Latin American consensus on diagnosis of gastroesophageal reflux disease

BACKGROUND

Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts.

METHODS

This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard.

KEY RESULTS

A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination.

CONCLUSIONS

Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.

[Successful esophageal pH monitoring with Bravo capsule in patients with gastroesophageal reflux disease]

INTRODUCTION

Esophageal 24-h pH monitoring (24-pH) is the most useful test to diagnose and treat patients with gastroesophageal reflux disease (GERD). The traditional system for 24-pH requires transnasal introduction of a catheter with pH sensors. This technique produces discomfort, inconvenience and interference with daily activity. Recently, the Bravo pH system has been proposed as an alternative and promising method for 24-pH. In this study, the initial experience in Mexico with this system is reported.

OBJECTIVE

To evaluate safety, tolerability and performance of the pH Bravo capsule in patients with GERD.

MATERIALS AND METHODS

Patients with GERD symptoms at least twice a week during the last three months, with indication for 24-pH were evaluated. pH Bravo capsule was placed 6 cm above squamocolumnar junction (SCJ). Symptoms, quality and duration of pH tracings, capsule detachment and patient global satisfaction were evaluated.

RESULTS

Eleven patients (nine female, two male) mean age 42 years (range 26-62 years), two with erosive and nine with non-erosive GERD were studied. pH capsule was correctly positioned at 6 cm above SCJ in all patients. Nine patients noted a mild foreign body sensation (especially while eating) and four had mild chest pain; two patients had no discomfort. Capsule detachment occurred spontaneously in all patients on day 10. pH record for > 43 h was obtained in the 11 patients. There were no differences in pH parameters between days 1 and 2. Two patients with normal acid exposure on day 1 had abnormal pH parameters on day 2.

CONCLUSIONS

Esophageal pH monitoring with Bravo capsule is a safe, reliable and tolerable method in patients with GERD. Extended pH recordings increases abnormal esophageal acid exposure detection in patients with this disease.

[Non-erosive gastroesophageal reflux disease. Incidence of clinical forms, characteristics of esophageal exposure to acid and symptomatic correlations]

BACKGROUND

It is estimated that up to 70% of community-based patients with heartburn have no evidence of esophageal mucosal injury or non-erosive gastroesophageal reflux disease (NERD). Studies in NERD patients using esophageal pH monitoring and symptom index (SI) have suggested different subgroups or clinical forms.

OBJECTIVE

Our aim was to investigate frequency of different subgroups of patients with NERD according to esophageal pH-monitoring parameters and SI, and to determine esophageal acid exposure characteristics and the relationship between symptoms and acid reflux in NERD.

MATERIAL AND METHODS

Patients with heartburn at least 3 times per week during 12 weeks during the last year and negative upper GI endoscopy were studied. All patients were submitted to 24 h esophageal pH-metry and SI was calculated. Patients were classified into three groups: group I, patients with abnormal pH-metry; group II, patients with normal pH-metry and positive SI (> or = 50%), and group III, patients with normal pH-metry and negative SI (< 50%). Total number of reflux episodes, length of episode, % time pH < 4, and Johnson-DeMeester score were evaluated.

RESULTS

Three hundred patients, 206 women and 94 men, were included. A total of 137 (46%) were classified in group I, 62 (21%) in group II, and 101 (33%) in group III. There were no significant differences in gender and age among groups. All pH parameters were significantly higher in group I. In group II, there was good correlation between heartburn and acid reflux. Esophageal acid exposure in group III was minimal and there was no relationship among symptoms and acid reflux episodes.

CONCLUSIONS

Subjects with NERD represent a heterogeneous group of patients. Three subgroups of patients with NERD were identified by pH-metry and SI; a) patients with abnormal acid exposure; b) patients with hypersensitive esophagus (heartburn with physiologic amounts of acid reflux), and c) patients with no correlation between symptoms and acid reflux.

[Obesity and gastroesophageal reflux disease]

INTRODUCTION

Obesity is a condition that has been associated with gastroesophageal reflux disease (GERD), however, a cause-effect relationship has not been established.

AIM

To analyze current evidence evaluating the relationship between obesity and GERD, as well as the impact of hypocaloric diets and bariatric surgery in gastroesophageal reflux symptoms.

MATERIAL AND METHODS

An electronic search in the MEDLINE was performed, looking for information published during the past 15 years: Cohort studies, case-control studies, case series and case reports, including the following key words: "heartburn", "reflux", "gerd", "reflux esophagitis", "obesity", "overweight", "diet", "bariatric surgery" were analized.

RESULTS

Thirty-one articles were included. These studies were classified according to the diagnostic method of GERD (i.e., manometry, 24-hour pH monitoring, esophageal transit, endoscopy) and type of bariatric surgery: Adjustable gastric banding (AGB), vertical banded gastroplasty (VBG), and Roux-en-Y gastric bypass (RYGB), or anti-reflux procedure.

CONCLUSIONS

Most studies suggest that obesity is a condition predisposing to the development of GERD. However, there are no studies that correlate the degree of obesity with the symptoms of reflux. Hypotonic lower esophageal sphincter, ineffective esophageal motility and presence of hiatal hernia are the pathophysiological mechanisms proposed as inductors of gastroesophageal reflux among obese patients. AGB and VBG seem to induce postoperative esophagitis in some patients, but RYGB has shown to be effective to control GERD symptoms. Overweight and obesity do not seem to affect the results of antireflux surgery. The impact of body weight loss on GERD following hypocaloric diets requires further investigation.