 0.034) and rebound severity (1.8 ± 0.7 vs. 2.8 ± 1.6, p = 0.031) 4 weeks after eradication and PPI treatment than those without. The incidence rates of symptom rebound and successful eradication rates were not significantly different between the early and late eradication groups.

CONCLUSIONS

GERD patients with concurrent H. pylori infection were less susceptible to symptom rebound after H. pylori eradication compared to those without.

TRIAL REGISTRATION

ClinicalTrial.gov (NCT02934152).

Esophageal chest pain resembles heartburn in reflux metrics and response to proton pump inhibitor therapy

BACKGROUND

Gastro-esophageal reflux disease (GERD) is the most common cause for noncardiac chest pain (NCCP), with an estimated prevalence rate ranging between 30% and 60%. Heartburn and NCCP may share common mechanisms.

AIMS/METHODS

To assess whether particular patterns of impedance-pH variables characterize patients with dominant heartburn, regurgitation, or NCCP and their ability to predict proton pump inhibitor (PPI) response for each symptom, GERD patients, evaluated with high-resolution manometry (HRM) and impedance-pH, were included.

RESULTS

In total, 109 NCCP, 68 heartburn, and 64 regurgitation patients were included. Pathological reflux episodes were observed in 28%, 19%, and 56% (p < 0.001). Pathological mean nocturnal baseline impedance (MNBI) values were observed in 55%, 53%, and 34% (p < 0.05). Hypomotility was more frequent in NCCP compared to heartburn patients (p < 0.05). When comparing NCCP with heartburn, hypomotility was associated with NCCP perception (OR: 2.34, 95% CI: 1.23-4.43; p < 0.01). When comparing NCCP with regurgitation, >80 refluxes and type 2/3 esophagogastric junction (EGJ) were associated with regurgitation perception (OR: 0.31, 95% CI: 0.16-0.59; p < 0.001, and OR: 0.5, 95% CI: 0.27-0.93; p < 0.05), while pathological MNBI was associated with NCCP perception (OR: 2.34, 95% CI: 1.23-4.43; p < 0.01). 45.5% NCCP patients, 45.6% with heartburn, and 36% with regurgitation responded to PPIs (p < 0.05). At multivariate analysis, pathological MNBI or PSPW index were associated with PPI responsiveness in patients with NCCP or heartburn, while in patients with regurgitation, pathological MNBI was associated with PPI responsiveness and a reflux number >80 to PPI refractoriness.

CONCLUSIONS

We highlight the usefulness of an accurate clinical and functional evaluation of GERD patients, allowing to discriminate particular characteristics in patients with dominant heartburn, NCCP, or regurgitation, which may benefit of distinct therapeutic strategies.

Achalasia: beyond the basics

Achalasia is a rare oesophageal disease characterised by an unrelaxing lower oesophageal sphincter and abnormal peristalsis of the oesophageal body. Achalasia symptoms include dysphagia to solid and liquid, chest pain, regurgitation and weight loss. Achalasia diagnosis might be delayed for many years when atypical symptoms dominate. Significant progress has been made over the last two decades regarding our understanding of pathophysiology, methods of evaluation and management. The development of high-resolution manometry in particular has improved the diagnosis of achalasia, as well as other major motility disorders. Subtyping achalasia into manometric patterns has pathophysiological and therapeutic implications. Furthermore, complementary tests such as timed barium swallow and the functional lumen imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland) have significantly added to achalasia diagnosis algorithm and management decision-making. Progression in management has helped optimise established therapy (pneumatic dilatation and Heller myotomy) and introduced new endoscopic treatments (peroral endoscopic myotomy) and surgical techniques (surgical robotic Heller myotomy). This review will aim to shed light on the most recent advances in achalasia diagnosis, classification and management.

Gastro-oesophageal reflux-related chronic cough: can new tools improve patient assessment?

Novel impedance pH monitoring parameters, such as mean nocturnal baseline impedance and post-reflux swallow induced peristaltic wave index, may be better markers for assessing chronic cough related to oesophageal hypersensitivity https://bit.ly/41woxTD.

The Role of High-Resolution Manometry Before and Following Antireflux Surgery: The Padova Consensus

BACKGROUND

In the last 2 decades the development of high-resolution manometry (HRM) has changed and revolutionized the diagnostic assessment of patients complain foregut symptoms. The role of HRM before and after antireflux procedure remains unclear, especially in surgical practice, where a clear understanding of esophageal physiology and hiatus anatomy is essential for optimal outcome of antireflux surgery (ARS). Surgeons and gastroenterologists (GIs) agree that assessing patients following antireflux procedures can be challenging. Although endoscopy and barium-swallow can reveal anatomic abnormalities, physiological information on HRM allowing insight into the cause of eventually recurrent symptoms could be key to clinical decision-making.

METHODS

A multidisciplinary international working group (14 surgeons and 15 GIs) collaborated to develop consensus on the role of HRM pre-ARS and post-ARS, and to develop a postoperative classification to interpret HRM findings. The method utilized was detailed literature review to develop statements, and the RAND/University of California, Los Angeles Appropriateness Methodology (RAM) to assess agreement with the statements. Only statements with an approval rate >80% or a final ranking with a median score of 7 were accepted in the consensus. The working groups evaluated the role of HRM before ARS and the role of HRM following ARS.

CONCLUSIONS

This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre-ARS and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.