The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus

An international primary care survey of GERD terminology and guidelines

BACKGROUND

Terminology used to describe upper gastrointestinal disorders differs by country and language. However, the extent of variation in physician understanding of GERD and associated conditions and symptoms is not known.

AIM

To determine the knowledge of primary care physicians with regard to: terminology related to GERD, their understanding of related complications and extra-esophageal symptoms/conditions, and their use of guidelines relating to GERD.

METHODS

Gastroenterologists from 17 countries asked primary care physician colleagues to complete a one-page online survey on GERD.

RESULTS

352 primary care physicians, (77% community-based, 23% hospital-based) completed the questionnaire. Gastroesophageal reflux disease/GERD (84%) or reflux/reflux disease (47%) were the terms mostly often used to record a diagnosis for patients with reflux-related symptoms or clinical manifestations; dyspepsia (15%), epigastric pain (10%), and gastritis (9%) were infrequently used. Erosive esophagitis, Barrett's esophagus, stricture, and esophageal adenocarcinoma were recognized as being associated with GERD by 88, 71, 61 and 51% of physicians, respectively. Extra-esophageal problems of cough, sleep-related disorders, laryngitis and asthma were recognized to be associated with GERD by 74, 50, 48 and 47% of respondents. Thirty-nine percent of physicians stated that they did not use a specific definition of GERD; 33% used an international and 14% used a national guideline in managing patients.

CONCLUSIONS

(1) GERD is well recognized, but its related terminology is variable throughout the world. (2) There was variable and incomplete recognition of extra-esophageal manifestations GERD. (3) Recognition of extra-esophageal diseases caused by GERD is variable. (4) Current GERD guidelines are infrequently used by primary care physicians.

Symptom evaluation in gastroesophageal reflux disease

The evaluation of the success of therapy for gastroesophageal reflux disease (GERD) has thus far been primarily on the basis of the endoscopic evaluation of the ability of drugs to heal esophageal mucosal breaks and to a lesser extent on their ability to decrease the diverse symptoms of acid reflux. However, because most patients with GERD have no visible esophageal lesions using conventional endoscopic methods, this paradigm requires serious reconsideration. As patients with nonerosive reflux disease (NERD) are just as symptomatic as patients with erosions and are no easier to treat the use of endoscopic end points alone, as criteria for determining healing and efficacy of therapy requires reassessment. In addition, the symptoms of GERD are now appreciated to be broad-based, including many extraesophageal symptoms that contribute to the marked reduction in quality of life for GERD patients. For this reason, and because endoscopic criteria cannot be applied to evaluating therapy in NERD, the success of GERD therapy should be judged primarily in terms of diminishment of GERD-related symptoms--a return to the traditional way that patients judge therapeutic success. To objectively determine the success of therapy in GERD, multisymptom GERD questionnaires have been developed. The most promising are those that reflect the numerous types of GERD symptoms, are patient-administered, quantitative, responsive, and have been validated in both NERD and erosive GERD patients. The ReQuest instrument is especially attractive as it records the entire range of GERD symptoms on a daily basis (including also their frequency and intensity) and is responsive to changes with time and with therapy. Symptom-based evaluative tools should greatly aid the objective evaluation of GERD symptoms, monitor precisely how patients respond to therapy and thereby lead to improvements in GERD management.

Management of Barrett's esophagus in the UK: overtreated and underbiopsied but improved by the introduction of a national randomized trial

OBJECTIVES

To assess the variation in practice of Barrett's esophagus (BE) management in comparison with accepted international guidelines before and after the introduction of a large BE randomized controlled trial (RCT) with protocols including those of tissue sampling.

DESIGN

A validated anonymized questionnaire was sent to 401 senior attending gastroenterologists asking for details of their current management of BE, especially histological sampling. Of the 228 respondents, 57 individuals (each from a different center) were in the first group to enter the ASPirin Esomeprazole (BE) Chemoprevention Trial (AspECT), and we assessed change in practice in these centers.

RESULTS

Ninety percent of specialists did not take adequate biopsies for histological diagnosis. Furthermore, 74% would consider aggressive surgical resection for prevalent cases of high-grade dysplasia in BE as their first-line choice despite the associated perioperative mortality. Ninety-two percent claim their lack of adherence to guidelines is because there is a need for stronger evidence for surveillance and medical interventions. Effect of the AspECT trial: Those clinicians in centers where the AspECT trial has started have improved adherence to ACG guidelines compared with their previous practice (P < 0.05). BE patients now get 18.8% more biopsies compared with previous practice, and 37.7% if the patient is entered into the AspECT trial (P < 0.01).

CONCLUSIONS

This large study indicates both wide variation in practice and poor compliance with guidelines. Because optimal histology is arguably the most important facet of BE management, the improvement in practice in centers taking part in the AspECT trial indicates an additional value of large international RCTs.

Relationship between symptom load of gastro-oesophageal reflux disease and health-related quality of life, work productivity, resource utilization and concomitant diseases: survey of a US cohort

BACKGROUND

Analysis of the burden of gastro-oesophageal reflux disease (GERD) in relation to the severity and frequency of symptoms is essential to identify individuals and groups in whom targeted management is justified.

AIM

To describe the relationship between symptoms of GERD and self-reported health-related quality of life (HRQL), work productivity, healthcare utilization and concomitant diseases.

METHODS

US respondents to the Internet-based 2004 National Health and Wellness Survey who had self-reported GERD (n = 10,028, mean age: 52 years, 58% female) were age- and gender-matched to a control group without GERD (n = 10,028). Respondents with GERD were classified according to symptom severity and frequency. HRQL and productivity were assessed using the Short-Form 8 survey (SF-8) and Work Productivity and Activity Impairment questionnaire, respectively.

RESULTS

Symptom frequency increased with increasing symptom severity. Compared with controls, respondents with GERD had more concomitant diseases [mean difference (MD): 1.6], lower SF-8 physical and mental health scores (MD: 4.1 units and 3.1 units, respectively), increased absenteeism (MD: 0.9 h/week), reduced percent productivity at work (MD: 7.5%) and increased healthcare utilization. All tested variables deteriorated with increasing symptom severity and/or frequency.

CONCLUSIONS

Increasing severity and frequency of GERD symptoms is associated with more concomitant diseases, lower HRQL, lower work productivity and increased healthcare utilization, suggesting that patients with moderate or severe GERD should receive targeted management with the most effective treatment strategies.

Validation of a brief symptom questionnaire (ReQuest in Practice) for patients with gastro-oesophageal reflux disease

BACKGROUND

A clinical need exists for a means of assessing symptom control in patients with gastro-oesophageal reflux disease. The ReQuest questionnaire has been extensively validated for symptom assessment in both erosive and non-erosive gastro-oesophageal reflux disease but was designed for research purposes. We derived a shorter version (ReQuest in Practice) that would be more convenient for clinical practice.

AIM

To validate ReQuest in Practice in patients suffering from gastro-oesophageal reflux disease.

METHODS

Multicentre, non-interventional, crossover comparison. Patients completed ReQuest in Practice followed by ReQuest or vice versa. Before and after a planned endoscopy, patients completed the health-related quality of life questionnaire GERDyzer. Internal consistency and the Intraclass Correlation Coefficient were calculated. Construct validity was evaluated by correlation with ReQuest and GERDyzer.

RESULTS

There was high internal consistency of ReQuest in Practice (Cronbach's alpha: 0.9) and a high Intraclass Correlation Coefficient of 0.99. The measurement error of ReQuest in Practice was 4.1. High correlation between ReQuest in Practice and ReQuest (Spearman correlation coefficient: 0.9) and GERDyzer (Spearman correlation coefficient: 0.8) demonstrated construct validity.

CONCLUSIONS

ReQuest in Practice was proven to be valid and reliable. Its close correlation with ReQuest makes it a promising tool to guide the clinical management of patients across the full spectrum of both erosive and non-erosive gastro-oesophageal reflux disease.

Esophageal dilated intercellular spaces (DIS) and nonerosive reflux disease

Esophageal mucosal dilated intercellular spaces (DIS) are frequently observed in patients with nonerosive reflux disease (NERD) and patients with esophagitis. The specificity of DIS is questionable, as it is present in up to 30% of asymptomatic healthy subjects and in patients with other esophageal disorders. DIS occurs in parallel with a drop in potential difference, diminished transepithelial resistance, and increased esophageal mucosal permeability. These alterations arise with exposure to acid and pepsin during gastroesophageal reflux, but the exact pathway of damage to the intercellular junctions remains unclear and seems to be multifactorial. Other noxious contents of the refluxate, such as bile acids, are harmful and DIS can also be induced by acute psychological stress. DIS can be assessed quantitatively with electron microscopy (EM), but it is also recognizable with light microscopy (LM). DIS can disappear after treatment with proton pump inhibitors (PPI); however, this is not the case in all NERD patients. A recent study showed that patients with NERD who are refractory to PPI might still have DIS; and animal experiments showed that persistence of DIS might be due to esophageal mucosal exposure to bile acids and/or psychological stress. In conclusion, DIS is a frequent but nonspecific histological feature of NERD. It can be caused by acid reflux, but bile acids in the refluxate and/or psychological stress can modulate the development or persistence of DIS. Although a causal relationship between DIS and heartburn has been proposed, it still needs to be proven and the underlying mechanisms investigated before considering DIS as a target for treatment of NERD.

Is acid relevant in the genesis of dyspeptic symptoms associated with nonerosive reflux disease?

[table: see text] A consistent subset of patients with NERD suffers from symptoms centered in the upper part of the abdomen that are more characteristic of functional dyspepsia than reflux disease. The cause of this overlap is still unclear, but acid has been implicated as one of the possible common pathophysiological factors responsible for these two categories of upper gastrointestinal (GI) symptoms. Many physiological investigations and the modest success of proton pump inhibitors in resolving dyspeptic symptoms associated with typical reflux syndrome seem to support the concept that functional dyspepsia and NERD are two separate entities, which need to be treated with different drugs.

Postmenopausal hormone therapy as a risk factor for gastroesophageal reflux symptoms among female twins

BACKGROUND & AIMS

Female sex hormones have been suggested to increase the risk of gastroesophageal reflux symptoms via a relaxing effect on the lower esophageal sphincter. We investigated the relationship of oral contraceptives and postmenopausal hormone therapy (HT) to risk of reflux symptoms, controlling for genetic factors and body mass.

METHODS

Information on exposures and reflux symptoms was obtained by telephone interviews conducted in 1998-2002 among women in the Swedish Twin Registry. Use of oral contraceptives was also assessed in 1973 by questionnaires. Both cross-sectional and prospective nested case-control designs were used, each with external control analysis. The cross-sectional design was further submitted to monozygotic co-twin control analysis.

RESULTS

The cross-sectional study design comprised 4365 twins with reflux and 17,321 without. In ever users of estrogen HT, the risk of reflux symptoms was increased by 32% (odds ratio, 1.32; 95% confidence interval, 1.18-1.47). This association remained in the nested case-control analyses and increased slightly with higher body mass index. A similar pattern was observed for the use of progestin in the cross-sectional design, but no association remained in the nested case-control analysis. Use of oral contraceptives was not associated with an increased risk of reflux symptoms. Generally, the risk estimates remained virtually unchanged after adjustments for potential confounding factors, including genetic factors.

CONCLUSIONS

This population-based twin study indicates that estrogen HT is an independent risk factor for reflux symptoms, while the influence of progestin HT and oral contraceptives is less consistent.

Clinical and endoscopic features of Chinese reflux esophagitis patients

AIM: To analyze the clinical and endoscopic features of Chinese patients with reflux esophagitis (RE).

METHODS: A total of 1405 RE patients were analyzed retrospectively. Data on gender, age, presence/absence of H pylori infection and associated esophageal hiatal hernia were collected. Esophagitis was divided into different grades according to Los Angeles Classification.

RESULTS: Of 18823 patients, 1405 were diagnosed as RE. The ratio of male to female patients was 1.75:1 (P < 0.01). The mean age of male and female patients was significantly different (P = 0.01). The peak age at onset of the disease was 40-60 years. According to Los Angeles Classification, there were significant differences in the age of patients with grades A and B compared to patients with grades C and D (P < 0.01). Two hundred and seventy-seven patients were infected with H pylori, the infection rate was low (P < 0.01). Complication of esophageal hiatal hernia was found to be significantly associated with the severity of esophagitis and age in 195 patients (P < 0.01). Esophageal mucosa damages were mainly located at the right esophageal wall.

CONCLUSION: The peak age of onset of RE is 40-60 years and higher in males than in females. The mean age of onset of RE is lower in males than in females. The infection rate of H pylori is significantly decreased in patients with esophagitis. Old age and esophageal hiatal hernia are associated with more severe esophagitis. Right esophageal mucosal damage can occur more often in RE patients.

Common causes and current guidelines

Chronic cough is a common and disabling symptom. Recent guidelines have attempted to provide direction in the clinical management of cough in both primary and secondary care. They have also provided a critical review of the available literature and identified gaps in current knowledge. Despite this they have been criticized for a reliance on a low quality evidence base. In this review, we summarize the current consensus on the clinical management of chronic cough and attempt to rationalize this based on recent evidence. We have also provided an overview of the likely pathophysiological mechanisms responsible for cough and highlighted areas, where knowledge deficits exist and suggest directions for future research. Such progress will be critical in the search for new and effective treatments for cough.

Functional heartburn, nonerosive reflux disease, and reflux esophagitis are all distinct conditions—A debate: Con

Gastroesophageal reflux disease (GERD) is currently defined as a condition that develops when the reflux of stomach contents causes recurrent symptoms and/or complications. The clinical presentation of GERD has been recognized to be much broader than before, when the typical symptoms of heartburn and acid regurgitation were considered as the main clinical presentation. However, now it is recognized that GERD can present with various other mainly extraesophageal symptoms, abdominal pain, and even sleep disturbance. Moreover, there is an important overlap with functional gastrointestinal disorders such as functional dyspepsia and irritable bowel syndrome. The morphologic spectrum of esophageal involvement in GERD encompasses erosive (erosive reflux disease ), Barrett's esophagus (BE), and nonerosive reflux disease (NERD). However, there is still no consensus on whether GERD represents one disease that can progress from NERD to ERD and BE, or whether it is a spectrum of different conditions with its own clinical, pathophysiologic, and endoscopic characteristics. Recently published data suggest that mild erosive esophagitis behaves in a way similar to NERD and that there is considerable movement between these categories. But follow-up data also show that after 2 years, some patients with NERD or GERD Los Angeles A or B went on to develop severe GERD or even BE. A practical approach is to categorize patients with reflux symptoms into "functional heartburn" (ie, reflux symptoms and negative endoscopy and absent objective evidence of acid reflux into the esophagus), NERD (negative endoscopy but positive documentation of acid reflux into the esophagus), and ERD (erosions documented endoscopically). In conclusion, it appears that GERD is a disease with a spectrum of clinical and endoscopic manifestations, with characteristics that make it a continuum and not a categorical condition with separate entities. It is difficult to clearly delineate the spectrum of GERD based on the clinical, endoscopic, and pathophysiologic characteristics, but therapeutic trials and follow-up studies suggest that GERD is not composed of different conditions.

Review article: respiratory manifestations of gastro-oesophageal reflux disease

BACKGROUND

Respiratory manifestations represent one of the most prevalent and difficult-to-manage extra-oesophageal syndromes of gastro-oesophageal reflux disease.

AIMS

To review the epidemiology, pathophysiological mechanisms and therapeutic outcomes of reflux-related respiratory disorders.

METHODS

Search of the literature published in English using PubMed database.

RESULTS

There is a discrepancy between the high prevalence of reflux in asthmatics and the limited efficacy of antireflux therapies. Asthma per se may cause reflux. Patients with difficult-to-treat asthma and/or nocturnal symptoms should be screened for reflux. Reflux can induce chronic cough through different mechanisms including micro-aspiration and both local and central reflexes. Cough and reflux may precipitate each other. A meta-analysis found no significant difference between placebo and proton pump inhibitors in the resolution of cough. Encouraging results have been reported, following antireflux surgery in patients selected on the basis of pH-impedance monitoring. Attention has been drawn to obstructive sleep apnoea syndrome.

CONCLUSIONS

The role of gastro-oesophageal reflux disease in the pathogenesis of miscellaneous respiratory disorders has been discussed for decades and established in asthma and cough. However, no major therapeutic advances have been reported recently. Future trials should concentrate on patient selection and the control of efficacy using recently developed technologies, such as pH-impedance monitoring.

Advances in roles of prokinetic agents in the treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is characterized by the reflux of gastric content into esophagus with or without histological changes. Pathogenesis of GERD is lower esophageal sphincter (LES) dysfunction, abnormal clearing capacity of refluxed materials, delayed gastric emptying and abnormal resistance of esophageal mucosa to gastric acid, but the primary upper gastrointestinal motility dysfunction is regarded as the most important factor in general. Therefore, prokinetic agents which can restore gastric motility with increasing of LES and esophageal motility have been developed and used frequently in the treatment of GERD. There are several prokinetic agents such as metoclopramide, domperidone, cisapride and mosapride that facilitate acetylcholine release from the enteric cholinergic neurons through a selective 5-HT₄ receptor agonistic action. It is considered that prokinetic agents have the same effect as H2 blocker in the treatment of patients with mild GERD. Additionally, it was reported that a combination therapy with prokinetic agents and proton pump inhibitors (PPI) or H2 receptor antagonists (H2RAs) is more effective than monotherapy in patients with severe GERD. This article reviews the recent advances in the role of prokinetic agents in the treatment of gastroesophageal reflux disease.

Use of pH-impedance testing to evaluate patients with suspected extraesophageal manifestations of gastroesophageal reflux disease

GOALS

To report the use of pH-impedance testing in evaluating patients with suspected gastroesophageal reflux disease (GERD) with atypical symptoms.

BACKGROUND

Although the role of acid reflux in causing atypical GERD symptoms is generally accepted, the role, if any, of nonacid reflux is controversial, largely because until recently it has not been possible to detect nonacid reflux. The advent of intraluminal combined pH impedance testing (MII-pH), to detect nonacid reflux has heightened interest in its possible contribution to atypical symptoms.

STUDY

Fifty consecutive patients referred for MII-pH testing to evaluate the cause of atypical symptoms presumed due to GERD were evaluated. The symptoms were either refractory to acid inhibition therapy or so atypical that further work up was desired by the referring physician. Patients underwent MII-pH testing to determine whether reflux was present, and, if so, if it was due to acid, nonacid, or gas.

RESULTS

Only 16%, 22%, and 2% patients were found to have symptoms due to acid reflux, nonacid reflux, or both, respectively. Ten percent of these patients had gas reflux. MII-pH testing was useful in redirecting the management of patients who did not have reflux as the cause of their symptoms.

CONCLUSIONS

MII-pH testing is useful in determining whether gastroesophageal reflux is present in patients with atypical symptoms that have not responded to proton pump inhibitor therapy. It also distinguishes between reflux due to acid, nonacid, and gas, with consequences for management.

Screening for esophagitis and Barrett's esophagus with wireless esophageal capsule endoscopy: a multicenter prospective trial in patients with reflux symptoms

BACKGROUND AND AIM

Esophageal capsule endoscopy (ECE) is a new technology that allows noninvasive investigation of the esophagus. Our aim was to evaluate prospectively the diagnostic yield of ECE in patients with chronic reflux symptoms.

PATIENTS AND METHODS

Eighty-nine patients (40 men, mean age 54 yr) referred to five endoscopic centers for esophagogastroduodenoscopy (EGD) were enrolled. Patients first underwent ECE, then EGD; endoscopists who performed the EGD were blind to the ECE data that were interpreted separately by two independent readers. The Los Angeles, Prague, and Montreal classification systems were used to describe endoscopic findings.

RESULTS

Seventy-seven patients completed the study. Esophagitis and endoscopically suspected esophageal metaplasia (ESEM) were present in 24 and 10 patients, respectively. Columnar lining was histologically confirmed in seven patients (3 with specialized intestinal metaplasia and 4 with gastric metaplasia). The kappa values for interobserver agreement regarding the diagnosis of esophagitis and ESEM were 0.67 (0.49-0.85) and 0.49 (0.17-0.81), respectively. The diagnostic yields of ECE to detect esophagitis and ESEM were as follows: sensitivity 79% and 60%, specificity 94% and 100%, positive predictive value (PPV) 83% and 100%, negative predictive value (NPV) 92% and 95%, respectively.

CONCLUSION

As a screening tool in patients with reflux symptoms, ECE has an excellent specificity and NPV for the diagnosis of esophagitis and ESEM. However, its sensitivity for the diagnosis of ESEM is not optimal. Further studies are necessary to improve the procedure, and to compare the cost-effectiveness of strategies using ECE or EGD.

Validation of the reflux disease questionnaire for an Italian population of patients with gastroesophageal reflux disease

BACKGROUND/AIMS

The reflux disease questionnaire (RDQ) is a very simple questionnaire based on only 12 questions that can be answered and evaluated quickly in a primary care setting, which was already found to be valid and reliable in the diagnosis of gastroesophageal reflux disease (GERD). As an English and a German version of the RDQ exist, but not an Italian one, we aimed at translating the RDQ into Italian and evaluating its reliability for the use of Italian-speaking GERD patients.

PATIENTS/METHODS

For the purpose of linguistic validation, we translated backward and forward the original RDQ into Italian and again into English. For the purpose of assessing internal consistency, test-retest, and interrater reliability, 130 GERD patients were used, of whom 57 patients had an endoscopic oesophagitis of grade A to C according to the Los Angeles classification and 63 patients had uninvestigated GERD symptoms but with a frequency of heartburn and/or regurgitation at least twice a week.

RESULTS

After professional translation, the Italian RDQ was judged to retain fully the meaning of the original RDQ. Internal consistency, as judged by the (Cronbach's alpha) was satisfactory, with an overall RDQ scale alpha=0.86 (minimum acceptable value=0.70). Test--retest reliability (Spearman coefficient) was again found to be optimal, with individual item values ranging between 0.74 (for 'pain in the upper stomach: frequency') and 0.90 (for 'burning feeling behind breastbone: severity'). Finally, the correlation coefficient was 0.96 for the total scale and a range of 0.85-0.98 for individual items, indicating extremely satisfactory concordance.

CONCLUSIONS

The Italian RDQ appears to be a simple, reproducible, and reliable tool for the diagnosis of GERD. We believe that this questionnaire is well suited for use, both in primary care settings and in epidemiological studies, in particular for the assessment of so-called typical symptoms.

Refractory gastrooesophageal reflux disease

The introduction of proton pump inhibitors (PPIs) has facilitated the treatment of gastrooesophageal reflux disease (GORD) enormously; however, treatment of GORD still fails in a small proportion of patients. This small proportion of therapy-resistant patients encompasses a substantial part of the working load of physicians and has become a common clinical problem. A strong variability in acid-suppressive effect of PPI treatment exists depending on compliance, Helicobacter pylori status and genotype. Nocturnal acid breakthrough does not seem to be a major determinant of refractory GORD. Recent data, however, show that PPI-refractory GORD can result from nonacid reflux episodes. It is wise to reconsider the diagnosis of GORD in patients who are PPI-refractory. Most patients in whom a PPI is not effective do not have GORD, instead they suffer from other disorders such as functional dyspepsia. If after a thorough history is taken the suspicion of GORD is still high, the next step would be to perform upper endoscopy and reflux monitoring. In case patients truly have PPI-refractory GORD, therapy can be aimed at oesophageal hypersensitivity or a surgical solution can be sought.

How useful is histologic confirmation of intestinal metaplasia in patients with long-segment Barrett's esophagus?

BACKGROUND

Controversy exists regarding the usefulness of histologic confirmation of intestinal metaplasia in patients with long-segment Barrett's esophagus (LSBE).

OBJECTIVES

To determine the frequency of intestinal metaplasia in patients with LSBE and to establish an optimal biopsy protocol to detect intestinal metaplasia in these patients.

DESIGN AND INTERVENTION

This retrospective, single-center study included consecutive patients with LSBE (defined as ≥1 cm of columnar-lined esophagus). Exclusion criteria included previous surgical repair of the lower esophageal sphincter. Patients were arbitrarily allocated to one of two endoscopic biopsy procedures: endoscopy with 1–4 biopsies taken, or endoscopy with >4 biopsies taken. The number of biopsies taken in the >4 biopsies group was influenced by clinician judgment. All biopsy specimens were histologically assessed using hematoxylin and eosin staining. At least three gastrointestinal pathologists examined each specimen to determine the mucosa type (intestinal metaplasia, cardiac type, fundic type, glandular not otherwise specified, or squamous). Intestinal metaplasia was diagnosed by the presence of goblet cells. Further histologic assessment with standard alcian blue-periodic acid–Schiff staining was performed in a subset of patients who had >6 biopsies taken during endoscopy. At least two pathologists assessed these specimens. Patients were stratified by the number of biopsies taken per endoscopy: 1–4, 5–8, 9–12, 13–16 and >16.

OUTCOME MEASURES

The main outcome measures were the detection of intestinal metaplasia, and the frequency of intestinal metaplasia detected according to the number of biopsies taken.

RESULTS

In total, 125 patients (mean age 65 years [range 41–85 years]) were included, in whom 296 endoscopies were performed and 1,646 biopsies were taken. Mean follow-up was 25 months. The mean length of a Barrett's esophagus segment was 4 cm (range 1–11 cm). Intestinal metaplasia was present in 80 patients (64%); 150 endoscopies (51%) revealed intestinal metaplasia and 557 biopsies (34%) contained foci of intestinal metaplasia. The mean percentage of patients in whom intestinal dysplasia was detected was significantly greater in the group that had 5–8 biopsies taken per endoscopy than the group that had 1–4 biopsies taken per endoscopy: 67.9% (95% CI 64–71.8%) and 34.6% (95% CI 32–37.6%), respectively; P <0.001. There was no significant difference in the mean percentage of intestinal metaplasia detected between patients who had 5–8 biopsies taken per endoscopy, and those who had 9–12, and 13–16 biopsies taken per endoscopy; the diagnostic yield of intestinal metaplasia was 100% if >16 biopsies were taken per endoscopy. Standard alcian blue-periodic acid–Schiff staining resulted in a change in diagnosis for 5 of 92 patients (5.4%) who underwent this assessment. Increasing age was associated with a significant reduction in the risk of detecting intestinal metaplasia.

CONCLUSION

A minimum of eight random biopsies are required to be taken per endoscopy to diagnose intestinal metaplasia in patients with LSBE.

Self-reported halitosis and gastro-esophageal reflux disease in the general population

BACKGROUND

Patients with halitosis contact primary care practitioners, dentists, and gastroenterologists alike.

OBJECTIVES

It is unclear whether gastroesophageal reflux disease (GERD) is a risk factor for halitosis. DESIGN AND PATIENTS/PARTICIPANTS: We studied this possible relationship in the general population using the cross-sectional Study of Health in Pomerania (SHIP). Employing structured interviews, self-reported halitosis was assessed among 417 edentulous (toothless) subjects aged 40 to 81 years and among 2,588 dentate subjects aged 20 to 59 years. The presence of heartburn or acid regurgitation (GERD-related symptoms) at 4 levels (absent, mild, moderate, severe) was taken as exposure and used for logistic regression. Analyses were adjusted for relevant confounders, such as age, sex, depressive symptoms, history of chronic gastritis, history of gastric or duodenal ulcer, smoking, school education, and dental status.

MEASUREMENTS AND MAIN RESULTS

We found a strong positive association between GERD-related symptoms and halitosis (odds ratio 12.94, 95% confidence interval (CI) 2.66-63.09, P = 0.002 for severe compared to no GERD-related symptoms) in denture-wearing subjects and a moderate, positive association between GERD-related symptoms and halitosis (odds ratio 2.24, 95% CI 1.27-3.92, P = 0.005) in dentate subjects with a clear dose-effect relationship.

CONCLUSIONS

The present study provides clear evidence for an association between GERD and halitosis. As there are effective treatments for GERD, these results suggest treatment options, such as proton pump inhibitors, for halitosis. These should be studied in randomized controlled trials.

Objective measurement of work absence and on-the-job productivity: a case-control study of US employees with and without gastroesophageal reflux disease

OBJECTIVE

To establish an association between gastroesophageal reflux disease (GERD) and increased work absence, as well as reduced productivity while at work, by using objective productivity measurements.

METHODS

Retrospective case-control analysis of a database containing US employees' administrative health care and payroll data for employees (N = 11,653 with GERD; N = 255,616 without GERD) who were enrolled for at least one year in an employer-sponsored health insurance plan.

RESULTS

Employees with GERD had 41% more sick leave days (P < 0.0001), 59% more short-term disability days (P < 0.0001), 39% more long-term disability days (P = 0.1910), 48% more workers' compensation days (P < 0.0001), 4.4% lower objective productivity per hour worked (P = 0.0481), and 6.0% lower annual objective productivity (P = 0.0391) than the employees without GERD.

CONCLUSIONS

GERD is associated with a significant impact on employees' work absence and productivity while at work as measured using objective data.

Endoscopy in GERD: Boondoggle, Diagnostic Test, or Risk Management Tool?

The role of endoscopy in reflux disease is debated. Diagnostic certainty is attractive to patients and physicians, to affirm health and to ensure the absence of serious disease, but it is expensive and the majority of patients will have no endoscopic abnormalities. Empirical treatment with acid suppression in patients with symptoms of gastroesophageal reflux disease (GERD) is now widely practiced in primary care in many countries but in others, endoscopy is mandatory to receive approval from the payors for proton pump inhibitor therapy. In patients with dysphagia, endoscopy has a role in ruling out an obstructing lesion. A "once-in-a-lifetime" endoscopy has been proposed as a way to improve our ability to diagnose Barrett's esophagus, but cost-models suggest that this strategy is not cost-effective if current surveillance guidelines are followed after the diagnosis of Barrett's esophagus is made. The role of routine endoscopic examination in GERD is therefore questionable and needs better definition in carefully designed trials.

Environmental factors in the etiology of gastroesophageal reflux disease

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

New algorithm for the treatment of gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is associated with a variety of typical and atypical symptoms. Patients often present in the first instance to a pharmacist or primary care physician and are subsequently referred to secondary care if initial management fails. Guidelines usually do not provide a clear guidance for all healthcare professionals with whom the patient may consult.

AIM

To update a 2002-treatment algorithm for GERD, making it more applicable to pharmacists as well as doctors.

METHODS

A panel of international experts met to discuss the principles and practice of treating GERD.

RESULTS

The updated algorithm for the management of GERD can be followed by pharmacists, for over-the-counter medications, primary care physicians, or secondary care gastroenterologists. The algorithm emphasizes the importance of life style changes to help control the triggers for heartburn and adjuvant therapies for rapid and adequate symptom relief. Proton pump inhibitors will remain a prominent treatment for GERD; however, the use of antacids and alginate-antacids (either alone or in combination with acid suppressants) is likely to increase.

CONCLUSION

The newly developed algorithm takes into account latest clinical practice experience, offering healthcare professionals clear and effective treatment options for the management of GERD.

Reliability and validity of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire in dyspepsia: a six-country study

BACKGROUND

Symptoms of dyspepsia significantly disrupt patients' lives and reliable methods of assessing symptom status are important for patient management. The aim of the current study was to document the psychometric characteristics of the Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD) in Afrikaans, German, Hungarian, Italian, Polish and Spanish patients with dyspepsia.

METHODS

853 patients with symptoms of dyspepsia completed the GSRS, the QOLRAD, the 36-item Short-Form Health Survey (SF-36) and the Hospital Anxiety and Depression scale.

RESULTS

The internal consistency reliability of the GSRS was 0.43-0.87 and of the QOLRAD 0.79-0.95. Test-retest reliability of the GSRS was 0.36-0.75 and of the QOLRAD 0.41-0.82. GSRS Abdominal pain domain correlated significantly with all QOLRAD domains in most language versions, and with SF-36 Bodily pain in all versions. QOLRAD domains correlated significantly with the majority of SF-36 domains in most versions. Both questionnaires were able to differentiate between patients whose health status differed according to symptom frequency and severity.

CONCLUSION

The psychometric characteristics of the different language versions of the GSRS and QOLRAD were found to be good, with acceptable reliability and validity. The GSRS and QOLRAD were found to be useful for evaluating dyspeptic symptoms and their impact on patients' daily lives in multinational clinical trials.

The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea

BACKGROUND

Prospective nationwide multicentre studies that have evaluated endoscopic findings and reflux symptoms using a well-designed questionnaire are very rare.

AIM

To compare the prevalence rates of and risk factors for erosive oesophagitis and non-erosive reflux disease (NERD) in the Korean population.

METHODS

A gastroscopic examination was performed on 25 536 subjects who visited 40 Healthcare Centers for a health check-up. A gastro-oesophageal reflux questionnaire and multivariate analysis were used to determine the risk factors for erosive oesophagitis and NERD.

RESULTS

2019 (8%) and 996 subjects (4%) had erosive oesophagitis and non-erosive reflux disease, respectively; only 58% of subjects with erosive oesophagitis had reflux symptoms. Multivariate analysis showed that the risk factors for erosive oesophagitis and NERD differed, i.e. those of erosive oesophagitis were male, a Helicobacter pylori eradication history, alcohol, body mass index > or =25 and hiatal hernia. In contrast, the risk factors for NERD were female, age <40 and > or =60 vs. 40-59 years, body mass index <23 and a monthly income <$1000, glucose > or =126 mg/dL, smoking, a stooping posture at work and antibiotic usage.

CONCLUSIONS

The prevalence rates of erosive oesophagitis and NERD were 8% and 4%, respectively, in Korean health check-up subjects. The risk factors for erosive oesophagitis and NERD were found to differ, which indicates that their underlying pathogeneses are distinct.

Is obesity associated with gastropharyngeal reflux disease?

AIM

To examine the association between obesity and gastropharyngeal reflux disease (GPRD) as well as gastroesophageal reflux disease (GERD).

METHODS

We conducted a cross-sectional study of consecutive patients undergoing ambulatory 24-h dual-probe pH monitoring from July 2003 to December 2006. The association between body mass index (BMI) and parameters about gastroesophageal or gastropharyngeal reflux was examined in univariate and multivariate analyses.

RESULTS

A total of 769 patients (307 men and 462 women; mean age 50.7 years) were finally enrolled. Most variables showing gastroesophageal reflux was higher in the obese patients than the patients with normal BMI. There was no difference in all the variables showing gastropharyngeal reflux according to the BMI. After adjustment for age, sex, alcohol intake and smoking, obese patients demonstrated an about 2-fold increase in risk of GERD compared with patients with normal BMI (OR, 1.9; 95 CI, 1.3-2.9), but overweight patients did not demonstrate increased risk of GERD (OR, 1.2; 95 CI, 0.8-1.7). Both obese patients and overweight patients did not demonstrated increased risk of GPRD compared with patients with normal BMI (OR, 1.1; 95 CI, 0.8-1.7; and OR, 0.9; 95 CI, 0.6-1.3, respectively).

CONCLUSION

Obesity is not associated with GPRD reflux while it is associated with GERD.

Differences in recognition of heartburn symptoms between Japanese patients with gastroesophageal reflux, physicians, nurses, and healthy lay subjects

OBJECTIVE

Patients who complain of "heartburn" to their general practitioner tend to use the word to indicate a variety of symptoms. The aim of this study was to investigate the differences in recognition of "heartburn" between normal healthy lay subjects (HS), patients with gastroesophageal reflux disease (GERD), nurses, and physicians.

MATERIAL AND METHODS

An anonymous questionnaire survey concerning "heartburn" obtained responses from 583 persons including 198 GERD patients (140 with non-erosive reflux disease (NERD) and 58 with reflux esophagitis (RE)) who were evaluated at Kawasaki Medical School Hospital and affiliated facilities, as well as 170 HS, 111 nurses, and 104 physicians. Subjects were asked to choose the option most closely describing a symptom that they would recognize as heartburn.

RESULTS

Recognition did not differ between RE patients and physicians, whereas NERD patients did not recognize "regurgitation" or "burning sensation in the chest" as heartburn as often as physicians, while confusing "stomach ache" with heartburn. Significantly more NERD patients chose "stomach ache" than RE patients.

CONCLUSIONS

Differences in recognition of heartburn were noticed between HS, GERD patients, nurses, and physicians. RE patients and physicians showed similar recognition patterns among the descriptions of heartburn, whereas NERD patients differed from physicians and RE patients.

Molecular mechanisms in therapy of acid-related diseases

Inhibition of gastric acid secretion is the mainstay of the treatment of gastroesophageal reflux disease and peptic ulceration; therapies to inhibit acid are among the best-selling drugs worldwide. Highly effective agents targeting the histamine H2 receptor were first identified in the 1970s. These were followed by the development of irreversible inhibitors of the parietal cell hydrogen-potassium ATPase (the proton pump inhibitors) that inhibit acid secretion much more effectively. Reviewed here are the chemistry, biological targets and pharmacology of these drugs, with reference to their current and evolving clinical utilities. Future directions in the development of acid inhibitory drugs include modifications of current agents and the emergence of a novel class of agents, the acid pump antagonists.

Severe symptoms of gastro-oesophageal reflux disease are associated with cardiovascular disease and other gastrointestinal symptoms, but not diabetes: a population-based study

BACKGROUND

Few population-based studies have examined comorbidity in relation to gastro-oesophageal reflux disease (GERD).

AIM

To study the association between cardiovascular disease, diabetes, gastrointestinal symptoms and GERD.

METHODS

Population-based, cross-sectional, case-control study based on a large Norwegian health survey conducted in 1995-97. Among 65,333 participants, 3153 persons reporting severe reflux symptoms were defined as cases, and 40,210 persons without such symptoms were defined as controls. Data on cardiovascular disease, diabetes, gastrointestinal symptoms and potential confounders were collected through questionnaires. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using unconditional logistic regression, in crude and adjusted models.

RESULTS

In the crude models, positive associations were observed between myocardial infarction (OR 1.7, 95% CI 1.4-2.1), angina pectoris (OR 2.5, 95% CI 2.1-2.9) and stroke (OR 1.6, 95% CI 1.2-2.1) and risk of GERD. The associations were attenuated in the adjusted models, but remained significant for angina pectoris (OR 1.9, 95% CI 1.6-2.2). No association was observed between diabetes and GERD. Strong positive associations were seen between all studied gastrointestinal symptoms, i.e. nausea, diarrhoea and constipation, and risk of GERD.

CONCLUSIONS

This population-based study indicates that myocardial infarction, angina pectoris, stroke and symptoms of nausea, diarrhoea and constipation are associated with GERD.

Asia-Pacific consensus on the management of gastroesophageal reflux disease: update

BACKGROUND AND AIMS

Since the publication of the Asia-Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed.

METHODS

A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded.

RESULTS

GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On-demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non-GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials.

CONCLUSIONS

Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy.

Does the evidence show that prokinetic agents are effective in healing esophagitis and improving symptoms of GERD?

Gastroesophageal reflux disease (GERD) is common in affluent societies, and its prevalence is also on the rise in developing regions such as Southeast Asia.1 When heartburn and regurgitation are the dominant symptoms, a diagnosis of GERD can be made. Manzotti and colleagues report in Open Medicine the findings of a systematic review in which they evaluate the use of prokinetic agents in the treatment of reflux esophagitis.

Accounting for the effect of GERD symptoms on patients' health-related quality of life: supporting optimal disease management by primary care physicians

AIM

To review, from a primary care physician (PCP) perspective, the use of patient-reported outcome (PRO) instruments for assessment of gastro-oesophageal reflux disease (GERD) symptoms, their impact on health-related quality of life (HRQL) and the effectiveness of therapy.

RESULTS

While generic and disease-specific PRO instruments have been used in the assessment of GERD, the latter can be considered to be more appropriate as they focus only on problems relevant to the disease in question (and therefore tend to be more responsive to change). Such instruments include the Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire and the Gastrointestinal Symptom Rating Scale and the Reflux Disease Questionnaire (RDQ). Their use indicates that GERD symptoms are troublesome and significantly reduce patients' HRQL, and that effective treatment of GERD improves HRQL. The GERD Impact Scale (GIS) questionnaire, primarily developed for use within primary care, can also help to determine the impact of symptoms on patients' everyday lives and, in turn, the benefit of appropriately targeted therapy. Notably, these PRO instruments were developed from focus groups of GERD patients, and only aspects rated of highest importance are used in the final instruments. Consequently, PCPs can feel confident that these questionnaires encompass the most relevant points that they are likely to ask in terms of how symptoms affect patients' everyday lives.

CONCLUSIONS

Primary care physicians are encouraged to make wider use of PRO instruments within routine practice to improve communication with their GERD patients that, in turn, could lead to improved clinical outcomes and greater patient satisfaction.

How do people with gastro-oesophageal reflux disease perceive their disease? Results of a multinational survey

OBJECTIVE

To determine how patients with gastro-oesophageal reflux disease (GERD) perceive their condition.

METHODS

Subjects with a formal diagnosis of GERD (n = 929) and those who did not have a formal diagnosis but regularly suffered from symptoms suggestive of GERD (heartburn or acid regurgitation, n = 924) were identified as part of a multinational survey.

RESULTS

Symptoms had been present for a mean of 11 years in diagnosed individuals and 8 years in undiagnosed individuals. Over-the-counter (OTC) antacids were used by 78% of undiagnosed individuals. Most patients (68% of undiagnosed and 46% of diagnosed subjects) did not consider themselves to have a serious condition, while 70% of undiagnosed and 58% of diagnosed respondents believed that their condition would not have any long-term health consequences. A key perception driving the decision to seek medical care was the belief that a physician, and prescribed medication, could help. Conversely, the perception that OTC medications work effectively was the greatest barrier to visiting a physician. Diagnosed patients, who, on average, waited 2 years before seeking medical advice, indicated that prescription medication reduced the severity and frequency of their symptoms.

CONCLUSIONS

There is widespread perception that GERD is a non-serious disease without long-term health consequences, and some patients find that OTC medications are a sufficiently effective treatment option. Educational initiatives should perhaps be targeted at those in greatest medical need, overcoming the barriers that dissuade many of these patients from seeking appropriate medical care.

Psychometric validation of the Japanese translation of the Quality of Life in Reflux and Dyspepsia questionnaire in patients with heartburn

BACKGROUND

The purpose of this study was to document the psychometric characteristics of the Japanese translation of the Quality of Life in Reflux and Dyspepsia (QOLRAD-J) questionnaire in patients with heartburn.

METHODS

Patients with heartburn or acid regurgitation and healthy subjects completed the QOLRAD-J and the Japanese version of the Short-Form 36-Item (SF-36) Health Survey.

RESULTS

Overall, 224 patients with heartburn and 24 healthy subjects entered the study; 72% of patients had heartburn 1-3 days per week; 84% reported their symptoms as mild. Psychometric validation of the QOLRAD-J showed that factor loadings were >0.55 for 19 of the 25 items in the five-factor structure. Pearson correlation coefficients for inter-item correlations in the same domain were all >0.30, demonstrating reliability. The internal consistency reliability was good (Cronbach's alpha, 0.83-0.94). Inter-item correlations between domains ranged from 0.70 to 0.80, indicating strong correlations. Each QOLRAD-J domain correlated positively with at least five of the eight SF-36 domains (Pearson r >or= 0.3). Negative correlations between the QOLRAD-J and patient-reported frequency and severity of heartburn symptoms indicated decreasing quality of life with increasing symptoms. All domains of the QOLRAD-J were able to differentiate between groups of patients whose health status differed according to severity and frequency of heartburn, thus confirming the known-groups validity. Patients with heartburn had clinically significant decreases in SF-36 scores compared with the Japanese general population.

CONCLUSIONS

The psychometric characteristics of the QOLRAD-J demonstrated good validity and reliability. The QOLRAD-J can be used to assess quality of life in Japanese patients with heartburn.

Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment

During the last decade, clinical practice saw a rapid increase of patients with esophageal eosinophilia who were thought to have gastroesophageal reflux disease (GERD) but who did not respond to medical and/or surgical GERD management. Subsequent studies demonstrated that these patients had a "new" disease termed eosinophilic esophagitis (EE). As recognition of EE grew, so did confusion surrounding diagnostic criteria and treatment. To address these issues, a multidisciplinary task force of 31 physicians assembled with the goal of determining diagnostic criteria and making recommendations for evaluation and treatment of children and adults with suspected EE. Consensus recommendations were based upon a systematic review of the literature and expert opinion. EE is a clinicopathological disease characterized by (1) Symptoms including but not restricted to food impaction and dysphagia in adults, and feeding intolerance and GERD symptoms in children; (2) > or = 15 eosinophils/HPF; (3) Exclusion of other disorders associated with similar clinical, histological, or endoscopic features, especially GERD. (Use of high dose proton pump inhibitor treatment or normal pH monitoring). Appropriate treatments include dietary approaches based upon eliminating exposure to food allergens, or topical corticosteroids. Since EE is a relatively new disease, the intent of this report is to provide current recommendations for care of affected patients and defining gaps in knowledge for future research studies.

The suppression of gastro-oesophageal reflux by alginates

AIMS

The aim of this study was to compare alginate products with the same amount of active ingredients but different dosage forms, in the suppression of reflux provoked by a standard meal in healthy human volunteers, using ambulatory oesophageal pH monitoring.

METHODS

This was a single centre, randomised, open, three-period crossover, controlled study comparing Gaviscon Advance (10 ml) with a control (10 ml water) and with a new tablet product containing the same active ingredients as Gaviscon Advance. Volunteers who had oesophageal pH < 4 for at least 2% of the 4-h period after ingestion of a test meal followed by control at a reflux screening visit were included in the study.

RESULTS

The difference between Gaviscon Advance and control in the mean angular transformed percentage of time for which oesophageal pH fell below four was statistically significant (p < 0.0001) demonstrating the sensitivity of the method. No significant difference between the two alginate products was found based on the least squares adjusted mean angular transformed percentage of time for which pH fell below four. There were also no significant differences between the two alginate dosage forms in the angular transformed percentage of time for which oesophageal pH fell below five and in the log-transformed number of occasions on which oesophageal pH fell below four and five.

DISCUSSION AND CONCLUSION

The study shows that alginate reflux suppressants containing a low amount of antacid are effective in suppressing acid reflux and that suspension and tablet forms are able to give equivalent acid suppression.

The many manifestations of gastroesophageal reflux disease: presentation, evaluation, and treatment

Gastroesophageal reflux disease (GERD) is a common problem that is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world, with important risk factors being obesity and the eradication of Helicobacter pylori. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory esophageal pH testing is the most sensitive test for GERD, whereas endoscopy is the most specific test. Medical treatment with proton pump inhibitors (PPIs) has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic anti-reflux surgery and PPIs have similar efficacy in the few available long-term trials. This article reviews the presentation, evaluation, and treatment of GERD.

Randomized-controlled trial of esomeprazole in functional dyspepsia patients with epigastric pain or burning: does a 1-week trial of acid suppression predict symptom response?

BACKGROUND

Early identification of true responders to acid suppression in functional dyspepsia patients with symptoms of epigastric pain or burning may enable clinicians to optimally tailor treatment.

AIM

To evaluate whether a 1-w acid suppression trial is useful for identifying true responders in this population.

METHODS

Patients (18-70 years) were randomized to either esomeprazole 40 mg q.d.s., b.d. or placebo for 1w, and then esomeprazole 40 mg q.d.s. or placebo for 7w. Epigastric pain and/or burning were recorded on a 4-point scale (0 = none, 3 = severe). Trial-week response was defined as symptom score sum < or = 1 on last 3d of therapy; response at 8w was symptom score sum < or = 1 over preceding 7d.

RESULTS

1-w response rates were 33% (199 of 597), 29% (188 of 629) and 23% (71 of 315) with esomeprazole q.d.s., esomeprazole b.d. and placebo, respectively (P = 0.002 for esomeprazole groups vs. placebo). At 8w, trial week sensitivity and specificity were 46% and 80%, respectively, for esomeprazole (40 or 80 mg), and 33% and 87%, respectively, for placebo. The positive and negative predictive values for esomeprazole were 60% and 69%.

CONCLUSION

Response to a 1-w acid suppression trial is of limited use for predicting symptom response at 8w in patients with unexplained epigastric pain or burning.

Severe gastro-oesophageal reflux symptoms in relation to anxiety, depression and coping in a population-based study

BACKGROUND

The association between psychiatric disorders and gastro-oesophageal reflux symptoms is uncertain, and few population-based studies are available.

AIM

To examine the association between psychiatric and psychological factors and reflux symptoms.

METHODS

Population-based, cross-sectional, case-control study based on two health surveys conducted in the Norwegian county Nord-Trondelag in 1984-1986 and 1995-1997. Reflux symptoms were assessed in the second survey, including 65,333 participants (70% of the county's adult population). 3153 subjects reporting severe reflux symptoms were defined as cases and 40,210 subjects without symptoms were defined as controls. Data were collected in questionnaires. Odds ratio with 95% confidence intervals were estimated using unconditional logistic regression, in adjusted models.

RESULTS

Subjects reporting anxiety without depression had a 3.2-fold (95% CI: 2.7-3.8) increased risk of reflux, subjects with depression without anxiety had a 1.7-fold (95% CI: 1.4-2.1) increased risk and subjects with both anxiety and depression had a 2.8-fold (95% CI: 2.4-3.2) increased risk, compared to subjects without anxiety/depression. We observed a weak inverse association between one measure of covert coping and risk of reflux and a weak positive association between another coping measure and risk of reflux.

CONCLUSIONS

This population-based study indicates that anxiety and depression are strongly associated with reflux symptoms, while no consistent association regarding coping and reflux was found.

Relationship between symptoms, subjective well-being and medication use in gastro-oesophageal reflux disease

AIM

To report data from a multinational survey investigating the relationship between gastro-oesophageal reflux disease (GERD) symptoms, treatment and subjective well-being.

METHODS

Patients formally diagnosed with GERD (n=929) and undiagnosed subjects with symptoms suggestive of GERD (n=924) were included.

RESULTS

Sixty per cent of diagnosed (mean age: 51.7 years) and 54% of undiagnosed (mean age: 44.3 years) participants were female. Over 50% of participants were overweight or obese. Most respondents consumed alcohol, and one-third were smokers. In total, 78% of diagnosed subjects were currently receiving medication prescribed by their doctor, and 65% were taking over-the-counter (OTC) treatments. The majority (97%) of undiagnosed subjects were taking OTC medication, the most common of which were antacids (78%). Despite medication, 58% of diagnosed and 73% of undiagnosed subjects still experienced GERD symptoms some of the time. Approximately one-third of subjects in each group reported that they ate less than usual, felt generally unwell, were tired/worn out or worried/fearful for the majority of the time because of their GERD symptoms, and around half reported decreased well-being, including reduced work or leisure time productivity.

CONCLUSIONS

These findings attest to the severity and impact of GERD symptoms, highlighting the need to improve the management of GERD in routine practice. Many symptomatic and long-term sufferers, for example, may benefit from taking steps towards a healthier lifestyle (e.g. weight reduction) in addition to optimisation of acid-suppressive therapy.

Gastrooesophageal reflux disease

Gastrooesophageal reflux disease, GERD, is a common problem which is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world with important risk factors being obesity and the eradication of Helicobacter pylori. Increasing research points to transient LES relaxation and spatial separation of the diaphragm and LES (hiatal hernia in chest) being the critical mechanisms of acid reflux. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory oesophageal pH testing is the most sensitive test for GERD, while endoscopy is the most specific test. Medical treatment with PPIs has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic antireflux surgery and PPIs have similar efficacy in the few available long-term trials. Currently, endoscopic treatments for GERD should not be a clinical alternative outside of research trials. New drug therapies should be directed at modulating transient LES relaxation.