[Reflux esophagitis]

Gastroesophageal reflux disease (GERD) is one of the most prevalent diseases in the industrialized countries. Approximately 15-25% of adults suffer from reflux symptoms, characterized mainly by heartburn and/or regurgitation. Currently, antisecretory medication with proton pump inhibitors (PPI) or antireflux surgery are the established options for GERD-treatment. PPI are the therapeutic gold standard in acute, long-term or on-demand therapy of GERD. Since PPI do not restore the antireflux barrier but merely suppress acid secretion a life-long tablet adherence is required in most cases. In view of limitations of PPI and the potential risks of laparoscopic surgery, several endoscopic antireflux techniques were developed and may evolve as a valuable third option. However, so far objective long-term data are lacking for choosing the appropriate patient who will benefit most from endoluminal antireflux therapy.

[Immunotropic treatment of patients with surgical treatment of the gastrointestinal tract]

Results of examination of systemic immunity state, microbiocenosis and immunohistological changes of tissues of the esophagus and stomach in 37 adult patients and 69 children with erosive-ulcerous diseases of the gastrointestinal tract were analyzed. Based on these examinations, up-to-date immunomodulator tamerit inhibiting pathologic activity of monocytes/macrophage system with simultaneous activation of neutrophil granulocytes was used in 154 adult patients and 69 children. Positive result was achieved in all the cases when tamerit was used.

[Reflux disease therapy]

The frequency of gastroesophageal reflux disease is on a constant rise in western countries. Reflux therapy can be subdivided into the treatment of acute erosive reflux esophagitis and the subsequent recurrence prophylaxis, and into the treatment of non-erosive reflux disease as well as the atypical reflux symptoms. Based on conventional large-scale studies, a highly effective therapy is available which offers virtually complete acid blockade using proton pump inhibitors (PPI) of the prazole type. Used for acute treatment, they offer a cure for reflux esophagitis and freedom from symptoms in approx. 90% of the cases, while also showing high efficacy in recurrence prophylaxis. Conversely, the rate of side effects, particularly serious ones, is very low and the long-term safety of this therapy has been good. Since the risk of erosive reflux esophagitis recurring is > 80% without PPI therapy, the majority of the patients will require a long-term, potentially even life-long therapy with PPI. Other therapeutic options are being discussed as alternatives to such long-term prophylaxis. In selected cases, surgical therapy by laparoscopic fundoplication is one option. Alternatively, endoscopical anti-reflux procedures are increasingly coming into use; their merit in long-term prophylaxis however, cannot yet be evaluated. Whenever PPI therapy does not lead to complete freedom from symptoms, an alternative therapeutic approach should be given consideration even in patients with atypical reflux symptoms. The therapy of the Barrett's esophagus, a potentially long-term sequelae of reflux disease, will not be dealt with in this overview, as it is the subject of a separate presentation.

Optimizing symptom relief and preventing complications in adults with gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) is a chronic illness causing recurrent typical and atypical symptoms. Possible complications include oesophagitis, ulcer, stricture and Barrett's oesophagus. Evidence suggests that the intraoesophageal pH correlates directly with the degree of mucosal injury. Proton pump inhibitors (PPIs) are the first choice of therapy because they are significantly more effective than histamine-2-receptor antagonists (H(2)RAs) in achieving and sustaining an intragastric pH above 4.0. Numerous trials have shown that PPIs provide superior and faster relief of heartburn compared with H(2)RAs. PPIs have also been shown to be superior to H(2)RAs in healing oesophageal ulcers and improving the clinical outcome of patients with stricture formation. Unfortunately, even higher-than-standard doses of PPIs do not provide a complete regression in the length of Barrett's oesophagus, which is the most serious complication of GORD. Although the majority of patients with oesophagitis relapse within 6 months of stopping PPI therapy, maintenance PPI therapy prevents this in more than 80% of cases. Surgical and endoscopic procedures are alternative approaches to managing GORD. Surgery is successful but is not without risk. Endoscopic procedures are promising, but comparative and longer-term efficacy and safety data are needed.

Gastroesophageal reflux disease: a typical spectrum disease (a new conceptual framework is not needed)

Gastroesophageal reflux disease (GERD) is a common GI disorder, particularly frequent in the primary care setting, with a high direct and indirect economic burden on society. Despite the high prevalence and costs of the disease, the epidemiology and natural history of GERD have not been fully elucidated. It has recently been suggested to abandon the current model of GERD as a "spectrum" disease and to adopt a new conceptual framework, e.g., categorizing GERD into three unique groups of patients: nonerosive reflux disease, erosive esophagitis, and Barrett's esophagus. In the present review we present arguments against this proposal, and argue that the concept of a single disease, potentially progressing from mild nonerosive forms toward metaplasia and neoplasia (adenocarcinoma), still holds true and may in fact help us in planning the diagnostic and therapeutic approach as well as in allocating financial resources much better than the proposed model of a "tripartited" disease. Independently from the conceptual model adopted, however, more data on the natural history of patients with GERD are eagerly needed.

GERD 2003: issues from the past and a consensus for the future

Gastroesophageal reflux disease (GERD) has evolved from a scarcely reported, little understood disease process just a century ago to a now highly prevalent disease with up to 25% of the population complaining of symptoms of reflux. Throughout history attempts have been made to delineate the esophagus and related pathologies, but it has not been until relatively recently that enough has been understood about its screening, diagnosis and treatment to make a substantial impact on sufferers. Although the use of antacids and thereafter histamine 2 receptor antagonists dramatically improved the management of GERD, it was the advent of the proton pump inhibitor (PPI) class of drugs that revolutionized medical care. Although the relationship of hiatus hernia to reflux was well accepted, the modest results of open fundoplication fell into further disregard given the efficacy of PPIs. The PPIs are currently the most effective form of therapy and are equivalent on a milligram for milligram basis. While currently no novel drugs or devices are of proven efficacy for GERD, the development of an acid-suppressive agent of equal efficiency to a PPI but with a more rapid onset of action and a greater duration of effectiveness would be of particular clinical utility for the future.

Diagnosis and management of reflux esophagitis

Esophagitis has generally been considered rare in dogs and cats. However, it may not be as uncommon as previously thought due to the increased awareness of the disease and the increasing availability of endoscopy. Esophagitis can be caused by gastroesophageal reflux, trauma, foreign bodies, ingestion of caustic substances, structural abnormalities (ie, hiatal hernia, neoplasms), and chronic vomiting. This article will focus on the diagnosis and treatment of esophagitis secondary to gastroesophageal reflux. This is a diagnosis based on clinical signs, exclusion of other causes of esophagitis, and typical radiographic, endoscopic, and histopathologic findings.

[Peptic stricture of the esophagus: long term outcome of conservative treatment]

BACKGROUND

Endoscopic dilatation of esophageal strictures is a simple and safe procedure.

AIM

To analyze the long term outcome of conservative treatment for esophageal peptic stricture in patients with high surgical risk.

PATIENTS AND METHODS

Twenty consecutive patients, 13 male, whose mean age was 75.2 years, with a peptic stricture of the esophagus and high surgical risk were prospectively studied. All were subjected to endoscopic esophageal dilatation and treated with continuous medical antireflux therapy thereafter.

RESULTS

Only five patients complied with antireflux treatment on a regular basis. The remaining 15 were non compliant or abandoned it. A total of 56 dilatations were done (mean 2.8 per patient, range 1-6). No complications were observed after the procedure. With a mean follow up period of 49 months, the outcome of the conservative treatment was classified as excellent or good in all the cases. Eight patients (40%) died of causes unrelated to the treatment. Two patients had an organic foreing body impactation. This situation was solved endoscopically in both.

CONCLUSION

In high risk patients, endoscopic dilatation, with or without regular antireflux medical treatment is a simple, safe and effective therapy in the management of peptic oesophagel stenosis.

Quality of life and cost-effectiveness of combined therapy for reflux esophagitis

OBJECTIVE

To evaluate clinical, Quality of Life (QoL) and medical cost outcomes in patients with symptomatic reflux esophagitis (RE) receiving different "triple combination therapy".

METHODS

A multicenter medical effectiveness trial conducted in 10 hospitals of 5 regions in Zhejiang Province. 248 patient-volunteers were assigned to 8 weeks of "triple combination therapy" with Lansoprazole plus Cisapride and Sucralfate or Ranitidine plus Cisapride and Sucralfate. Main outcomes assessment included symptoms scale scores, RE severity, QoL at baseline and 8 weeks. Medical cost data were collected with cost analysis questionnaire.

RESULTS

(1) More Lansoprazole group patients noted RE symptoms resolution than Ranitidine group (92.3% vs 78.4%, P<0.01). There was no striking difference between two groups in RE healing rate (90.8% vs 82.9%, P>0.05). (2) RE significantly impaired QoL of patients (P<0.001). Compared with Ranitidine group, QoL in Lansoprazole group had significant improvement (rate of "good" QoL 64.5% vs 45.6%, P<0.01). (3) There was close correlation between symptomic effectiveness and QoL rating scale in both the Lansoprazole and Ranitidine group (P<0.01, r=0.235 and 0.353 respectively). There were no statistical difference of medical cost between the two groups (P>0.05).

CONCLUSION

RE significantly impaired QoL of patients. "Triple combination therapies" can significantly improve RE symptoms and QoL. Lansoprazole combination therapy was more cost-effective than Ranitidine combination group.

Asthmatics with gastroesophageal reflux: long term results of a randomized trial of medical and surgical antireflux therapies

OBJECTIVE

In short term studies, asthma symptoms and pulmonary function have been reported to improve during and after medical treatment or surgical correction of gastroesophageal reflux (GER). In this study, we aimed to determine whether prolonged treatment of GER altered the long term natural history of asthma in asthmatics with GER.

METHODS

A total of 62 patients with both GER and asthma entered a randomized study of antireflux treatments for at least 2 yr: 24 controls (antacids as needed); 22 medical (ranitidine 150 mg t.i.d.); and 16 surgical (Nissen fundoplication). Asthma was defined as a previous diagnosis of asthma with discrete attacks of wheezing and 20% reversibility in airway disease. GER was defined as an abnormal ambulatory 24-h esophageal pH test and macroscopic or microscopic evidence of GER disease. Overall clinical status, asthma symptom scores, and pulmonary medication requirements were recorded monthly. Peak expiratory flow rates were recorded up to seven times per day for 1 wk of each month throughout the years. Pulmonary function, esophageal manometry, and endoscopy with biopsy were repeated yearly.

RESULTS

The 62 patients were followed for up to 19.1 yr. In the surgical group, but not in the medical or control groups, there was an immediate and sustained reduction in acute nocturnal exacerbations of wheezing, coughing, and dyspnea. By the end of 2 yr, improvement, marked improvement, or cure in the overall asthma status occurred in 74.9% of the surgical group, 9.1% of the medical group and 4.2% of the control group, whereas the overall status worsened in 47.8% of the control group, 36.4% of the medical group, and 12.5% of the surgical group (p < 0.001, surgical vs medical and control). The mean asthma symptom score of the surgical group improved 43%, compared with less than 10% in the medical and control groups (p = 0.0009). As determined by changes in peak expiratory flow rates, there was no statistically significant difference in pulmonary function during the 2-yr period or during regularly scheduled follow-up. There was no difference in medication requirements among the groups. There was no difference between the groups in overall survival.

CONCLUSION

In patients with both GER and asthma, antireflux surgery (but not medical therapy with ranitidine 150 mg t.i.d.) has minimal effect on pulmonary function, pulmonary medication requirements, or survival, but significantly improves asthma symptoms and overall clinical status.

Schatzki's rings do not protect against acid reflux and may decrease esophageal acid clearance

Schatzki's rings (SR) are a common cause of intermittent solid food dysphagia, but their etiology is unclear. Many believe they are related to acid reflux, hypothesizing that the rings act as a protective barrier against further reflux. The purpose of this study was to determine whether dilation of SR affected the degree of acid reflux. Twenty patients participated in the study. All patients underwent esophageal manometry and 24-hr pH monitoring off all acid inhibitory medications before and two weeks after esophageal dilation. No significant differences were noted in any of the reflux parameters measured before and after dilation. However, there was a trend toward reduction in symptom score in all patients, a decrease in Johnson-DeMeester score, and a decrease in supine reflux time in patients with thick SR after dilation. There was no correlation between ring diameter and the presence or absence of reflux. In conclusion, Schatzki's rings do not prevent esophageal reflux, and they may act to decrease esophageal acid clearance, especially in the supine position, thereby increasing esophageal acid exposure.

[Reflux esophagitis]

There are some factors which influence reflux esophagitis, in our country atrophic gastritis is important for the degree of it especially. Helicobacter pylori(H.P.) infection is popular in aged patients, so atrophic gastritis is also popular in such patients, then the frequency of reflux esophagitis is low comparing with other countries. But because of the late of H.P. infection comes to be higher and the eradication therapy for the peptic ulcer diseases has been done in these days, the late of atrophic gastritis comes to be lower and reflux esophagitis comes to be higher. In aged patients medication and physical factors influence reflux esophagitis and these factors are different in each patient. So it is very important to treat the patient of reflux esophagitis considering of each factor.

[Psycho-physiological aspects of gastroesophageal reflux disease]

It is well known that there is an interaction between physiological and psychological aspects of gastrointestinal diseases, also in esophageal symptoms. Based on this bio-psycho-social interaction, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) is really unknown. The present article reviews the basic pathophysiological factors of GERD including psycho-physiological aspects and presents potential concepts of multidisciplinary GERD treatment.