Oesophageal hypersensitivity is associated with features of psychiatric disorders and the irritable bowel syndrome

Incomplete Response of Gastroesophageal Reflux Symptoms Poorly Predicts Erosive Esophagitis or Barrett's Esophagus

BACKGROUND & AIMS

Many patients with symptoms of gastroesophageal reflux disease (GERD) not responding to a proton pump inhibitor (PPI) undergo an upper endoscopy. We hypothesized that an incomplete response to a PPI is not associated with findings of esophageal pathology on endoscopy, and that psychological distress is associated inversely with pathology.

METHODS

We enrolled consecutive individuals aged 40 to 79 years with prior heartburn or regurgitation. Logistic regression was used to estimate the effects of incomplete response of GERD symptoms and psychological distress on the odds of finding erosive esophagitis or Barrett's esophagus.

RESULTS

A total of 625 patients completed the study. A total of 254 (66.8% of those taking PPI) had GERD symptoms incompletely responsive to a PPI and 352 (56.3%) had severe somatization. An incomplete response to a PPI was associated with psychological distress (P < .001). Erosive esophagitis was found in 148 subjects (23.7%) and Barrett's esophagus in 58 (9.3%). Overall, an incomplete response to a PPI was not found to be associated with these pathologies (odds ratio, 1.17; 95% CI, 0.720-1.91). In contrast, greater psychological distress was associated inversely with erosive esophagitis or Barrett's esophagus (in particular, highest vs lowest tertile somatization: odds ratio, 0.590; 95% CI, 0.365-0.952).

CONCLUSIONS

Patients undergoing upper endoscopy frequently have GERD symptoms incompletely responding to a PPI and a high burden of somatization. However, an incomplete response of GERD symptoms is a poor predictor for endoscopic pathology, and should not be relied upon for selecting patients for screening for Barrett's esophagus. Patients with high psychological distress are less likely to have esophageal pathology.

Esophageal Hypervigilance and Visceral Anxiety Are Contributors to Symptom Severity Among Patients Evaluated With High-Resolution Esophageal Manometry

OBJECTIVES

Symptoms are inconsistently associated with esophageal motor findings on high-resolution manometry (HRM). We aimed to evaluate predictors of dysphagia severity, including esophageal hypervigilance and visceral anxiety, among patients evaluated with HRM.

METHODS

Adult patients undergoing HRM at 4 academic medical centers (United States and France) were prospectively evaluated. HRM was completed and analyzed per the Chicago Classification v3.0. Validated symptom scores, including the Brief Esophageal Dysphagia Questionnaire and Esophageal Hypervigilance and Anxiety Scale, were completed at the time of HRM.

RESULTS

Two hundred thirty-six patients, aged 18-85 (mean 53) years, 65% female, were included. Approximately 59 (25%) patients had a major motor disorder on HRM: 19 achalasia, 24 esophagogastric junction outflow obstruction, 12 absent contractility, and 4 jackhammer. Approximately 177 (75%) patients did not have a major motor disorder: 71 ineffective esophageal motility and 106 normal motility. Having a major motor disorder was a significant predictor of dysphagia severity (Radj = 0.049, P < 0.001), but the Esophageal Hypervigilance and Anxiety Scale score carried a predictive relationship of Brief Esophageal Dysphagia Questionnaire that was 2-fold higher than having a major motor disorder: Radj = 0.118 (P < 0.001). This finding remained when evaluated by the major motor disorder group. HRM metrics were nonsignificant.

DISCUSSION

In a prospective, international multicenter study, we found that esophageal hypervigilance and visceral anxiety were the strongest predictors of dysphagia severity among patients evaluated with HRM. Thus, an assessment of esophageal hypervigilance and visceral anxiety is important to incorporate when evaluating symptom severity in clinical practice and research studies.

Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn

BACKGROUND

Heartburn that persists despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with reflux-reducing medication (e.g., baclofen) or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators (e.g., desipramine).

METHODS

Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20 mg of omeprazole twice daily for 2 weeks, and those with persistent heartburn underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the Gastroesophageal Reflux Disease (GERD)-Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at 1 year.

RESULTS

A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomization procedures excluded 288 patients: 42 had relief of their heartburn during the 2-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had non-GERD esophageal disorders, and 99 had functional heartburn (not due to GERD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomization. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to that with active medical treatment (7 of 25 patients, 28%; P = 0.007) or control medical treatment (3 of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and the control medical group was 16 percentage points (95% confidence interval, -5 to 38; P = 0.17).

CONCLUSIONS

Among patients referred to VA gastroenterology clinics for PPI-refractory heartburn, systematic workup revealed truly PPI-refractory and reflux-related heartburn in a minority of patients. For that highly selected subgroup, surgery was superior to medical treatment. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT01265550.).

Gastroesophageal reflux disease, functional dyspepsia and irritable bowel syndrome: common overlapping gastrointestinal disorders

Several studies have indicated an overlap between gastroesophageal reflux disease (GERD) and various functional gastrointestinal disorders (FGIDs). The overlapping conditions reported have mainly been functional dyspepsia (FD) and irritable bowel syndrome (IBS). The available literature is frequently based on symptomatic questionnaires or endoscopic procedures to diagnose GERD. Rarely, among patients with heartburn, pathophysiological evaluations have been considered to differentiate those with proven GERD from those without. Moreover, both GERD and IBS or FD showed enormous heterogeneity in terms of the criteria and diagnostic procedures used. The GERD-IBS overlap ranges from 3-79% in questionnaire-based studies and from 10-74% when GERD has been diagnosed endoscopically. The prevalence of functional dyspepsia (after normal upper endoscopy) is 12-15% and an overlap with GERD has been reported frequently. Only a few studies have considered a potential overlap between functional heartburn (FH) and IBS using a 24-h pH-metry or impedance-pH evaluation. Similar data has been reported for an overlap between FH and FD. Recently, a revision of the Rome criteria for esophageal FGIDs identified both FH and hypersensitive esophagus (HE) as potential functional esophageal disorders. This might increase the potential overlap between different FGIDs, with FH and HE rather than with GERD. The aim of the present review article was to appraise and discuss the current evidence supporting the possible concomitance of GERD with IBS and FD in the same patients and to evaluate how various GERD treatments could impact on the quality of life of these patients.

Psychosocial Distress and Quality of Life Impairment Are Associated With Symptom Severity in PPI Non-Responders With Normal Impedance-pH Profiles

OBJECTIVES

Up to 50% of patients with reflux symptoms do not manifest a satisfactory symptom response to proton pump inhibitor (PPI) therapy. Our primary aim in this study was to identify factors associated with symptom perception among PPI non-responder phenotypes.

METHODS

This prospective observational cohort study was performed from September 2014 to January 2017 at a single academic medical center and included PPI non-responders who underwent 24-h impedance-pH monitoring and completed a questionnaire set measuring patient-reported symptom severity, quality of life (QOL), and psychosocial distress. Participants were separated into cohorts based on impedance-pH results: on PPI: -acid exposure time (AET)/-symptom-reflux association (SRA), +AET, and -AET/+SRA; off PPI: functional (-AET/-SRA), gastroesophageal reflux disease (GERD) (+AET), and reflux hypersensitivity (RHS) (-AET/+SRA). The primary outcome was abnormal GERD symptom severity defined by GerdQ≥8.

RESULTS

One hundred and ninety-two participants were included. Impedance-pH on PPI was performed on 125: 72 (58%) -AET/-SRA, 42 (34%) +AET, and 11 (9%) -AET/+SRA. Among the -AET/-SRA group, younger age, higher dysphagia scores, QOL impairment, and higher brief symptom index were associated with GerdQ≥8. Among the +AET group, higher number of reflux-associated symptoms and lower distal contractile integral was associated with GerdQ≥8. Impedance-pH off PPI was performed on 67 participants: 39 (58%) functional, 16 (24%) GERD, and 12 (18%) RHS. Among the functional group, higher QOL impairment and dysphagia scores were seen with GerdQ≥8.

CONCLUSIONS

Perceptions of reflux symptoms are associated with psychosocial distress, reduced QOL, and sensation of dysphagia among PPI non-responders with normal impedance-pH. Among PPI refractory GERD patients, patient-reported symptom severity is associated with physiological differences, as opposed to psychosocial factors.

Dexlansoprazole - a new-generation proton pump inhibitor

Dexlansoprazole modified release (MR) is an R-enantiomer of lansoprazole and a new-generation proton pump inhibitor exhibiting high efficacy in the treatment of symptoms and lesions associated with erosive oesophagitis caused by gastroesophageal reflux disease (GERD). The dual release of the active ingredient - in the duodenum and the small intestine - makes it possible to achieve two peak concentrations at various times, within two and five hours of administration. Dexlansoprazole MR ensures the longest maintenance of drug concentration in the plasma of all known proton pump inhibitors, and the longest proton pump inhibitory effect. The basic indications for the drug include all forms of gastroesophageal reflux disease, especially with night-time heartburn and sleep disorders resulting from GERD. Dexlansoprazole can be taken regardless of meal times. It has a good safety profile and carries a low risk of adverse interactions with other drugs.

Patients with refractory reflux symptoms: What do they have and how should they be managed?

With the widespread use of proton pump inhibitors (PPIs), the frontier of treating reflux disease has shifted from refractory esophagitis to PPI-refractory symptoms. However, symptoms are inherently less specific than mucosal disease and, as noted by Herregods et al. in their contribution appearing in this issue of Neurogastroenterology and Motility, patients with refractory gastroesophageal reflux disease (GERD) symptoms often do not have GERD. This review discusses potential etiologies for PPI-refractory symptoms. Three major concepts are explored: subendoscopic esophagitis, weakly acidic reflux events, and alternative explanations for persistent symptoms. With respect to subendoscopic esophagitis and unsuppressed reflux, ample evidence exists that these are present in PPI-refractory patients. The problem is that these findings are also often present in substantial numbers of individuals with a satisfactory response to PPI therapy. Hence, the emphasis shifts to determinants of symptom perception. The major conclusion of the review is that psychogenic factors such as hyperalgesia, allodynia, hypervigilance, and heightened anxiety are the most plausible explanations as the dominant determinants of PPI-refractory symptoms.

Risk factors and populations at risk: selection of patients for screening for Barrett's oesophagus

Screening for Barrett's oesophagus is an attractive notion due to the rising incidence of oesophageal adenocarcinoma, the relative ease of acquiring tissue from the oesophagus, and the availability of endoscopic therapy for early neoplastic lesions. If screening is recommended, the question remains: which patients should be screened? Endoscopy is frequently performed in patients with symptoms of gastro-oesophageal reflux disease, but the vast majority of patients diagnosed with oesophageal adenocarcinoma have never undergone a prior endoscopy. The efficiency of screening needs to be improved. A number of tools for predicting the presence of Barrett's oesophagus or future risk of developing oesophageal adenocarcinoma are available. More research is needed to validate these tools and to identify the thresholds at which screening should be offered.

Nonmedical therapeutic strategies for nonerosive reflux disease

There has been a marked decline over the last several years in drug development for gastroesophageal reflux disease and specifically for nonerosive reflux disease (NERD), despite there being many areas of unmet need. In contrast, we have seen a proliferation, during the same period of time, in development of novel, nonmedical therapeutic strategies for NERD using cutting-edge technology. Presently, compliance and lifestyle modifications are readily available noninvasive therapeutic interventions for NERD. Other nonmedical therapies include, the Stretta procedure, transoral incisionless fundoplication, and the magnetic sphincter augmentation device (LINX). Antireflux surgery, in experienced hands, has been repeatedly shown to be efficacious in resolving NERD-related symptoms. Psychological therapeutic interventions and alternative medicine techniques, such as acupuncture, continue to show promise, especially in NERD patients who failed antireflux treatment.

Psychological modulation in patients surgically intervened for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) has been related with certain psychological dimensions. The influence of mood, emotional intelligence, and perceived quality of life on clinical symptoms and outcome of antireflux surgery was evaluated in GERD patients with and without hiatal hernia. The study included 61 patients who were diagnosed with GERD between 2003 and 2008: 16 of them without hiatal hernia (group A) and 45 of them with hiatal hernia (group B). All of these patients had undergone laparoscopic antireflux surgery. Patients were clinically examined and evaluated with the following instruments: Short Form (SF)-36 Health Survey, Gastrointestinal Quality of Life Index, Hospital Anxiety and Depression (HAD) Scale, and Trait Meta-Mood Scale (TMMS)-24. Proportions were compared by using the chi-squared test; averages were compared by using the Student's t-test (with Bonferroni's correction). In general, our patients intervened for GERD showed results lower than normal or close to the lower limit of normal in the administered tests. Patients in the group without hernia were younger (P < 0.001) and with lower American Society of Anaesthesiologists risk. They showed higher scores in the SF-36 dimensions: Physical Functioning, Physical Role and Emotional Role, and lower scores in the Social Role (P < 0.001). They showed lower scores in the Emotional dimension of Gastrointestinal Quality of Life Index (P = 0.0068) and worse results in the Hospital Anxiety and Depression subscales of Anxiety (P < 0.001) and Depression (not significant). Men in the group without hernia showed higher scores than men in the group with hernia in the TMMS subscales corresponding to Emotional Clarity and Emotional Repair (P < 0.001). Women in the group with hernia showed higher scores than women in the group without hernia regarding Emotional Clarity (P = 0.0012). GERD patients showed poor results in all the tests, and patients without hiatal hernia compared with patients with hernia showed higher levels of anxiety, which interfered with their social life. Moreover, they showed lower tolerance to stress and higher frustration, fear, and worry. On the basis of such unfavorable phychoemotional results observed with GERD patients (especially those without hernia) in the different tests, we propose that improving our knowledge of the psychological profile of GERD patients - particularly those without hiatal hernia - could help in designing individualized medical and psychological therapies and increase success rates.

Refractory gastroesophageal reflux disease: advances and treatment

'Refractory gastroesophageal reflux disease' is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with 'refractory symptoms.' We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue.

New Approaches to Management of PPI-Refractory Gastroesophageal Reflux Disease

OPINION STATEMENT

"Refractory GERD" is one the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive, often twice-daily proton pump inhibitor therapy. The term should be replaced with "refractory symptoms." We must acknowledge that in many patients, symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus, and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to esophagogastroduodenoscopy followed by pH or impedance monitoring. In the majority of patients these tests are normal. The role of non-acid reflux measured by impedance pH testing in this group is uncertain at best and the results from this test alone should not be used to refer patients to surgical fundoplication. In patients unresponsive to acid suppressive therapy, reflux is most commonly not causal and a search for non-GERD causes must ensue.

[Natural history and overlap of functional gastrointestinal disorders]

Functional gastrointestinal (GI) disorders are common in the general population. Based on the Rome III classification, these disorders are mutually exclusive disorders keeping the homogeneity of each functional GI disorder in research area. In contrast, many population and clinical studies have reported a considerably high rate of overlap between functional GI disorders. The overlap of functional GI disorders over other intestinal diseases might simply occur by chance due to a highly prevalent disorder. Moreover, functional GI disorders is considered a chronic stable disorder that may wax and wane for several years. However, a recent study about the natural history of functional GI disorders showed substantial transition among functional GI disorders over time. The natural history of functional GI disorders with overlapping other functional GI disorders are still in infancy and better understanding of these will be important in determining the efficacy of future therapeutic interventions.

Overlap of functional heartburn and gastroesophageal reflux disease with irritable bowel syndrome

Several studies indicate a significant degree of overlap between irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). Likewise, both functional heartburn (FH) and IBS are functional digestive disorders that may occur in the same patients. However, data establishing a solid link between FH and IBS are lacking, mainly because the clinical definition of FH has undergone substantial changes over the years. The available literature on the overlap between GERD or FH and IBS highlights considerable heterogeneity in terms of the criteria and diagnostic procedures used to assess heartburn and IBS. In particular, several epidemiological studies included patients with concomitant IBS and GERD without any attempt to distinguish FH (as defined by the Rome III criteria) from GERD via pathophysiological investigations. Independent of these critical issues, there is preliminary evidence supporting a significant degree of FH-IBS overlap. This underscores the need for studies based on updated diagnostic criteria and accurate pathophysiological classifications, particularly to distinguish FH from GERD. This distinction would represent an essential starting point to achieving a better understanding of pathophysiology in the subclasses of patients with GERD and FH and properly assessing the different degrees of overlap between IBS and the subcategories of heartburn.The present review article intends to appraise and critically discuss current evidence supporting a possible concomitance of GERD or FH with IBS in the same patients and to highlight the pathophysiological relationships between these disorders.

The val66met polymorphism of brain-derived neurotrophic factor is associated with human esophageal hypersensitivity

BACKGROUND

Recent evidence implicates brain-derived neurotrophic factor (BDNF) in visceral hypersensitivity and pain in functional gastrointestinal disorders. We hypothesized that presence of the val66met polymorphism in the BDNF gene would be linked to increased esophageal sensitivity to electrical stimulation.

METHODS

A total of 39 healthy volunteers (20 males, mean age 30) compliant with inclusion criteria after screening procedures were genotyped for BDNF polymorphisms and completed an Hospital Anxiety and Depression Scale (HADS) questionnaire. Sensory (ST) and pain (PT) thresholds in the proximal (PE) and distal (DE) esophagus were determined using electrical stimuli to a swallowed intraluminal catheter with bipolar electrodes by an investigator blinded to the subjects' genotype. For comparison, somatic ST and PT (hand and foot) were also tested. HADS scores together with esophageal and somatic thresholds were then correlated with BDNF polymorphism status.

KEY RESULTS

Eleven of 39 (28%) volunteers had at least one Met allele (Met carriers). When compared with Val/Val, Met carriers had lower esophageal PT (Median PT [mA]: Val/Val vs Met carriers, PE; 49.4 vs 44.3, P = 0.033, DE: 63.8 vs 55.4, P = 0.045) with higher proportion of Val/Val subjects in the upper quartile for PT in both PE (P = 0.021) and DE (P = 0.033), yet similar somatic PT (Median PT [mA] Hand; 33.6 vs 38.0, P = 0.22, Foot; 44.7 vs 44.0, P = 0.48). Sensitivity results were independent of anxiety (P = 0.66) and depression (P = 0.33) scores.

CONCLUSIONS & INFERENCES

val66met BDNF polymorphisms are associated with increased esophageal sensitivity to experimental electrical stimulation. Thus, BDNF genotype may be a useful biomarker for electrical sensitivity in the healthy human esophagus.

Prevalence of gastro-esophageal reflux-type symptoms in individuals with irritable bowel syndrome in the community: a meta-analysis

OBJECTIVES

Irritable bowel syndrome (IBS) and gastro-esophageal reflux-type symptoms (GERS) are highly prevalent in the general population, and the two appear to be related. We conducted a systematic review and meta-analysis to estimate the prevalence of GERS in individuals with IBS, and to quantify the overlap between the two disorders.

METHODS

MEDLINE, EMBASE, and EMBASE Classic were searched (up to October 2011) to identify population-based studies reporting the prevalence of IBS and GERS in adults (≥ 15 years), defined using a specific symptom-based criteria or a questionnaire. The prevalence of IBS and GERS were extracted for all studies. Pooled prevalence, according to study location and criteria used to define IBS or GERS, as well as odds ratios (OR), with 95% confidence intervals (CIs) were calculated. The degree of overlap between the two was examined.

RESULTS

Of 390 papers evaluated, 81 reported prevalence of IBS. Thirteen of these, containing 49,939 participants, reported the proportion of individuals with GERS. The prevalence of GERS in IBS was 42.0% (95% CI, 30.0-55.0). The pooled OR for GERS in individuals with IBS, compared with those without, was 4.17 (95% CI, 2.85-6.09). The OR for GERS in IBS remained significantly higher in all geographical regions studied, and for all diagnostic criteria used. The degree of overlap between the two conditions varied from 14.2, when the Rome II criteria for IBS were used, to 26.7% with the Manning criteria.

CONCLUSIONS

The OR of GERS in individuals with IBS was four-fold that of individuals without IBS. Reasons for this remain speculative, but may include shared pathophysiological mechanisms or residual confounding.

Many patients continue using proton pump inhibitors after negative results from tests for reflux disease

BACKGROUND & AIMS

Ambulatory reflux testing is used to evaluate symptoms of gastroesophageal reflux disease (GERD) refractory to protein pump inhibitors (PPIs). We investigated the prevalence of PPI use in patients with negative results from Bravo pH or multichannel intraluminal impedance-pH (MII-pH) tests and factors that might predict the use of PPIs.

METHODS

We analyzed data from patients who had undergone Bravo pH monitoring or MII-pH testing at Northwestern University, without evidence of reflux disease. Demographics, endoscopy findings, pathology results, and provider recommendations were obtained via chart review. Eligible patients (n = 90) were contacted by telephone, and a cross-sectional survey was administered with questions about symptom severity, demographics, medication use, and health behaviors. Patients were compared by current PPI use, and statistical analyses were performed by using SAS version 9.2 software.

RESULTS

Thirty-eight patients (42.2%) reported current PPI use despite a negative result from a pH study. Only 17 patients (18.9%) recalled being instructed to stop taking PPIs; chart review showed documented instructions to stop PPI therapy for 15 patients (16.7%). There were no significant differences in demographic or clinical characteristics among patients compared by current PPI use. Patients taking a PPI were more likely than those not taking a PPI to report troublesome symptoms that affected their daily life, as measured by a questionnaire for the diagnosis of GERD (the GerdQ).

CONCLUSIONS

More than 42% of patients with negative results from pH monitoring studies continue PPI therapy despite physiological data that they do not have GERD.

Therapeutic options for refractory gastroesophageal reflux disease

Refractory gastroesophageal reflux disease may affect up to one-third of the patients that consume proton pump inhibitor (PPI) once daily. Treatment in clinical practice has been primarily focused on doubling the PPI dose, despite lack of evidence of its value. In patients who failed PPI twice daily, medical treatment has been primarily focused on reducing transient lower esophageal sphincter relaxation rate or attenuating esophageal pain perception using visceral analgesics. In patients with evidence of reflux as the direct trigger of their symptoms, endoscopic treatment or antireflux surgery may be helpful in remitting symptoms. The role of psychological interventions, as well as non-traditional therapeutic strategies remains to be further elucidated.

Systematic review: the association between symptomatic response to proton pump inhibitors and health-related quality of life in patients with gastro-oesophageal reflux disease

BACKGROUND

Some patients with gastro-oesophageal reflux disease (GERD) experience persistent reflux symptoms on proton pump inhibitor (PPI) therapy. The relationship between persistent reflux symptoms and health-related quality of life (HRQoL) is unclear.

AIM

To assess the relationship between persistent reflux symptoms on PPI therapy and HRQoL in patients with GERD.

METHODS

Systematic searches were conducted in PubMed and Embase. Eligible studies had to have used psychometrically evaluated patient reported outcome instruments to assess HRQoL.

RESULTS

Nine studies were included; supplementary data were obtained for four of these. The effect of persistent reflux symptoms despite PPI therapy on physical HRQoL was assessed in seven studies and that on mental HRQoL in five studies. Compared with patients whose reflux symptoms responded to PPIs, those with persistent symptoms had, on average, 8-16% lower scores for physical health (five studies) and 2-12% lower scores for mental health (three studies). Three studies included data on the effect of baseline HRQoL on subsequent symptomatic response to PPI therapy. Patients with persistent symptoms had clinically relevant lower psychological well-being at baseline compared with those whose symptoms responded to PPIs (average score difference: 7%; two studies). High anxiety levels at baseline seemed to be an important aspect of persistent symptoms.

CONCLUSIONS

Persistent reflux symptoms on PPI therapy are associated with reduced physical and mental HRQoL, while reduced mental HRQoL at baseline seems to impair symptomatic response to PPIs. HRQoL may need to be considered alongside reflux symptom frequency and severity when making decisions about disease management.

Concomitant irritable bowel syndrome is associated with failure of step-down on-demand proton pump inhibitor treatment in patients with gastro-esophageal reflux disease

BACKGROUND

The predictors for treatment failure of on-demand proton pump inhibitor (PPI) therapy in gastro-esophageal reflux disease (GERD) patients are unclear. We studied the efficacy and predictors for treatment failure of step-down on-demand PPI therapy in patients with non-erosive reflux disease (NERD) and those with low grade erosive esophagitis.

METHODS

Consecutive symptomatic GERD patients who had positive esophageal pH studies and complete symptom resolution with initial treatment of esomeprazole were given step-down on-demand esomeprazole for 26 weeks. Patients with esophagitis of Los Angeles (LA) grade C or above and recent use of PPI were excluded. Treatment failure was defined as an inadequate relief of reflux symptoms using global symptom assessment. Potential predictors of treatment failure were determined using multivariate analysis.

KEY RESULTS

One hundred and sixty three NERD and 102 esophagitis patients were studied. The 26-week probability of treatment failure was 36.2% (95% CI: 23.9-46.5%) in NERD group and 20.1% (95% CI: 10.9-28.3%) in esophagitis group, respectively (P = 0.021). Irritable bowel syndrome (adjusted HR: 2.1, 95% CI: 1.5-3.8, P = 0.01), in addition to daily reflux symptom (adjusted hazard ratio: 2.7, 95% CI: 1.9-4.2, P = 0.001) and concomitant dyspepsia (adjusted hazard ratio: 1.7, 95% CI: 1.1-2.8, P = 0.04), were independent predictors for treatment failure.

CONCLUSIONS & INFERENCES

Compared to patients with esophagitis, NERD patients have higher failure rate of on-demand PPI therapy. Concomitant irritable bowel syndrome, in addition to daily reflux symptom and dyspepsia, is associated with the failure of on-demand PPI in these patients.

The hypersensitive esophagus: pathophysiology, evaluation, and treatment options. Curr Gastroenterol Rep. 2010;12:417-426. [PMID: 20669058 DOI: 10.1007/s11894-010-0122-3]

Visceral hypersensitivity plays a key role in the pathogenesis of esophageal functional disorders such as functional heartburn and chest pain of presumed esophageal origin (noncardiac chest pain). About 80% of patients with unexplained noncardiac chest pain exhibit lower esophageal sensory thresholds when compared to controls during esophageal sensory testing (ie, esophageal barostat, impedance planimetry). Such information has led to prescription of peripherally and/or centrally acting therapies for the management of these patients. This review summarizes and highlights recent and significant findings regarding the pathophysiology, evaluation, and treatment of the hypersensitive esophagus, a central factor in functional esophageal disorders.

Patient and physician satisfaction with proton pump inhibitors (PPIs): are there opportunities for improvement?

BACKGROUND

Few studies have explored the satisfaction with proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD).

AIM

The aim of this study was to assess patient and physician satisfaction with currently prescribed PPIs for patients with GERD.

METHODS

Separate online surveys were completed by 1,002 physicians and 1,013 GERD patients. Physician surveys examined satisfaction, symptom relief, long-term therapy, side-effects, breakthrough symptoms, and use of supplemental medications with PPIs. Patient surveys evaluated PPI regimen, length of therapy, satisfaction with PPI, symptom relief, use of supplemental medications, and perceptions about long-term use and side-effects.

RESULTS

Most respondents were satisfied with PPI therapy, but 35.4% of GERD patients and 34.8% of physicians perceived patients as "somewhat satisfied" to "completely dissatisfied" with PPI therapy. Patients who were highly satisfied were more likely to indicate complete symptom relief (P < 0.001) relative to patients who were less satisfied. However, over 35% of patients on once-daily and 54% on twice-daily PPI indicated that therapy failed to completely relieve symptoms. Patients who were highly satisfied were more likely to recommend medication to patients with the same symptoms (P < 0.001) and less likely to report that the medication is too expensive (P < 0.001), worry about long-term use (P < 0.001), or add OTC medications for supplemental control (P < 0.004).

CONCLUSIONS

Approximately one-third of GERD patients reported persistent symptoms and were dissatisfied with PPI therapy.

An algorithm for diagnosis and treatment of refractory GERD

Patients with gastro-esophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade. Upper endoscopy appears to have a limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for weakly or residual acidic reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxation rate. Esophageal pain modulators are commonly offered to patients with functional heartburn although supportive clinical studies are still missing.

Anxiety increases acid-induced esophageal hyperalgesia

OBJECTIVE

Anxiety at the time of gastrointestinal injury or inflammation increases the risk of developing visceral hyperalgesia. Distal esophageal acidification induces hyperalgesia in the non-acid exposed proximal esophagus, due to the sensitization of spinal dorsal horn neurones. The objective was to determine whether anxiety influences acid-induced hyperalgesia.

METHODS

A total of 19 healthy volunteers (n = 12 females; age, 22-57 years; mean, 35.7 years) completed a 10-minute mood induction paradigm (anxiety or neutral) with autonomic monitoring (visit 1). On visits 2 and 3, pain thresholds to electrical stimulation, in milliamperes (mA), were determined in the proximal esophagus and foot (control) before and after a 30-minute infusion of 0.15 M of hydrochloric acid. During esophageal acid infusion, the subjects randomly received anxiety or neutral mood induction with autonomic monitoring, in a crossover design. Anxiety and pain ratings were recorded pre and post infusion.

RESULTS

Visit 1: Anxiety induction increased anxiety scores (p < .001), mean arterial pressure (p < .001), and cardiac sympathetic index (p = .007), and reduced parasympathetic measures (cardiac vagal tone [p = .05] and cardiac sensitivity to baroreflex [p = .006)]). Visit 2: Anxiety induction conferred greater acid-induced hyperalgesia compared with neutral (-4.9 mA versus 2.7 mA, p = .009, analysis of covariance). No differences in autonomic measures were found during acid infusion with anxiety or neutral mood induction.

CONCLUSIONS

Anxiety induction increases acid-induced esophageal hyperalgesia; anxiety, thus, facilitates central sensitization in the esophagus. Our studies provide a new model for studying the effects of anxiety on esophageal hyperalgesia and may allow testing of therapeutic strategies to reduce this effect.

Systematic review: persistent reflux symptoms on proton pump inhibitor therapy in primary care and community studies

BACKGROUND

Persistent gastro-oesophageal reflux disease (GERD) symptoms can occur despite proton pump inhibitor (PPI) therapy.

AIM

To assess the prevalence and potential determinants of persistent GERD symptoms in primary care and community-based studies.

METHODS

Studies were identified by systematic PubMed and Embase searches; pooled prevalence data are shown as sample-size weighted means and 95% confidence intervals.

RESULTS

Nineteen studies in individuals with GERD taking a PPI were included. In interventional, nonrandomized primary care trials, the prevalence of persistent troublesome heartburn and regurgitation was 17% (6-28%) and 28% (26-30%) respectively; in randomized trials, it was 32% (25-39%) and 28% (26-30%), respectively. In observational primary care and community-based studies, 45% (30-60%) of participants reported persistent GERD symptoms. Overall, persistent GERD symptoms despite PPI treatment were more likely in studies with a higher proportion of female participants [>60% vs. <50%, risk ratio (RR): 3.66; P < 0.001], but less likely in studies from Europe than in those from the USA (RR: 0.71; P < 0.001), and were associated with decreased psychological and physical well-being.

CONCLUSIONS

Persistent GERD symptoms despite PPI treatment are common in the primary care and community setting. Alternative approaches to management are required.

Management of gastroesophageal reflux disease that does not respond well to proton pump inhibitors

PURPOSE OF REVIEW

Patients with gastroesophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade and presently pose a significant therapeutic challenge to the practicing physician. We reviewed newly accumulated information about the management of PPI failure that has been published over the past 2 years.

RECENT FINDINGS

There are diverse mechanisms that contribute to the failure of PPI treatment in GERD patients and they are not limited to residual reflux. Some of the causes of PPI failure may coincide in the same patient. Upper endoscopy appears to have limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for residual reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxations. Esophageal pain modulators are commonly offered to patients with functional heartburn, although supportive clinical studies are still missing.

SUMMARY

Management of refractory GERD patients remains an important clinical challenge. Recent studies have cemented the value of impedance-pH testing in pursuing proper treatment. Presently, the most promising therapeutic development for this patient population is transient lower esophageal sphincter relaxation reducers.

Overlapping gastroesophageal reflux disease and irritable bowel syndrome: Increased dysfunctional symptoms

AIM: To investigate the association of gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) in Iranian patients and examine the prevalence of functional symptoms of the gastrointestinal tract in patients presenting with either IBS, GERD or both.

METHODS: Six thousand four hundred and seventy six patients presented to the Gastro-intestinal (GI) clinic with symptoms of functional dysfunction of GI tract, 1419 patients (62.0% women, 38.0% men; mean age: 37.4 ± 11.5 years) met Rome II or Rome III criteria (depending on the year of diagnosis) for IBS. 2658 patients were diagnosed with GERD based on clinical presentation and endoscopic findings. We assessed other functional symptoms (epigastric pain, nausea, vomiting, belching, constipation and diarrhea) in patients suffering from GERD, IBS or both.

RESULTS: Among IBS subjects, 63.6% (69.0% women, 31.0% men; mean age: 36.4 ± 10.3 years) also had GERD, whereas 34.7% of the non-IBS patients had GERD [odds ratio (OR) = 3.2, 95% confidence interval (CI): 2.9-3.7, P < 0.0001]. Among patients with GERD, 33.9% of subjects met Rome criteria compared to 13.5% of non-GERD patients (OR = 3.6, 95% CI: 3.1-4.3, P < 0.0001). Prevalence of all functional symptoms was higher in overlapping GERD and IBS subjects, when compared with their prevalence in the IBS subjects without GERD or GERD only subjects (P < 0.05).

CONCLUSION: This finding shows that in overlapping GERD and IBS, other functional abnormalities of the GI tract are also highly prevalent, suggesting a common underlying dysfunction.

Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS)--is it one disease or an overlap of two disorders?

Up to 79% of IBS patients report gastroesophageal reflux disease (GERD) symptoms, and up to 71% of GERD patients report irritable bowel syndrome (IBS) symptoms. There are two principal hypotheses for the common presence of IBS symptoms in GERD patients. The first theory suggests that GERD and IBS overlap in a significant number of patients. The second theory suggests that IBS-like symptoms are part of the spectrum of GERD manifestation. The first theory is supported by genetic studies and similarities in gastrointestinal sensory-motor abnormalities potentially due to general gastrointestinal disorder of smooth muscle or sensory afferents. The other theory is primarily supported by studies demonstrating improvement of IBS-like symptoms in GERD patients receiving anti-reflux treatment. The close relationship between GERD and IBS could be explained by either GERD affecting different levels of the GI tract or a high overlap rate between GERD and IBS due to similar underlying GI dysfunction.

Treatment patterns and symptom control in patients with GERD: US community-based survey

BACKGROUND

Proton pump inhibitors (PPIs) are the most commonly used pharmacological treatment for gastroesophageal reflux disease (GERD).

OBJECTIVE

To examine the utilization patterns of PPIs and other GERD-related medications, satisfaction with PPI treatment and presence of GERD symptoms.

PATIENTS AND METHODS

GERD patients using prescription PPIs were identified from a mixed-model HMO health plan. Utilization patterns of PPIs and other GERD medications, satisfaction with PPI treatment and presence of GERD symptoms were assessed using questionnaires.

RESULTS

Among the 617 patients who completed the survey, 71.0% used PPIs once a day (QD), 22.2% used twice a day (BID) and 6.8% more than twice a day or on an as-needed basis. Approximately 42.1% of all patients supplemented their prescription PPIs with other GERD medications, including over-the-counter medications and H(2)-receptor antagonists. Over 85% of the patients still experienced GERD symptoms and 82.7% nighttime symptoms. Overall, 72.8% of all patients were satisfied or very satisfied with their PPI treatment.

LIMITATIONS

The study used self-reported data which may have been subject to recall bias. As the study was conducted in a specific region of the US, the results may have limited generalizability to other US regions or countries.

CONCLUSIONS

Patients on PPI treatment often experience GERD symptoms and supplement their prescription PPIs with other GERD medications. A substantial proportion of GERD patients receiving PPI treatment are on a BID regimen. Furthermore, more than a quarter of the patients are not completely satisfied with their PPI treatment.

Proton pump inhibitor failure--what are the therapeutic options?

Proton pump inhibitor (PPI) failure is very common and may affect up to one-third of the PPI consumers. Identifying the underlying mechanisms for PPI failure in each individual patient is essential for treatment success. For residual acid reflux, increasing the PPI dose to twice daily; switching to another PPI, or adding an histamine 2 receptor antagonist could be a successful therapeutic strategy. In patients with duodenogastroesophageal reflux, weak acidic/alkaline reflux and hypersensitivity to acid reflux, therapeutic modalities that reduce transient lower esophageal sphincter relaxation or visceral pain could be entertained. Treatment of PPI failure due to delayed gastric emptying should be focused on improving gastric motor activity. Psychological management may supplement any medical or surgical approach toward PPI failure.

Review article: gastro-oesophageal reflux disease and psychological comorbidity

BACKGROUND

A growing number of studies have shown the impact of psychological comorbidities on gastro-oesophageal reflux disease (GERD) patients' symptom reports and healthcare-seeking behaviour.

AIM

To review the reported relationship between GERD and psychological comorbidity.

METHODS

Review of the literature on GERD and psychological comorbidity.

RESULTS

Psychological comorbidity is common among GERD patients and appears to afflict all GERD phenotypes. Sexual and physical abuse is also common in GERD patients. Stress enhances perception of oesophageal acid exposure. Treatment for GERD, especially in those who are not responsive to antireflux treatment, may require further evaluation for psychological comorbidity.

CONCLUSIONS

Psychological comorbidity is very common in GERD patients and is likely to play an important role in response, or failure of response, to proton pump inhibitor treatment.

Refractory GERD: what is it?

Refractory gastroesophageal reflux disease (GERD) is very common and may affect up to 40% of patients who use a proton pump inhibitor (PPI) once daily. Refractory GERD can present as incomplete or lack of response to PPI therapy. The disorder is clearly driven by patients, who present with a wide range of symptom severity and frequency while on PPI treatment. Poor compliance and improper timing of PPI consumption should always be excluded before further evaluation of this patient population. The putative mechanisms for refractory GERD include weakly acidic reflux, duodenogastroesophageal/bile reflux, visceral hypersensitivity, delayed gastric emptying, psychological comorbidity, and concomitant functional bowel disorders. Reduced PPI bioavailability, rapid PPI metabolism, PPI resistance, nocturnal reflux, and Helicobacter pylori infection status have very limited roles in refractory GERD. The contribution of eosinophilic esophagitis to refractory GERD is still unknown. Pill-induced esophagitis, Zollinger-Ellison syndrome, achalasia, and other disorders are rarely responsible for PPI failure and usually are not confused with GERD.