Effect of graded running on esophageal motility and gastroesophageal reflux in fed volunteers

Physical Activity Protects Against the Risk of Erosive Esophagitis on the Basis of Body Mass Index

GOAL

To determine whether physical activity lowers the risk for erosive esophagitis on the basis of body mass index (BMI).

BACKGROUND

Although previous studies have shown that physical activity is closely associated with erosive esophagitis, these data may be confounded by obesity.

STUDY

In this retrospective study, we included 182,409 patients who underwent an upper endoscopy and were diagnosed with erosive esophagitis. The impact of the amount and intensity of physical activity on the risk for erosive esophagitis was analyzed based on BMI groups. Subjects were classified into three BMI groups with equal numbers in each group.

RESULTS

Overall, 10.3% (n=18,859) of patients were diagnosed with erosive esophagitis. After adjusting for confounding factors, a greater amount of exercise [lower tertile: odd ratio (OR), 0.86; 95% confidence interval (CI), 0.77-0.96; middle tertile: OR, 0.91; 95%, CI 0.84-1.00; upper tertile: OR, 0.79; 95% CI, 0.73-0.85) and increased exercise intensity (lower tertile, moderate: OR, 0.61; 95% CI, 0.52-0.71; vigorous: OR, 0.51; 95% CI, 0.44-0.58; middle tertile, moderate: OR, 0.62; 95% CI, 0.55-0.70; vigorous: OR, 0.58; 95% CI, 0.51-0.65; upper tertile, moderate: OR, 0.58; 95% CI, 0.53-0.65; vigorous: OR, 0.58; 95% CI, 0.53-0.64) was associated with a decreased risk for erosive esophagitis in all 3 BMI groups. In addition, we observed that increased physical activity intensity notably decreased the risk for erosive esophagitis in subjects performing lesser physical activity, but slightly decreased the risk for erosive esophagitis in subjects performing more physical activity.

CONCLUSION

Physical activity is inversely associated with erosive esophagitis.

Effect of Running on Gastroesophageal Reflux and Reflux Mechanisms

OBJECTIVES

Reflux symptoms are common among athletes and can have a negative impact on athletic performance. At present, the mechanisms underlying excess reflux during exercise are still poorly understood. The aim of this study was to investigate the effect of exercise on reflux severity and examine the underlying reflux mechanisms.

METHODS

Healthy sporty volunteers were studied using both high-resolution manometry and pH-impedance monitoring. After a meal and a rest period, subjects ran on a treadmill for 30 min at 60% of maximum heart rate, followed by a short rest period and another 20-min period of running at 85% of maximum heart rate.

RESULTS

Ten healthy volunteers were included. Exercise led to a significantly higher percentage of time with an esophageal pH<4 and a higher frequency and duration of reflux episodes. Moreover, exercise resulted in a decrease in contractility and duration of peristaltic contractions. The minimal lower esophageal sphincter resting pressure decreased during exercise, whereas the average and maximum abdominal pressure both increased. Importantly, the percentage of transient lower esophageal sphincter relaxations (TLESRs) that resulted in reflux significantly increased during exercise and all but one reflux episode occurred during TLESRs. In six subjects a hiatus hernia was detected during the exercise period but not during rest.

CONCLUSIONS

Running induces gastroesophageal reflux almost exclusively through TLESRs. These are not more frequent during exercise but are more often associated with a reflux episode, possibly due to increased abdominal pressure, body movement, a change in esophagogastric junction morphology, and a decreased esophageal clearance during exercise.

The influence of physical strain on esophageal motility in healthy volunteers studied with gas-perfusion manometry

BACKGROUND

The influence of physical strain on the esophageal motility has already been examined in a number of studies. It was found that high physical strain compromises the sufficient contractility of the esophagus. However, it needs more examinations to verify these findings.

METHODS

To validate these results healthy volunteers were examined using gas-perfusion manometrie. Bicycle ergometry was performed to generate an exactly defined physical exercise. After a pilot study, the changing of the contraction amplitude was determined as the main variable to evaluate the esophageal motility, and the sample size was calculated. Eight subjects without esophageal diseases or symptoms were examined by simultaneous gas-perfusion esophageal manometry and bicycle ergometry.

KEY RESULTS

The results showed that high physical strain during bicycle ergometry can induce a significant decrease of the contraction amplitude (α = 5%, β = 10%). The 95% confidence interval of the quotient of contraction amplitude at rest and under physical strain is (1.074; 1.576). This effect is more pronounced in liquid acts of swallowing than in dry and is also more obvious at the middle measuring point (7.8 cm above the lower esophageal sphincter) than at the distal and proximal point (2.8 and 12.8 cm). Furthermore, a decreasing tendency of the contraction duration could be found.

CONCLUSIONS & INTERFERENCES

Gas-perfusion manometry is an inexpensive examination method, which enables the evaluation of the esophageal motility in moving test subjects under conditions of physical strain. It could be proved that physical strain negatively influences the esophageal motility by a decrease of the contraction amplitude.

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.

Current concepts: recognition and management of common activity-related gastrointestinal disorders

Sports medicine clinicians may encounter a wide variety of activity-related gastrointestinal (GI) disorders. The advancing ages and burgeoning obesity rates of the US population have generally increased the prevalence of GI conditions among adults. However, conditioned younger athletes with normal body mass indices also may experience disquieting activity-related GI disorders. While often mild and transient, some of these GI conditions may disrupt exercise routines or pose significant health risks to affected individuals. Gastroesophageal reflux occurs frequently during physical activity and should be empirically treated with activity reduction and dietary modifications in conjunction with antisecretory agents. Persistent or worrisome symptoms merit upper endoscopy, a thorough evaluation for non-GI causes and, rarely, surgery. Altered GI motility commonly occurs during vigorous activities that use dynamic or fluctuating body positions. Dietary and exercise modifications are usually enough to resolve these symptoms. Physical activity may also precipitate GI bleeding from upper and/or lower sources. Although mild or occult bleeding is most common, significant bleeding merits a thorough diagnostic evaluation after stabilization and treatment. Adequate hydration and gradual exercise progression may be particularly helpful to prevent the recurrence of bleeding. The judicious use of medications in conjunction with nonsteroidal anti-inflammatory drug avoidance may also be necessary. Fortunately, most activity-related GI disorders are self-limited and can be managed conservatively. After a brief period of modified activity, clinically stable individuals may progress their activity levels as symptoms allow.

Running, esophageal acid reflux, and atrial fibrillation: a chain of events linked by evidence from separate medical literatures

Using a previously described approach to generating novel medical hypotheses, this paper shows how two separate medical literatures taken together can suggest new information not apparent in either literature alone. Many studies have demonstrated that aerobic exercise in healthy people can induce esophageal acidic reflux that increases with the duration and intensity of exercise. Separately, independently of exercise, it has been shown that, in patients with gastroesophageal reflux, esophageal acid exposure can lead to atrial fibrillation (AF) and to other heart dysrhythmias. The two arguments together suggest that a regimen of excessive exercise may be conducive to AF mediated by acid reflux, an implicit, but unpublished, hypothesis. Proton pump inhibitors are widely used to treat gastroesophageal reflux. Remarkably, several small clinical trials of these drugs have been shown also to reduce symptoms and frequency of AF episodes in patients with comorbid acid reflux. Plausible mechanisms have been suggested. These small-scale tests in a highly restricted population may be of particular interest in the light of a possible exercise-reflux-AF causal chain of events in a broader population of athletes. Because the minimum degree of esophageal acidity exposure required to induce AF is unknown, further tests of proton pump inhibitors for that purpose are therefore merited without regard to any known prior reflux in a population of runners with lone AF. The prospect of reducing AF burden with a relatively benign agent is attractive in view of the limited options for effective treatment otherwise available. The study of arrhythmia and esophageal reflux in athletes may offer insights on the origin and natural history of lone atrial fibrillation.

Effect of Esophageal Acid and Prophylactic Rabeprazole on Performance in Runners

INTRODUCTION

Acid reflux occurs during exercise. The effects of esophageal acid and prophylactic antisecretory treatment on exercise performance are unknown.

AIMS

To determine 1) the effect of esophageal acid perfusion during exercise on pulmonary function and exercise performance, and 2) whether acid suppression with rabeprazole (RAB) 20 mg x d(-1) increases exercise performance during esophageal acid infusion.

METHODS

This was a two-phase study. Twenty-four conditioned runners (11 with heartburn, 13 without) completed phase 1. Sixteen runners with heartburn completed phase 2 (RAB). For phase 1, esophageal evaluation, baseline maximum exertion test, and a standard Bruce protocol maximal stress test were performed. Runners were randomized to sham esophageal infusion (NG tube placed in the distal esophagus, no fluid) or esophageal acid perfusion (0.1 N HCl perfused) during exercise. Subjects were crossed over to the alternate perfusion. For phase 2, runners underwent three sessions with both acid and sham perfusion during running; the sessions were randomly conducted on different days at baseline and 8 and 12 wk of RAB 20 mg.

RESULTS

For phase 1, esophageal function and sensitivity were normal. There was no difference in airway resistance or work capacity between groups. The acid-perfusion group significantly decreased time to exhaustion in the no-heartburn group (23.13 to 20.66 min) with a decrease in energy expenditure. For phase 2, time to exhaustion was significantly decreased with acid perfusion at all time points (P < 0.05). Total energy expenditure during exercise was less in each acid-perfusion test. No difference in pulmonary function was present at week 12 versus baseline.

CONCLUSIONS

Esophageal acid perfusion decreased performance. In runners with heartburn, suppression of endogenous acid secretion did not improve exercise performance. Changes in cardiopulmonary function do not explain the decreased exercise performance during acid perfusion.

Esophagogastric junction morphology predicts susceptibility to exercise-induced reflux

BACKGROUND AND AIM

Although strenuous exercise has been reported to increase gastroesophageal reflux, there are few data exploring the mechanism behind this relationship. The aim of this study was to use vigorous exercise as a provocation for strain-induced reflux and examine the correlation between endoscopically assessed EGJ integrity and exercise-induced reflux.

METHODS

Ten controls and 10 GERD patients were studied for a 2-day period using the wireless Bravo pH monitoring system. The subjects were randomly assigned to perform 60 min of exercise on day 1 or 2 consuming the same diet on both days. Exercise consisted of 30 min of running and 30 min of 5 resistance exercises. Subjects underwent endoscopy to grade the EGJ "flap valve" and manometry to measure basal LES pressure.

RESULTS

Nineteen subjects completed the 2-day study with 100% data capture during exercise. Median acid exposure was increased more than threefold for both controls and GERD patients during exercise when compared to nonexercise periods. In addition, a strong correlation existed between EGJ grade and % time pH < 4 during exercise while there was not a significant correlation between LES pressure and EGJ grade. These findings were present even after exclusion of hiatus hernia patients (flap valve grade 4).

CONCLUSIONS

Exercise caused a threefold increase in esophageal acid exposure in both controls and GERD patients. The degree of exercise-induced reflux is strongly correlated with EGJ morphology and this supports the hypothesis that anatomical integrity of the EGJ is of cardinal importance in preventing strain-induced reflux.