Dyspepsia and heartburn

Dyspepsia and heartburn are the two cardinal symptoms of foregut dysfunction. When confronting such a problem, that physician must first learn to discern between the two, because treatment can be quite different for the conditions presenting with these symptoms. This article details the approach to work-up and treatment of patients presenting with dyspepsia or heartburn.

Patterns of consultation and treatment for heartburn: findings from a Singaporean community survey

BACKGROUND

The prevalence of reflux-type symptoms among community individuals in Singapore is low.

AIM

To describe the healthcare-seeking behaviour of those subjects with heartburn.

METHODS

A cross-sectional survey, using a reliable and valid questionnaire, was carried out on a race-stratified random sample of residents, aged 21-95 years, in a Singaporean town; 93% responded (n = 696).

RESULTS

The ethnic-adjusted prevalence of heartburn for the past 1-year was 4.6%. Sixteen (30%) of the 53 heartburn sufferers had sought consultation for their symptoms. They were more likely to have severe heartburn (P<0.001), and to have complained of nocturnal awakening due to heartburn (P<0.05) than those who did not present to medical attention. Ethnic origin did not influence the consultation pattern. Only 18 (34%) of the 53 heartburn sufferers received pharmacological therapy for their symptoms. The most commonly used medication was antacid. Medication use was associated with symptom severity (P<0.05), but not ethnicity.

CONCLUSIONS

Heartburn is uncommon in the general population of Singapore. Few heartburn sufferers seek medical attention, and most do not receive medications for symptomatic control. The decision to seek medical advice and/or to medicate was generally linked to symptom severity, but not to ethnicity.

Heartburn risk factors, knowledge, and prevention strategies: a population-based survey of individuals with heartburn

BACKGROUND

Twenty-five million adults experience heartburn daily. To target individuals for prevention programs, characteristics of persons with heartburn and the associated causes of this condition must first be identified.

METHODS

We conducted a population-based telephone survey of 2000 individuals with heartburn to describe the cause of the disease, knowledge of risk factors, and prevention strategies.

RESULTS

Lifestyle and work habits, and certain food and beverage consumption, were associated with heartburn. Women reported the onset of heartburn about 5 years later than men. Survey respondents were unaware of the risk factors for heartburn, and sex-dependent differences in knowledge were apparent. Logistic regression modeling identified increasing age, female sex, higher level of education, and frequent vs infrequent heartburn as significant (P<.02) predictors of whether patients told a physician about their heartburn symptoms. Increasing age, higher body mass index, and reduced level of education were significant (P<.02) predictors of frequent vs infrequent heartburn in this study population.

CONCLUSION

The findings of this study provide a framework for the development of a heartburn prevention program based on lifestyle modification.

Barrett's esophagus: a surgical disease

Barrett's metaplasia can develop in patients with gastroesophageal reflux disease (GERD), and metaplasia can evolve into dysplasia and adenocarcinoma. The optimal treatment for Barrett's metaplasia and dysplasia is still being debated. The study reported herein was designed to assess the following: (1) the incidence of Barrett's metaplasia among patients with GERD; (2) the ability of laparoscopic fundoplication to control symptoms in patients with Barrett's metaplasia; (3) the results of esophagectomy in patients with high-grade dysplasia; and (4) the character of endoscopic follow-up programs of patients with Barrett's disease being managed by physicians throughout a large geographic region (northern California). Five-hundred thirty-five patients evaluated between October 1989 and February 1997 at the University of California San Francisco Swallowing Center had a diagnosis of GERD established by upper gastrointestinal series, endoscopy, manometry, and pH monitoring. Thirty-eight symptomatic patients with GERD and Barrett's metaplasia underwent laparoscopic fundoplication. Eleven other consecutive patients with high-grade dysplasia underwent transhiatal esophagectomies. Barrett's metaplasia was present in 72 (13%) of the 535 patients with GERD. The following results were achieved in patients who underwent laparoscopic fundoplication (n = 38): Heartburn resolved in 95% of patients, regurgitation in 93% of patients, and cough in 100% of patients. With regard to transhiatal esophagectomy (n = 11), the average duration of the operation was 339 +/- 89 minutes. The only significant complications were two esophageal anastomotic leaks, both of which resolved without sequelae. Mean hospital stay was 14 +/- 5 days. There were no deaths. The specimens showed high-grade dysplasia in seven patients and invasive adenocarcinoma (undiagnosed preoperatively) in four (36%). These results can be summarized as follows: (1) Barrett's metaplasia was present in 13% of patients with GERD being evaluated at a busy diagnostic center; (2) laparoscopic fundoplication was highly successful in controlling symptoms of GERD in patients with Barrett's metaplasia; (3) in patients with high-grade dysplasia esophagectomy was performed safely (invasive cancer had eluded preoperative endoscopic biopsies in one third of these patients); and (4) even though periodic endoscopic examination of Barrett's disease is universally recommended, this was actually done in fewer than two thirds of patients being managed by a large number of independent physicians in this geographic area.

The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture

BACKGROUND

Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia.

METHODS

Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery.

RESULTS

Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery.

CONCLUSIONS

Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia.

Effects of comorbidity on health-related quality-of-life scores: an analysis of clinical trial data

Coexisting diseases may have unforeseen yet clinically significant effects on patients' well-being. Both generic and disease-specific measures are frequently used to assess health-related quality of life (QOL). The present study assessed the effects of comorbidity on the results of QOL measures through an analysis of longitudinal data from 3 double-masked, randomized, placebo-controlled clinical trials dealing with heartburn, asthma, and ulcer. Patients were assigned to subgroups by comorbidity status: those with no comorbid diseases and those whose principal disease was heartburn, asthma, or ulcer and whose comorbid condition was chronic obstructive pulmonary disease, asthma, or chronic bronchitis; hypertension; migraine, coronary artery disease, or varicose veins; chronic gastrointestinal conditions; arthritis or back pain; diabetes; or depression. Multivariate analysis of covariance was used to test the study hypotheses. The study results suggest that comorbid conditions significantly and extensively affect patients' scores on generic QOL measures and estimation of treatment effect, whereas their influence on disease-specific QOL scores and estimation of treatment effect is considerably smaller. Further, the most important comorbidities in the 3 trial populations were arthritis or back pain and depression, which respectively accounted for 17% and 5% of the patient population. These findings have significant practical implications for the estimation of true treatment effects, control of comorbidity effects, and design of QOL trials.

Pneumatic balloon dilation in achalasia: a prospective comparison of balloon distention time

OBJECTIVE

Duration of Inflation in pneumatic balloon dilatation as treatment of achalasia has been variable ranging from 15 s to 6 min. A 60 s duration appears to be most often used. We compared the efficacy of dilation of achalasia with either 6- or 60-s inflation duration using a Rigiflex dilator of 3.0 cm diameter.

METHODS

Eighty-one consecutive patients were prospectively studied in a randomized fashion, 41 in the 60-s group (A) and 40 patients in the 6-s group (B). Mean age of group A was 43 +/- 16.2 yr and of group B was 40 +/- 16.4 yr. Symptoms of dysphagia, chest pain, heartburn, regurgitation, and night cough were evaluated at basal (before dilation), 1- and 6-month intervals after dilation in both groups. Barium swallow was done to assess esophageal emptying 1 wk before dilation and 5 min postdilation in both groups.

RESULTS

Significant and sustained improvement was seen for all symptoms in both groups. In addition, the degree of improvement in symptom scores between the two groups was similar. Barium esophagram in both groups at basal and immediately postdilation showed significant improvement in barium emptying but there was no significant difference between the two groups, indicative of equal efficacy in both distention times. Two patients needed repeat dilatation in group A and one in group B, with one drop out from group A, who was lost to follow-up, and was excluded from the analysis. No perforation occurred.

CONCLUSION

Short duration of pneumatic balloon dilatation (6-s) is as effective as longer duration (60-s) in treatment of achalasia.

Gastroesophageal reflux disease: gaining control over heartburn

GERD is a common disorder. Symptoms of reflux, such as heartburn, are due to a combination of factors: relaxation of the lower esophageal sphincter, hypersecretion of gastric acid, and resulting burning of the esophageal mucosa. Symptoms are usually classified as classic, atypical, or complicated. Treatment approaches include dietary and lifestyle changes, reduction of acidity with use of H2 receptor antagonists, and reduction of acid secretion with use of proton pump inhibitors. Patient motivation is an important factor in the management of gastroesophageal reflux. In rare instances, patients do not respond to medical treatment and are candidates for antireflux surgery.

Health care seeking by heartburn sufferers is associated with psychosocial factors

AIM

To determine whether individuals who consult a doctor because of gastroesophageal reflux disease have psychological characteristics and social support patterns that distinguish them from those who remain within the community.

METHODS

Comparison of 138 consecutive patients presenting to a gastrointestinal clinic for the first time because of heartburn with 39 heartburn sufferers who had never sought medical help for their reflux disease and 40 healthy individuals with no heartburn. Instruments used were the State-Trait Anxiety Index, the Crown-Crisp Experiential Index, the Hassles Scale, and the Interview Schedule for Social Interaction.

RESULTS

Heartburn sufferers who remained within the community in no way differed from healthy controls. Patients who sought medical attention were older and their heartburn was more severe than community heartburn sufferers. When these variables were controlled for in the analysis, patients experienced greater phobia, obsessionality, and somatization, more hassles but of significantly lower intensity, and had less-adequate close social support than those who did not seek medical help.

CONCLUSION

Psychological and social factors are associated with individuals with gastroesophageal reflux disease who seek medical help.

Results of myotomy and partial fundoplication after pneumatic dilation for achalasia

BACKGROUND

We questioned whether results of myotomy for achalasia are influenced by previous pneumatic dilation and whether surgical outcome is influenced by a dilation-related perforation necessitating urgent operation.

METHODS

We performed a retrospective analysis of 60 patients who underwent transthoracic myotomy and fundoplication from 1977 to 1995. Dysphagia, heartburn, pain, and regurgitation were scored on a scale of 0 to 3 and results were classified according to combined symptom score.

RESULTS

Dilation was performed before myotomy once in 15 patients, twice in 25, 3 times or more in 9, and never in 11 patients. Operation was urgent due to perforation in 6 patients (10%). There was no postoperative leak or mortality. Overall symptom score at last follow-up (57 +/- 8 months; 90% of patients) was improved compared with preoperative score (2.1 +/- 0.3 months versus 5.1 +/- 0.2 months; p < 0.0001). Outcome was unrelated to whether or not a perforation occurred (excellent/good outcomes in 100% and 88%, respectively) or to whether or not preoperative dilations had been performed (excellent/good outcomes in 90% and 89%, respectively).

CONCLUSIONS

Myotomy and partial fundoplication is an effective technique for management of achalasia. Results are unaffected by the need for urgent operation for perforation and are unrelated to whether pneumatic dilation is performed preoperatively.

Indigestion and heartburn: a descriptive study of prevalence in persons seeking care from chiropractors

OBJECTIVE

To determine the prevalence of indigestion and mid-back pain in persons seeking chiropractic care.

DESIGN

A cross-sectional survey using a self-report questionnaire.

SETTING

Three primary care private chiropractic practices in metropolitan Perth, Australia.

SUBJECTS

Persons seeking chiropractic care during a 1-month period.

INTERVENTION

None.

OUTCOME MEASURES

Six-month prevalence of indigestion and mid-back pain, rate of association between indigestion and mid-back pain, and distribution of thoracic dysfunction and manipulation. Proportion who report relief from manipulation.

OBSERVATIONS

Of 1567 persons who consulted 8 chiropractors on 2974 occasions during November 1994, 1494 responses were obtained. There were 119 first-time consultations. The mean age of respondents was 41 yr (range 10-94); 57% were women. Fifty-seven percent reported indigestion infrequently or more and 71% reported mid-back pain during the previous 6 months. Forty-six percent experienced both symptoms during this time. Of these, 36% reported the symptoms together at some time. Twenty-two percent of those with indigestion reported some relief after chiropractic care. Compared with those reporting no relief, mid-back pain was more common among those reporting indigestion. The level at which the manipulation was given was unrelated to relief. No major differences were noted between the three clinics in patient demographics or the main outcome measures.

CONCLUSIONS

Indigestion and mid-back pain are commonly experienced in this population. A person with indigestion is more likely to report mid-back pain. Relief of indigestion by manipulation is more common among those who report mid-back pain. Further research is needed to understand differences between subgroups and differences compared with other studies.

Chronic cough and hoarseness in patients with severe gastroesophageal reflux disease. Diagnosis and response to therapy

Gastroesophageal reflux may be responsible for atypical symptoms such as chronic cough and hoarseness. Our aim was to evaluate and treat patients with severe gastroesophageal reflux and chronic cough or hoarseness with intensive antireflux therapy. Twenty-seven patients with typical heartburn symptoms in addition to significant cough or hoarseness were treated with aggressive antireflux therapy. We recorded the response of each symptom to the antireflux therapy. Two patients were lost to follow-up. Twenty of the 25 (80%) patients showed some improvement in cough or hoarseness, nine (36%) had no atypical symptoms at follow-up. The response of heartburn to therapy was strongly predictive of successful therapy for the atypical symptoms. Cough and hoarseness improved in only two of the five patients with residual heartburn symptoms compared to 18 of 20 patients with no heartburn (P < 0.04). Only patients with no heartburn symptoms at follow-up had complete resolution of atypical symptoms. There were no important differences on ambulatory pH monitoring between partial and complete responders. Improvement in atypical reflux symptoms, such as chronic cough and hoarseness, is common with aggressive antireflux therapy. There are no findings on ambulatory esophageal pH monitoring that uniquely identify patients who are likely to respond to antireflux therapy.

Treatment advances in reflux disease

The author, a sister in an endoscopy unit, noticed a remarkable reduction in the numbers of patients presenting for oesophageal dilatation and re-dilatation in the years following the introduction of proton-pump inhibitor drugs. This article describes the presentation and treatment of oesophageal stricture, and how the author was able to demonstrate reductions in endoscopic interventions for the problem.

A critical review of current medical therapy for gastroesophageal reflux disease

Gastroesophageal reflux (GER) disease is a common, multifactorial medical condition that may be difficult to treat. Simple lifestyle modifications decrease reflux episodes and should serve as the cornerstone for medical therapy. Antacids or alginic acid may be helpful in mild disease but recent studies suggest they may be no better than placebo. Metoclopramide improves symptomatic GER disease but side effects are a major limiting factor. Only bethanechol and the histamine H2 antagonists have been conclusively shown to improve esophagitis significantly. Therefore, more severe disease is currently best treated with a histamine H2 antagonist alone or in combination with bethanechol. The treatment of GER complications and maintenance therapy have only been recently addressed in clinical trials, but again the histamine H2 antagonists may have a useful role. Five to 10% of patients may require antireflux surgery, but the competency of the repair appears to deteriorate with time. Future clinical trials need to address specific areas of difficulty including entry criteria, test of efficacy, study duration, and usefulness of combination drug therapy.