Symptoms in gastro-oesophageal reflux disease

Regional gastric emptying abnormalities in functional dyspepsia and gastro-oesophageal reflux disease

To characterize proximal and distal stomach emptying in functional dyspepsia (FD) and gastro-oesophageal reflux disease (GORD). Eighty-three patients underwent gastric emptying (GE) scintigraphy and symptom scoring for the evaluation of upper gastrointestinal symptoms and were divided into three groups: FD (n = 25), GORD (n = 20) and FD + GORD (n = 38). Total, proximal and distal gastric retention were determined scintigraphically and compared with normal controls. Delayed total GE was observed in each subgroup: FD (56%), GORD (45%) and FD + GORD (55%). Greater proximal gastric retention was observed after meal ingestion in GORD compared to FD. Greater distal gastric retention was observed in FD and FD + GORD but it was only mild in GORD. Nausea, vomiting, early satiety, distention and regurgitation were associated with proximal gastric retention whereas there was no symptom associated with distal gastric retention. Multiple regression demonstrated total gastric retention at 30 min and 1 h was positively correlated with regurgitation whereas early proximal gastric retention was positively correlated with regurgitation and negatively correlated with nausea. Selective abnormalities of proximal and distal stomach emptying were demonstrated in GORD and FD. GORD and FD symptoms were associated with proximal gastric retention suggesting that proximal stomach motor function may be important in the pathogenesis of symptoms associated with these disorders.

Digestive symptoms and their psychosocial impact: validation of a questionnaire

OBJECTIVE

Questionnaires evaluating digestive symptoms and their psychosocial impact have not been extensively validated in Norwegian populations. In this study a self-administered questionnaire developed in Norway is evaluated for this purpose.

MATERIAL AND METHODS

The questionnaire, the Digestive Symptoms and Impact Questionnaire, DSIQ, was developed by a cooperative group of general practitioners and gastroenterologists. The DSIQ contains 18 similarly structured global-type questions focusing on the patient's own judgement. The validation was based on 567 patients with dyspeptic symptoms or reflux symptoms referred to gastroscopy from general practice.

RESULTS

Eighty percent of the patients responded to all the questions. All response categories were used for all questions. Factor analysis revealed 4 subscales: abdominal pain and bowel symptoms; gastric dysfunction; health impairment and impairment of everyday life. A question about reflux symptoms was retained as a subscale on its own. Overall score was established by calculating the mean of all question responses. Test-retest reliability in stable patients (intraclass correlation coefficient, range 0.80- 0.91) and internal consistency reliability (Cronbach's alpha, range 0.65-0.91) were satisfactory. Criterion validity was supported by significant correlations to patients' globally estimated quality of life and the General Health Questionnaire (GHQ-30). Responsiveness in spontaneously improved patients or patients given effective treatment ranged from moderate to highly responsive (responsiveness statistic range from 0.54 to 2.83).

CONCLUSIONS

The DSIQ is a self-administered, simple and well-validated method for evaluating digestive symptoms and their psychosocial impact. The DSIQ shows satisfactory internal consistency reliability, test-retest reliability, responsiveness and criterion validity.

Gastroesophageal reflux disease in 2006. The imperfect diagnosis

There continues to be significant controversy related to diagnostic testing for gastroesophageal reflux disease (GERD). Clearly, barium contrast fluoroscopy is superior to any other test in defining the anatomy of the upper gastrointestinal (UGI) tract. Although fluoroscopy can demonstrate gastroesophageal reflux (GER), this observation does not equate to GERD. Fluoroscopy time should not be prolonged to attempt to demonstrate GER during barium contrast radiography. There are no data to justify prolonging fluoroscopy time to perform provocative maneuvers to demonstrate reflux during barium contrast UGI series. Symptoms of GERD may be associated with physiologic esophageal acid exposure measured by intraesophageal pH monitoring, and a significant percentage of patients with abnormal esophageal acid exposure have no or minimal clinical symptoms of reflux. Abnormal acid exposure defined by pH monitoring over a 24-h period does not equate to GERD. In clinical practice presumptive diagnosis of GERD is reasonably assumed by substantial reduction or elimination of suspected reflux symptoms during therapeutic trial of acid reduction therapy.

Gastroesophageal reflux disease in primary care. Prevalence, epidemiology and Quality of Life of patients

AIM

To determine the prevalence of typical symptoms of gastroesophageal reflux disease in a large group of patients consulting their general practitioners (GP) for diverse reasons, as well as the quality-of-life (QoL) of patients with such symptoms.

PATIENTS AND METHODS

During the same day, participating GPs (N=3 200) systematically asked all of their patients about the presence of heartburn and regurgitation. For all patients who responded positively, the GPs filled in a questionnaire and the patient a specific QoL questionnaire.

RESULTS

Among 40 982 patients attending GP consultations, 4 124 (10.1%) had one or both symptoms. Prevalence was higher in men (11.1%) than in women (9.3%, P<0.001), and increased with age up to 50-59 yrs then slowly declined. Symptoms were present on a weekly basis in 72.8% of patients. Smoking, frequent or nocturnal occurrence of symptoms, regurgitation, and esophagitis were significantly linked up with a higher occurrence of extra-digestive symptoms (cough, ENT symptoms, chest pain). QoL declined with increasing frequency of symptoms, which especially affected food intake, psychology, well-being and daily life.

CONCLUSION

In France, typical symptoms of gastroesophageal reflux disease are observed in 10% of the adult population, and markedly alter their QoL.

Air swallowing, belching, and reflux in patients with gastroesophageal reflux disease

OBJECTIVES

Belching and gastroesophageal reflux share a common physiological mechanism. The aim of this study was to investigate whether air swallowing leads to both belching and reflux.

METHODS

Esophageal impedance, pH, and pressure were measured during two 20-min recording periods in 12 controls and 12 patients with gastroesophageal reflux disease (GERD), before and after intragastric inflation of 600 mL of air. This was repeated after a meal. Subsequently, ambulatory 24-h impedance-pH measurement was performed.

RESULTS

During the 24-h study, patients showed a higher incidence of air swallows (287 +/- 45 vs 176 +/- 24, p < 0.05), belches (52.4 +/- 6.6 vs 32.7, p < 0.01), and acid reflux (42.3 +/- 7.6 vs 19.1 +/- 2.8, p < 0.01) than controls. After air infusion the incidence of gas reflux episodes was increased, both in patients (0.58 +/- 0.36 vs 3.50 +/- 0.61, p < 0.01) and in controls (0.75 +/- 0.67 vs 4.08 +/- 0.59, p < 0.01). In contrast, the incidence of acid and weakly acidic reflux episodes was not increased after air infusion, neither in patients (acid: 1.25 +/- 0.37 vs 1.20 +/- 0.33, weakly acidic: 1.08 +/- 0.40 vs 0.80 +/- 0.23) nor in controls (acid: 0.72 +/- 0.34 vs 0.50 +/- 0.23, weakly acidic: 0.80 +/- 0.35 vs 0.33 +/- 0.19). Air infusion increased transient lower esophageal sphincter relaxations (TLESR) frequency in patients and controls, but this was entirely because of an increase in gas reflux-associated TLESRs.

CONCLUSIONS

Patients with GERD swallow air more frequently and belch more frequently than healthy subjects. However, air swallowing is not the cause of their increase in reflux.

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

OBJECTIVES

A globally acceptable definition and classification of gastroesophageal reflux disease (GERD) is desirable for research and clinical practice. The aim of this initiative was to develop a consensus definition and classification that would be useful for patients, physicians, and regulatory agencies.

METHODS

A modified Delphi process was employed to reach consensus using repeated iterative voting. A series of statements was developed by a working group of five experts after a systematic review of the literature in three databases (Embase, Cochrane trials register, Medline). Over a period of 2 yr, the statements were developed, modified, and approved through four rounds of voting. The voting group consisted of 44 experts from 18 countries. The final vote was conducted on a 6-point scale and consensus was defined a priori as agreement by two-thirds of the participants.

RESULTS

The level of agreement strengthened throughout the process with two-thirds of the participants agreeing with 86%, 88%, 94%, and 100% of statements at each vote, respectively. At the final vote, 94% of the final 51 statements were approved by 90% of the Consensus Group, and 90% of statements were accepted with strong agreement or minor reservation. GERD was defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The disease was subclassified into esophageal and extraesophageal syndromes. Novel aspects of the new definition include a patient-centered approach that is independent of endoscopic findings, subclassification of the disease into discrete syndromes, and the recognition of laryngitis, cough, asthma, and dental erosions as possible GERD syndromes. It also proposes a new definition for suspected and proven Barrett's esophagus.

CONCLUSIONS

Evidence-based global consensus definitions are possible despite differences in terminology and language, prevalence, and manifestations of the disease in different countries. A global consensus definition for GERD may simplify disease management, allow collaborative research, and make studies more generalizable, assisting patients, physicians, and regulatory agencies.

Evaluation of health-related quality of life in gastroesophageal reflux disease patients before and after treatment with pantoprazole

Gastrooesophageal reflux disease (GERD) is highly prevalent in the Western world but its true population prevalence is difficult to estimate without a validated instrument to detect it. The evaluation of health-related quality of life (HRQoL) is an useful tool in this assessment. The aims of this study are to translate and validate a GERD specific HRQoL questionnaire and evaluate HRQoL in a Brazilian population before and after GERD treatment. GERD patients with typical symptoms and Los Angeles Classes A to C esophagitis were included in the study. Two HRQoL questionnaires and upper digestive endoscopy were performed before and after 6 weeks treatment with pantoprazole 40 mg/day followed by 80 mg/day for another 8 weeks if healing did not occur. A generic (SF-36) and one disease-specific questionnaire (GERD score) were used. The latter was translated and validated for Brazilian Portuguese. From January 2002 to December 2003, 100 patients were enrolled. Of these, 78 patients were evaluated in a per protocol analysis (35 men, mean age: 40 years). The translated questionnaire (Brazilian GERD Score, BGERDS) demonstrated adequate psychometric properties (validity, responsiveness and reliability). SF-36 and BGERDS domains significantly improved after treatment (P < 0.01 and P < 0.001 respectively). The BGERDS was shown to be valid and reliable. Patients with esophagitis showed an impaired HRQoL that improved or normalized after treatment with pantoprazole.

Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease

BACKGROUND

Approximately 25% of adults experience heartburn, the cardinal feature of gastro-oesophageal reflux disease (GORD), at least monthly. The evaluation and treatment of patients with suspected GORD is associated with a substantial economic burden. Most patients are treated empirically (without specific diagnostic evaluation). They include a wide range of underlying oesophageal injury. The severity of oesophageal injury can only be established in those who have undergone upper endoscopy. Patients without visible damage to the oesophagus have been referred to as having endoscopy negative reflux disease (ENRD). The pathogenesis of ENRD as well as its response to treatment may differ from GORD with oesophagitis.

OBJECTIVES

Summarise, quantify and compare the efficacy of the short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in adults with GORD, treated empirically and in those with endoscopy negative reflux disease (ENRD).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE (January 1966 to December 2005), EMBASE (January 1988 to December 2005).

SELECTION CRITERIA

Randomised controlled trials focussing on symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Studies were included provided that participants could be classified in the empirical treatment group (no endoscopy used in treatment allocation) or in the endoscopy negative reflux disease group (no endoscopic signs of erosive oesophagitis).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Thirty-one trials (9457 participants) were included: fifteen in the empirical treatment group, twelve in the ENRD group and four in both. In empirical treatment of GORD the relative risk (RR) for heartburn remission (the primary efficacy variable) in placebo-controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32 to 0.44), for H2RAs 0.77 (two trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73 to 1.01). In a direct comparison PPIs were more effective than H2RAs (seven trials, RR 0.66, 95% CI 0.60 to 0.73) and prokinetics (two trials, RR 0.53, 95% CI 0.32 to 0.87). In treatment of ENRD, the RR for heartburn remission for PPI versus placebo was 0.69 (seven trials, 95% CI 0.62 to 0.78) and for H2RA versus placebo was 0.84 (two trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.78 (three trials, 95% CI 0.62 to 0.97) and for PPI versus prokinetic 0.72 (one trial, 95% CI 0.56 to 0.92).

AUTHORS' CONCLUSIONS

PPIs are more effective than H2RAs in relieving heartburn in patients with GORD who are treated empirically and in those with ENRD, although the magnitude of benefit is greater for those treated empirically.

Systematic review: does gastro-oesophageal reflux disease progress?

BACKGROUND

Gastro-oesophageal reflux disease affects approximately 20% of western populations. Barrett's oesophagus, associated with severe gastro-oesophageal reflux disease, is premalignant and regular endoscopic surveillance is generally performed. In contrast, mild gastro-oesophageal reflux disease is thought not to progress and is not generally subjected to endoscopic follow-up. Aim To investigate whether gastro-oesophageal reflux disease progresses endoscopically.

METHODS

Systematic review of the literature.

RESULTS

Well-designed prospective studies are few, diagnostic criteria were not always standardized, management strategies varied and various sources of bias could not be excluded. Whilst most patients do not progress to more severe forms of gastro-oesophageal reflux disease, and some cases actually regress, progression is seen in a small proportion of patients. Annual progression rates for non-erosive gastro-oesophageal reflux disease developing erosive oesophagitis ranged from 0% to 30%. About 1-22% of patients with mild erosive oesophagitis developed more severe inflammation annually, while 1-13% of patients with erosive oesophagitis developed Barrett's oesophagus each year.

CONCLUSION

Although most patients with gastro-oesophageal reflux disease do not progress, and some actually regress, progression does occur in a minority. Better data are required to determine whether patients with mild gastro-oesophageal reflux disease would benefit from increased surveillance with the aim of detecting more advanced disease.

Cough in the community: a cross sectional survey and the relationship to gastrointestinal symptoms

BACKGROUND

The prevalence and severity of chronic cough in the community is uncertain. In a large population of representative normal subjects, we explored the relationship between self-reported cough severity and frequency, and factors known to be related to the aetiology of chronic cough. In particular, we have examined the relative association between cough and symptoms of gastrointestinal disease.

METHODS

A cross-sectional survey was undertaken in 36 general practices with subjects randomly selected from practice computer databases. Baseline lifestyle and demographic characteristics were recorded. Participants were asked how often in the previous 2 months they had experienced bouts or spasms of coughing. Cough symptom status was dichotomised into symptomatic using a cut off of bouts or spasms of coughing at a frequency of between once a week and once a day or above. Gastrointestinal data were collected using validated methodology.

RESULTS

Questionnaires were sent to 6416 subjects and 4003 (62%) responded. The prevalence of chronic cough was 12%, and was severe in 7%. Following multivariate analysis, regurgitation (OR 1.71; 99% CI 1.20 to 2.45) and irritable bowel syndrome (OR 2.00; 99% CI 1.47 to 2.72) were strong predictors of cough. Smoking (OR 1.61; 99% CI 1.18 to 2.19), declining social class (OR 1.63; 99% CI 1.04 to 2.57), and quality of life at baseline (OR 1.63; 99% CI 1.13 to 2.35) were also significantly associated.

CONCLUSION

Chronic cough is a common symptom in the general population. Its strong association with gastrointestinal disease may have aetiological significance.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease refers to reflux of gastric contents into the oesophagus leading to oesophagitis, reflux symptoms sufficient to impair quality of life, or long-term complications. Transient relaxation of the lower oesophageal sphincter is believed to be the primary mechanism of the disease although the underlying cause remains uncertain. Obesity and smoking are weakly associated with the disease and genetic factors might be important. A negative association with Helicobacter pylori exists, but eradication of H pylori does not seem to cause reflux disease. Diagnosis is imprecise as there is no gold standard. Reflux symptoms are helpful in diagnosis but they lack sensitivity. Ambulatory oesophageal pH monitoring also seems to be insensitive despite high specificity. Empirical acid suppression with a proton-pump inhibitor (PPI) has reasonable sensitivity but poor specificity. Some evidence suggests that once patients develop the disease, severity is determined early and patients seem to continue with that phenotype long term. Unfortunately, most patients do not respond to life-style advice and require further therapy. H2 receptor antagonists and PPIs are better than placebo in oesophagitis, with a number needed to treat of five and two, respectively. In non-erosive reflux disease, acid suppression is better than placebo but the response rate is lower. Most patients need long-term treatment because the disease usually relapses. The role of endoscopic therapy is uncertain. Anti-reflux surgery is probably as effective as PPI therapy although there is a low operative mortality and morbidity.

Body-mass index and symptoms of gastroesophageal reflux in women

BACKGROUND

Overweight and obese persons are at increased risk for gastroesophageal reflux disease. An association between body-mass index (BMI)--the weight in kilograms divided by the square of the height in meters - and symptoms of gastroesophageal reflux disease in persons of normal weight has not been demonstrated.

METHODS

In 2000, we used a supplemental questionnaire to determine the frequency, severity, and duration of symptoms of gastroesophageal reflux disease among randomly selected participants in the Nurses' Health Study. After categorizing women according to BMI as measured in 1998, we used logistic-regression models to study the association between BMI and symptoms of gastroesophageal reflux disease.

RESULTS

Of 10,545 women who completed the questionnaire (response rate, 86 percent), 2310 (22 percent) reported having symptoms at least once a week, and 3419 (55 percent of those who had any symptoms) described their symptoms as moderate in severity. We observed a dose-dependent relationship between increasing BMI and frequent reflux symptoms (multivariate P for trend <0.001). As compared with women who had a BMI of 20.0 to 22.4, the multivariate odds ratios for frequent symptoms were 0.67 (95 percent confidence interval, 0.48 to 0.93) for a BMI of less than 20.0, 1.38 (95 percent confidence interval, 1.13 to 1.67) for a BMI of 22.5 to 24.9, 2.20 (95 percent confidence interval, 1.81 to 2.66) for a BMI of 25.0 to 27.4, 2.43 (95 percent confidence interval, 1.96 to 3.01) for a BMI of 27.5 to 29.9, 2.92 (95 percent confidence interval, 2.35 to 3.62) for a BMI of 30.0 to 34.9, and 2.93 (95 percent confidence interval, 2.24 to 3.85) for a BMI of 35.0 or more. Even in women with a normal baseline BMI, an increase in BMI of more than 3.5, as compared with no weight changes, was associated with an increased risk of frequent symptoms of reflux (odds ratio, 2.80; 95 percent confidence interval, 1.63 to 4.82).

CONCLUSIONS

BMI is associated with symptoms of gastroesophageal reflux disease in both normal-weight and overweight women. Even moderate weight gain among persons of normal weight may cause or exacerbate symptoms of reflux.

Peptic ulcer disease in a general adult population: the Kalixanda study: a random population-based study

The authors' aim in this study was to explore the prevalence, symptomatology, and risk factors for peptic ulcer in a general adult population. Between December 1998 and June 2001, the authors surveyed a random sample (n=3,000) of the adult population (n=21,610) in two communities in northern Sweden using a validated questionnaire, the Abdominal Symptom Questionnaire (response rate=74%). A subsample (n=1,001) of the responders was randomly invited to undergo esophagogastroduodenoscopy and symptom assessment (response rate=73%). The prevalence of peptic ulcer was 4.1% (20 gastric ulcers and 21 duodenal ulcers). Nausea and gastroesophageal reflux were significant predictors of peptic ulcer disease, but epigastric pain/discomfort was not. Six persons with gastric ulcer and two persons with duodenal ulcer were asymptomatic. Eight subjects with duodenal ulcer (38%) lacked evidence of current Helicobacter pylori infection. Five (25%) of the gastric ulcers and four (19%) of the duodenal ulcers were idiopathic (no use of aspirin or nonsteroidal antiinflammatory drugs, no H. pylori infection). Smoking, aspirin use, and obesity were risk factors for gastric ulcer; smoking, low-dose (<or=160 mg) aspirin use, and H. pylori infection were risk factors for duodenal ulcer. Peptic ulcer disease often coexists with atypical symptoms or no symptoms at all, and idiopathic duodenal ulcer may be more common than anticipated.

Proximal stomach function in obesity with normal or abnormal oesophageal acid exposure

There is an increased prevalence of gastro-oesophageal reflux and symptoms in obese patients. Information about the proximal stomach in obese patients with reflux is lacking. Gastric volume and compliance are similar between obese and lean subjects. To study the proximal stomach function and perception in obese patients with normal or abnormal oesophageal acid exposure, thirty-one obese patients, with normal or abnormal oesophageal acid exposure, underwent medical evaluation of oesophageal and gastrointestinal symptoms by a questionnaire and measurement of proximal stomach function and perception by an electronic barostat and a standardized questionnaire. Nineteen obese patients had abnormal oesophageal acid exposure. The percentage of total time with pH <4 is significantly related to the presence of hiatal hernia, the oesophageal intensity-frequency symptom score and gender, i.e. higher percentage in men. The perception cumulative score was significantly different between patients with normal and abnormal oesophageal acid exposure after adjusting for covariates (gender, body mass index, age, minimal distending pressure, gastric tone and gastric compliance). Gastric tone and compliance were significantly related to the perception cumulative score. In conclusion, patients with abnormal oesophageal acid exposure have increased gastric perception. A significant relation among gastric tone, gastric compliance and upper gastrointestinal sensations was shown.

The relation between gastroesophageal reflux and respiratory symptoms in a population-based study: the Nord-Trøndelag health survey

BACKGROUND

In spite of numerous investigations, the relation between respiratory symptoms and reflux symptoms in the general population remains unclear, since population-based studies are few.

STUDY OBJECTIVES

To investigate the relation between respiratory symptoms and reflux symptoms in the population.

SUBJECT AND METHODS

In a cohort of 65,363 individuals representing 71.2% of the adult population in the Norwegian county of Nord-Trøndelag, 58,596 individuals (89.6%) responded to questions concerning reflux symptoms. The 3,153 persons (5.4%) with severe and recurrent reflux symptoms constituted the case group, and the 40,210 persons (68.6%) without reflux symptoms served as the control group. Odds ratios (ORs) with 95% confidence intervals (CIs) represented relative risks. Potential confounding was tested in multivariable logistic regression analysis.

RESULTS

Persons with asthma had reflux to a 60% greater extent than those without asthma after including adjustment for asthma medication (OR, 1.6; 95% CI, 1.4 to 1.9). There was a statistically significant dose-response association between breathlessness and reflux symptoms (p for trend < 0.0001), and the OR of severe breathlessness was 12.0 (95% CI, 9.5 to 15.2). Persons with heavy and wheezy breathing, daily cough, daily productive cough, or chronic cough showed a twofold to threefold statistically significant increase in risk of reflux symptoms. Adjustment for asthma or use of asthma medication did not substantially influence the risk estimates for any of the studied respiratory disorders.

CONCLUSIONS

Reflux symptoms commonly coexist with asthma and other respiratory symptoms on a population-based level, seemingly irrespective of asthma medication.

Prevalence and impact of gastroesophageal reflux in adolescents with asthma: a population-based study

We determined the prevalence of gastroesophageal reflux disease (GERD) symptoms and the associations between GERD symptoms and asthma morbidity in a population of adolescents with asthma. Two thousand, three hundred and ninety-seven students attending six middle schools in Seattle completed the International Study of Asthma and Allergy in Children (ISAAC) written and video survey that included additional questions pertaining to GERD symptoms and asthma morbidity. Based on their responses, children were categorized as having undiagnosed current asthma, physician-diagnosed current asthma, or no asthma symptoms. The prevalence of GERD symptoms occurring at least weekly or daily was determined for each group. The asthma morbidity outcomes were emergency department visits, physician visits, missed school days, and use of inhaled medications for respiratory symptoms within the past year. Associations between GERD symptoms and asthma morbidity outcomes were determined using logistic regression. The prevalence of GERD symptoms was significantly higher among students with current asthma (19.3%; 95% confidence interval (CI), 14.9-24.2) than students with no asthma symptoms (2.5%; 95% CI, 1.8-3.4). In children with current asthma (n = 296), symptoms of GERD that occurred at least weekly were strongly associated with emergency department visits (odds ratio (OR), 5.0; 95% CI, 2.6-9.6), physician visits (OR, 2.5; 95% CI, 1.3-4.6), missed school (OR, 2.0; 95% CI, 1.1-3.7), and inhaled medication use (OR, 2.5; 95% CI, 1.3-4.7). The associations between GERD symptoms and emergency department visits, physician visits, and inhaled medication use were stronger among children with asthma who reported daily GERD symptoms (n = 14) than among children reporting weekly GERD symptoms (n = 57). The prevalence of GERD symptoms was greater in adolescents with current asthma than in those without asthma. In addition, the presence of at least weekly GERD symptoms was strongly associated with greater asthma morbidity and the use of asthma medications.

Gastroesophageal reflux disease: clinical features

Gastroesophageal reflux disease (GERD) is a chronic disease affecting up to 40% of people in the Western world. Risk factors associated with GERD include age and lifestyle habits, although the clinically relevant contribution of many of these factors is unclear. In GERD, refluxed gastric acid damages the oesophageal mucosa, generally when the pH falls below 4. GERD patients present a variety of symptoms, most commonly heartburn and regurgitation. Oesophageal complications associated with GERD include erosions, ulcers, peptic strictures, and Barrett's oesophagus which is implicated in the development of oesophageal adenocarcinoma. Diagnosis of GERD is problematic due to the range of symptoms which may be presented to the physician and symptom severity is frequently unrelated to disease severity. While endoscopic monitoring may be used to assess the presence and severity of GERD, a lack of visible damage does not necessarily indicate an absence of GERD. Techniques used to diagnose GERD include addition of an acid solution into the oesophagus in order to replicate symptoms (Bernstein test) or 24-hour intra-oesophageal pH monitoring. Proton pump inhibitors are effective in the treatment of GERD, acting to reduce the acidity of the gastric juice and hence reduce oesophageal damage and symptoms associated with GERD. Symptoms most indicative of GERD are those associated with erosive oesophagitis, including heartburn and acid regurgitation. Less common GERD-associated symptoms include chest pain, a range of ear, nose and throat conditions, and asthma. In contrast to perceptions of the disease as 'merely' heartburn, the impact on patients' quality of life can be profound. Increasing awareness of GERD by health care professionals has led to improved diagnosis and a greater appreciation of the need for maintenance therapy.

The relationship between gastro-oesophageal reflux symptoms and achalasia

BACKGROUND AND AIMS

Patients with achalasia can experience heartburn, which may be misinterpreted as gastro-oesophageal reflux disease (GORD), leading to a delay in diagnosis and subsequent treatment. We investigated the relationship between gastro-oesophageal reflux (GOR) and reflux symptoms in a large cohort of patients with achalasia.

METHODS

The symptoms of all patients with a manometric diagnosis of achalasia made over the past 15 years were studied. The types of treatment, onset and pattern of heartburn, lower oesophageal sphincter pressure (LOSP) and 24-h oesophageal pH studies were compared.

RESULTS

A total of 110 out of 225 untreated (48.9%) and 57 out of 99 treated (57.6%) patients experienced heartburn. An oesophageal pH study was performed on 80 patients and GOR was found in only six out of 57 untreated (10.5%) and 10 out of 23 treated (43.5%) patients. A low LOSP (<10 mmHg) was associated with an increased risk of GOR [odds ratio (OR) 14.2; 95% confidence interval (CI) 1.6-128.7; P<0.02). Treated patients were also more likely to develop GOR (OR 7.9; 95% CI 2.0-32.1; P<0.005). Neither the LOSP nor previous treatment was, however, a predictor of heartburn. The timing of the onset of dysphagia and heartburn was categorized in 111 patients. There was no significant difference in mean (or median) LOSP between these three groups, indicating that the LOSP is unlikely to predict the occurrence of symptoms.

CONCLUSIONS

Heartburn is common in patients with untreated and treated achalasia, but is a poor predictor of GORD. Such patients should always be investigated with a 24-h oesophageal pH study to clarify the presence of GORD.

An evidence-based, Latin-American consensus on gastro-oesophageal reflux disease

In recognition of the high prevalence of gastro-oesophageal reflux disease (GORD) and its importance in Latin America, the InterAmerican Association of Gastroenterology and the InterAmerican Society of Digestive Endoscopy organized a Latin-American Consensus on GORD in Cancun, Mexico in September 2004. The main objectives of the consensus meeting were to provide evidence-based guidance with respect to the diagnosis and treatment of GORD, relevant to all countries in the region. The methodology, results and recommendations of the consensus are described in detail.

Controversies surrounding body mass, reflux, and risk of oesophageal adenocarcinoma

At first the association between body mass, reflux, and oesophageal adenocarcinoma might seem easily interpreted, but a more thorough assessment of the published work shows that several factors are missing. Reflux and obesity are established risk factors for oesophageal adenocarcinoma, particularly when they occur in combination. However, the interplay between these and other factors with regard to oesophageal adenocarcinoma is uncertain. Moreover, the contribution of these risk factors in explaining the increasing incidence of oesophageal adenocarcinoma is unclear, because the trends in prevalence of reflux and obesity do not match those of incidence of oesophageal adenocarcinoma. Moreover, none of these factors contribute strongly to the striking predominance of oesophageal adenocarcinoma in men. Thus, several factors that can explain the development of oesophageal adenocarcinoma need to be addressed.

Functional gastroduodenal disorders

A numerically important group of patients with functional gastrointestinal disorders have chronic symptoms that can be attributed to the gastroduodenal region. Based on the consensus opinion of an international panel of clinical investigators who reviewed the available evidence, a classification of the functional gastroduodenal disorders is proposed. Four categories of functional gastroduodenal disorders are distinguished. The first category, functional dyspepsia, groups patients with symptoms thought to originate from the gastroduodenal region, specifically epigastric pain or burning, postprandial fullness, or early satiation. Based on recent evidence and clinical experience, a subgroup classification is proposed for postprandial distress syndrome (early satiation or postprandial fullness) and epigastric pain syndrome (pain or burning in the epigastrium). The second category, belching disorders, comprises aerophagia (troublesome repetitive belching with observed excessive air swallowing) and unspecified belching (no evidence of excessive air swallowing). The third category, nausea and vomiting disorders, comprises chronic idiopathic nausea (frequent bothersome nausea without vomiting), functional vomiting (recurrent vomiting in the absence of self-induced vomiting, or underlying eating disorders, metabolic disorders, drug intake, or psychiatric or central nervous system disorders), and cyclic vomiting syndrome (stereotypical episodes of vomiting with vomiting-free intervals). The rumination syndrome is a fourth category of functional gastroduodenal disorder characterized by effortless regurgitation of recently ingested food into the mouth followed by rechewing and reswallowing or expulsion. The proposed classification requires further research and careful validation but the criteria should be of value for clinical practice; for epidemiological, pathophysiological, and clinical management studies; and for drug development.

[Gastroesophageal reflux in the French general population: national survey of 8000 adults]

OBJECTIVES

To assess the population-based prevalence in France of gastroesophageal reflux disease (GERD) and to report its characteristics, consultation rate, modes of management, as well as patients' satisfaction.

METHODS

This epidemiological quantitative mail survey sent to a sample of 8000 persons representative of the French adult population comprised 46 questions about GERD, its risk factors, management, last episode, and satisfaction with treatment. GERD was defined in accordance with the guidelines of the 1999 consensus conference as the existence of typical symptoms (heartburn, acid regurgitation) and frequent GERD as occurring at a frequency of at least once a week.

RESULTS

The overall prevalence of GERD in France is 31.3%. The prevalence of frequent GERD is 7.8% (6% among those younger than 50 years, 10% among those older than 50). Most subjects with frequent GERD (86%) had seen a doctor for it, often long after the first occurrence of symptoms - 26% had waited for more than one year before consulting - while 14% had never discussed it with a doctor, mainly because they considered it not serious and treated it themselves. Of those who had consulted, 58% had undergone an endoscopy. Most subjects (85%) had treated their last episode of frequent GORD, most often by their doctor's prescription treatment (68%), less often by self-treatment or a medication recommended by the pharmacist or both (17%). The prescription treatment was most often used alone (61%) and only rarely combined with self-treatment or a pharmacist's recommendation (7%). Two thirds of the subjects had used a single medication, and one-third a combination of drugs. Single medications were mainly proton-pump inhibitors (PPIs) (45%) and antacids/alginates (46%). Combinations were essentially made up of PPIs (83%), most often combined with antacids/alginates (61%). Two-thirds of subjects reported that they were entirely satisfied with their treatment, but symptoms had persisted in 24% of treated subjects.

DISCUSSION

Prevalence of frequent GERD increases with age. Sex, obesity, and consumption of tobacco and alcoholic beverages do not appear to affect it markedly. The proportion of subjects with frequent GERD with no regular medical follow-up and resorting to self-treatment is substantial. Only two thirds are totally satisfied with their treatment.

CONCLUSION

Nearly 3.5 million French adult subjects currently suffer from frequent GERD, and many do not - or wait unduly to - see a doctor, despite symptom frequency. Better management of frequent GERD in France remains desirable in order to improve symptom relief and surveillance of possible complications.

Cost-effectiveness of Helicobacter pylori "test and treat" for patients with typical reflux symptoms in a population with a high prevalence of H. pylori infection: a Markov model analysis

OBJECTIVE

Patients with typical reflux symptoms may have underlying peptic ulcer disease (PUD) in a population with a high prevalence of Helicobacter pylori infection. In the present study we sought to compare the cost-effectiveness of the H. pylori "test and treat" strategy with that of empirical proton-pump inhibitor (PPI) therapy and endoscopy in patients with typical reflux and a high prevalence of H. pylori infection.

MATERIAL AND METHODS

A Markov model was designed to compare the outcomes of three treatment strategies over 12 months among a hypothetical cohort of patients presenting with typical reflux symptoms. There were four exclusive underlying H. pylori- and PUD-related comorbidities in the hypothetical cohort: (1) H. pylori-related PUD, (2) H. pylori infection without PUD, (3) PUD without H. pylori infection and (4) absence of both PUD and H. pylori infection. The transition probabilities and resource utilization were derived from the literature. Percentage of PUD patients treated, total number of symptom-free patient-years gained and total direct medical cost were estimated.

RESULTS

By comparing each strategy individually with the no therapy strategy, it was found that the incremental costs per ulcer treated for H. pylori "test and treat", endoscopy and empirical PPI therapy were USD 1778, USD 1797 and USD 2158, respectively. The results of the model were sensitive to the prevalence of H. pylori infection.

CONCLUSIONS

Both the H. pylori "test and treat" and initial endoscopic strategies were shown to be more cost-effective than empirical PPI therapy for treating undiagnosed PUD among patients presenting with typical reflux symptoms. The H. pylori "test and treat" strategy appeared to be only slightly more cost-effective than initial endoscopy in a population with a high prevalence of H. pylori infection.

Functional dyspepsia--a multicausal disease and its therapy

Functional dyspepsia is a common chronic disorder with non-specific upper abdominal symptoms which can not be explained by organic or biochemical abnormalities. The dyspeptic symptoms are very compromising and bothersome and result in a substantial reduction of quality of life. The substantial direct and indirect medical and economical costs induce a high socioeconomic interest in the pathogenesis and the treatment options of this disease. Over the past 30 years several theories about the etiology of the symptoms in functional dyspepsia patients have been put forward. These include disorders of gastrointestinal motility, acid secretion, visceral hypersensitivity, adaptation and accommodation, Hp-infection, mucosal inflammation and finally genetic predisposition. There is increasing evidence that functional dyspepsia is a multi-causal disorder, which leads to altered processing of afferent information from the gastrointestinal tract to the CNS. Autonomic hypersensitivity and altered central processing could be a common phenomenon whereas motility changes, inflammation or altered secretion could increase neural afferent inputs. Treatment of this complex disorder could and should involve these different levels of symptom generation. Thus different approaches with anti-secretory, spasmolytic, prokinetic and anti-inflammatory effects and most preferably reduction of visceral hypersensitivity seem logical. This could explain the variety of drugs which show a positive symptomatic response. This could also offer the conclusion, whether a combination of these drugs could be clinically superior which remains to be proven. And this could offer a logical approach for the use of substances with a multi-target action, e.g. STW 5.

Prevalence of Barrett's esophagus in the general population: an endoscopic study

BACKGROUND & AIMS

Barrett's esophagus (BE) is associated with esophageal adenocarcinoma, the incidence of which has been increasing dramatically. The prevalence of BE in the general population is uncertain because upper endoscopy is required for diagnosis. This study aimed to determine the prevalence of BE and possible associated risk factors in an adult Swedish population.

METHODS

A random sample (n = 3000) of the adult population (n = 21,610) in 2 municipalities was surveyed using a validated gastrointestinal symptom questionnaire (response rate, 74%); a random subsample (n = 1000; mean age, 53.5 years; 51% female) underwent upper endoscopy. Endoscopic signs suggestive of columnar-lined esophagus (CLE) were defined as mucosal tongues or an upward shift of the squamocolumnar junction. BE was diagnosed when specialized intestinal metaplasia was detected histologically in suspected CLE.

RESULTS

BE was present in 16 subjects (1.6%; 95% confidence interval, 0.8-2.4): 5 with a long segment and 11 with a short segment. Overall, 40% reported reflux symptoms and 15.5% showed esophagitis; 103 (10%) had suspected CLE, and 12 (1.2%) had a visible segment > or = 2 cm. The prevalence of BE in those with reflux symptoms was 2.3% and in those without reflux symptoms was 1.2% (P = .18). In those with esophagitis, the prevalence was 2.6%; in those without, the prevalence was 1.4% (P = .32). Alcohol (P = .04) and smoking (P = .047) were independent risk factors for BE.

CONCLUSIONS

BE was found in 1.6% of the general Swedish population. Alcohol and smoking were significant risk factors.

Review article: the management of heartburn in pregnancy

Heartburn is a normal consequence of pregnancy. The predominant aetiology is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. Serious reflux complications during pregnancy are rare; hence upper endoscopy and other diagnostic tests are infrequently needed. Gastro-oesophageal reflux disease during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line drug therapy. If symptoms persist, any of the histamine2-receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. All but omeprazole are FDA category B drugs during pregnancy. Most drugs are excreted in breast milk. Of systemic agents, only the histamine2-receptor antagonists, with the exception of nizatidine, are safe to use during lactation.

Gastroesophageal reflux and cancer

The causal relationship between GERD and esophageal adenocarcinoma, although unclear just a few decades ago, now is established fairly well. The physiologic changes and the biocellular alterations of the damaged esophageal mucosa are documented better. Despite this knowledge, the dramatic increase in the incidence of esophageal cancer cannot be explained. The absolute risk of esophageal adenocarcinoma arising from GERD is low, and, at present, does not justify population-screening programs. Still, with the notion that adenocarcinoma of the esophagus is an aggressive cancer once documented, important questions still are in need of answers for patients suffering from reflux symptoms. Patients who have reflux disease are not necessarily symptomatic. It remains unclear if patients experiencing reflux symptoms should undergo mandatory endoscopy with biopsies at the esophagogastric junction. Furthermore, metaplasia of the lower esophagus often is not readily recognizable at endoscopy, and only biopsies can document abnormal histology. A severe and prolonged history of reflux always should orient to the possibility of a reflux-related columnar-lined esophagus. Once documented, Barrett's esophagus needs to be seen as a premalignant condition not necessarily leading to adenocarcinoma formation; despite their increased risk of tumor formation, most patients who have Barrett's esophagus die of other causes. During regular endoscopic follow-up, multilevel circumferential biopsies should document the evolution of the histologic changes in the lower esophagus and at the gastroesophageal junction of these patients. It is the only method available to document the appearance of dysplasia. It still is unclear if medicine or surgery provides the best quality of life and the best protection against the development of dysplasia and the possible progression toward adenocarcinoma formation when intestinal metaplasia is present in the esophagus.

Current medical management of gastroesophageal reflux disease

Gastroesophageal reflux symptoms are common. Not everyone who has heartburn has reflux, as some people have functional heartburn in addition to many other symptoms. Alternatively, not everybody who has reflux has heartburn, and many symptoms are identified in which reflux may be playing a role. In most cases, the initial management strategy is empiric medical therapy. Often, this brings symptom relief, but when it does not, alternative diagnoses need to be considered. High-dose treatment trials and ambulatory pH monitoring have become more important than endoscopy in the diagnosis of reflux. Patients who have reflux typically require a chronic disease approach. This can be with medical therapy, surgery, or endoscopic approaches. GERD is associated with decreased quality of life; however, given the many helpful treatment options, no one should suffer from the symptoms of GERD.

Acid perfusion test: a useful test for evaluating esophageal acid sensitivity

The acid perfusion test (APT) is a test of esophageal acid sensitivity. In gastroesophageal reflux disease (GERD), the APT has largely been superseded by indexes derived from 24-hr esophageal pH monitoring: symptom index (SI), symptom sensitivity index (SSI), and symptom association probability (SAP). To evaluate the role of APT in patients with GERD we compared values of SI, SSI, and SAP in 126 APT+ and 146 APT- patients. Median values for SI, SSI, and SAP were higher in the APT+ compared with the APT- group (P < 0.001). More patients had a positive SI, SSI, and SAP in the APT+ compared with the APT- group (SI, P < 0.0001; SSI and SAP, P < 0.001). Patients with a negative APT were unlikely to have symptoms caused by acid reflux (negative predictive value, 86%). APT may be useful in detecting acid sensitivity in patients who do not report symptoms on 24-hr esophageal pH monitoring.

Prevalence, clinical spectrum and atypical symptoms of gastro-oesophageal reflux in Argentina: a nationwide population-based study

BACKGROUND

Population-based data on gastro-oesophageal reflux in Latin America are lacking.

AIM

To assess gastro-oesophageal reflux symptom prevalence, clinical spectrum and association with the atypical symptoms in our country.

METHODS

Gastro-oesophageal reflux self-report questionnaires validated at Mayo Clinic, USA, were submitted to a sample of 1000 residents (aged 18-80 years) from 17 representative geographical areas of Argentina. The samples were selected and stratified according to age, gender, geographical areas and size of town of residence provided by the Argentine Bureau of Statistics and Census.

RESULTS

The overall prevalence of any typical gastro-oesophageal reflux symptom experienced in the previous year was 61.2% (95% CI, 57.9-64.6), the prevalence of frequent gastro-oesophageal reflux symptoms was 23.0% (95% CI, 20.1-25.9) and the prevalence of gastro-oesophageal reflux disease was 11.9% (95% CI, 9.6-14.1). Frequent gastro-oesophageal reflux symptoms were associated with dysphagia (OR 2.12, 95% CI, 1.27-3.54, P < 0.01), globus (OR 2.22, 95% CI, 1.35-3.66, P < 0.01) and non-cardiac chest pain (OR 1.55, 95% CI, 1.04-2.31, P < 0.05).

CONCLUSIONS

In Argentina, typical symptoms of gastro-oesophageal reflux are highly prevalent at the national level, and frequent gastro-oesophageal reflux symptoms are significantly associated with dysphagia, globus and non-cardiac chest pain.

Review article: gastro-oesophageal reflux disease--the extent of the problem

There have been little review data on the period prevalence of heartburn symptoms in the community. We analysed reflux symptom data from a test-and-treat trial that evaluated community Helicobacter pylori levels and added these to data identified from a literature search. We found 31 papers reporting on 77,671 subjects who provided information on the frequency of heartburn symptoms in the community. Pooled data from these papers suggested that, in Western populations, 25% had symptoms at least once per month, 12% had symptoms at least weekly and 5% had heartburn daily. Reflux symptoms were less common in East Asian populations with only 7% having heartburn at least once per month. Heartburn is a significant problem in Western societies.

Routine management of gastro-oesophageal reflux disease by gastroenterologists in France: a prospective observational study

AIMS

To obtain data on routine care of gastro-oesophageal reflux disease by French gastroenterologists.

PATIENTS

Five thousand and forty-five adults with gastro-oesophageal reflux disease.

METHODS

Patients were recruited by a representative sample of 598 French gastroenterologists. A full disease history, with treatments given/investigations undertaken, was obtained from all patients. The patients' expectations with regard to the improvement of the symptoms' control and the corresponding assessments made by the gastroenterologists were recorded on a 4-point scale.

RESULTS

The mean time since diagnosis was approximately 4 years. The most commonly presented symptom was heartburn (79% of patients). A total of 3735 patients (74%) underwent endoscopy because of gastro-oesophageal reflux disease. Erosive oesophagitis was present in 38% and Barrett's oesophagus in 8%. Medical therapy for gastro-oesophageal reflux disease was prescribed in 92% of patients, of whom 86% received proton pump inhibitors. Lifestyle advice was given to 73% of patients. Overall, 84% of patients and 72% of physicians expected 'highly' or 'moderately' improved control of gastro-oesophageal reflux disease. Gastroenterologists underrated the need for improvement of the symptoms' control as expressed by 'de novo' as well as 'previously diagnosed' patients.

CONCLUSIONS

This study provides cross-sectional data on the management of gastro-oesophageal reflux disease by gastroenterologists in France. Most patients have high expectations of an improvement in their management, but gastroenterologists generally underrate these expectations.

Review: what do we mean by GERD?--definition and diagnosis

Gastro-oesophageal reflux disease (GERD) is a condition in which the gastro-oesophageal reflux provokes symptoms or complications. Since the majority of patients with heartburn do not have mucosal breaks, expressions such as 'endoscopy-negative reflux disease' (ENRD), 'non-erosive reflux disease' (NERD), or even 'reflux-like dyspepsia' and 'functional heartburn' are frequently employed despite the lack of consensus concerning their exact meaning. Moreover, definition of a disease does not mean that precise diagnostic criteria exist. Diagnostic approaches to GERD differ considerably between primary and secondary care. The primary care physician's role is to decide, on the basis of symptoms and clinical examination, if it is likely that the patient has some serious problem which requires urgent investigation and intervention. In practice, a symptom-based diagnosis can often be made reliably because heartburn and regurgitation are very specific for GERD. The secondary care physician has to make a full evaluation of an already highly-selected patient and, as far as possible, to make a comprehensive, accurate diagnosis, using whatever investigative tools are required. However, there is no 'gold standard' for the diagnosis of GERD and 24-hour pH monitoring lacks sensitivity in NERD. Recently, impedance-pH monitoring has been introduced and promising results have been reported. However, this new technology needs further validation and technical improvement before being employed in routine clinical investigation.

Treatment of uncomplicated reflux disease

Uncomplicated reflux disease comprises the non-erosive reflux disease (NERD) and erosive reflux disease (ERD). The objectives of treatment are the adequate control of symptoms with restoration of quality of life, healing of lesions and prevention of relapse. Treatment of NERD consists in the administration of proton pump inhibitors (PPI) for 2-4 wk, although patients with NERD show an overall poorer response to PPI treatment than patients with ERD owing to the fact that patients with NERD do not form a pathophysiologically homogenous group. For long-term management on-demand treatment with a PPI is probably the best option. In patients with ERD, therapy with a standard dose PPI for 4-8 wk is always recommended. Long-term treatment of ERD is applied either intermittently or as continuous maintenance treatment with an attempt to reduce the daily dosage of the PPI (step-down principle). In selected patients requiring long-term PPI treatment, antireflux surgery is an alternative option. In patients with troublesome reflux symptoms and without alarming features empirical PPI therapy is another option for initial management. Therapy should be withdrawn after initial success. In the case of relapse, the long-term care depends on a careful risk assessment and the response to PPI therapy.

Rates of endoscopy and endoscopic findings among people with frequent symptoms of gastroesophageal reflux in the community

BACKGROUND

Epidemiological studies have confirmed that gastroesophageal symptoms are highly prevalent. However, studies linking epidemiology with clinical or chart data are scarce. We aimed to determine the frequency of endoscopy and endoscopic findings, as well as predictors of health-care utilization, among people with reflux symptoms in the community.

METHODS

A previous survey of 2,118 Olmsted County, MN, residents in 1993 identified 242 subjects with frequent reflux symptoms (at least weekly) who received care at a medical center in the county. Data were abstracted from Mayo Clinic records between 1988 and 1998.

RESULTS

Overall, 130 of the 242 (54%, 95% CI 47-60%) had sought care for reflux. Twenty-five patients (10%) had visited a gastroenterologist; 47 (19%) had an upper endoscopy (EGD), 64 (26%) had an upper GI X-ray, and one had an ambulatory 24-h esophageal pH study. Long segment Barrett's esophagus was detected in 4 (9%) of those having an EGD and adenocarcinoma was found in one patient with Barrett's. Three patients had surgery for gastroesophageal reflux disease. Thirteen patients (5%) died, but no deaths were due to esophageal reflux or adenocarcinoma. Age, higher education, frequent heartburn, and dysphagia were all significant, independent predictors of consulting.

CONCLUSIONS

Although many people in the community have frequent reflux symptoms, few have investigations, and deaths were unrelated to reflux disease or its complications. Data from referral clinic or endoscopy series should not be extrapolated to the large numbers of people in the community with symptoms of reflux.

Prevalence, risk factors and impact of gastroesophageal reflux disease symptoms: a population-based study in South China

OBJECTIVE

There are few data on the epidemiology of gastroesophageal reflux disease (GERD) in South China. The aim of this study was to assess the prevalence of GERD symptoms in South China and to evaluate the impact on health-related quality of life.

MATERIALS AND METHODS

A face-to-face interview was carried out in South China using a validated Chinese version of the Reflux Disease Questionnaire to assess the prevalence of GERD symptoms. A randomly clustered sampling of permanent inhabitants aged 18 to 90 years was carried out under stratification of urban and suburban areas. The impact of GERD symptoms on health-related quality of life was evaluated using the Chinese version of SF-36.

RESULTS

A total of 3338 residents (1468 M, 1870 F) were investigated. Mean age of the responders was 42.6 +/- 16.4 years; response rate was 95%. The prevalence of heartburn and/or acid eructation occurring at least weekly was 6.2%. The age- and gender-adjusted point prevalence of GERD symptoms in South China is 2.3% (95% CI, 1.8%, 2.8%) according to the definition in this study. There was no difference in prevalence between male (2.6%) and female (2.4%) subjects and there was no significant association between age and prevalence of GERD symptoms. Divorced/widowed/separated subjects (OR 4.61; 95% CI, 2.15%, 9.89%) and subjects with a heavy burden of work (OR 3.43, 95% CI, 1.72%, 6.84%) were significantly more likely to report GERD symptoms. As compared with the general population, subjects with GERD symptoms experienced considerable impairment in quality of life.

CONCLUSION

The prevalence of GERD symptoms in South China was much lower than that reported in Western countries. GERD had a negative impact on quality of life.

Gastro-oesophageal reflux is more prevalent in Western dyspeptics: a prospective comparison of British and South-East Asian patients with dyspepsia

BACKGROUND

There is a paucity of data directly comparing dyspepsia in Western and Eastern populations.

AIM

To compare clinical symptoms, epidemiological factors and endoscopic diagnoses in two sample populations with dyspepsia from the United Kingdom and South-East Asia in a cross-sectional study.

METHODS

Patients with uncomplicated dyspepsia attending endoscopy units in Leeds, UK, and Kuala Lumpur, Malaysia, were prospectively interviewed and underwent subsequent endoscopy.

RESULTS

A total of 1003 Malaysian patients (January 2002 to August 2003) and 597 Caucasian British patients (January 2000 to October 2002) were studied. The mean age was 48.7 +/- 15.8 and 47.5 +/- 13.8 years for the Malaysian and British patients respectively (P = NS). There was a higher proportion of cigarette smoking (35.7% vs. 12.4%, P < 0.0001) and alcohol consumption (34.4% vs. 2.0%, P < 0.0001) amongst British patients, but no difference in non-steroidal anti-inflammatory drug use nor having Helicobacter pylori infection. Gastro-oesophageal reflux disease (GERD) symptoms were more common in British compared with South-East Asian patients [heartburn (72% vs. 41%), regurgitation (66% vs. 29.8%) and dysphagia (21.1% vs. 7.3%), P < 0.0001]. This correlated with an increased endoscopic finding of oesophagitis (26.8% vs. 5.8%) and columnar-lined oesophagus (4.4% vs. 0.9%) amongst British patients (P < 0.001). A logistic regression model revealed that British Caucasian race (OR 9.7; 95% CI = 5.0-18.8), male gender (OR 2.0; 95% CI = 1.4-2.9) and not having H. pylori infection (OR 0.5; 95% CI = 0.3-0.7) were independent predictors for oesophagitis.

CONCLUSION

GERD is more common in British compared with South-East Asian dyspeptic patients suggesting that race and/or western lifestyle are important risk factors.

Relationships between air swallowing, intragastric air, belching and gastro-oesophageal reflux

BACKGROUND

With each swallow a certain amount of air is transported to the stomach. The stomach protects itself against excessive distention by swallowed air through belching (gas reflux). The mechanism of belching (transient lower oesophageal sphincter relaxation) is also one of the mechanisms underlying gastro-oesophageal reflux.

AIM

To investigate whether swallowing of air leads to an increase in size of the intragastric air bubble and to gastro-oesophageal reflux.

METHODS

Multichannel intraluminal impedance measurement was used to quantify the incidence of swallowing of air in 20 healthy volunteers before and after a meal. Radiography was used to measure the size of the intragastric air bubble. Gastro-oesophageal reflux was assessed by concurrent impedance and pH measurement.

RESULTS

The rate of air swallowing was correlated to the size of the intragastric air bubble postprandially and to the rate of gaseous gastro-oesophageal reflux. The number of air swallows and the size of the intragastric air bubble did not correlate with the number of liquid acid and non-acid reflux episodes.

CONCLUSIONS

In healthy subjects, air swallowing promotes belching but does not facilitate acid reflux.

Human leucocyte antigen determinants of susceptibility to Barrett's oesophagus in Asians--a preliminary study

BACKGROUND

Characteristic immune profiles have been demonstrated in gastro-oesophageal reflux disease. However, the genetic basis of gastro-oesophageal reflux disease remains unclear.

AIM

To investigate whether certain human leucocyte antigen genes are associated with Barrett's oesophagus.

METHODS

Asian patients of Malay, Chinese and Indian descent with Barrett's oesophagus (n = 59) and those without reflux symptoms and a normal oesophagus (n =60) were recruited prospectively using endoscopic and histopathological criteria. Human leucocyte antigen class I and II typing was performed using a polymerase chain reaction sequence-specific primers method.

RESULTS

The HLA-B7 allele was present in 17% (10 of 59) of patients with Barrett's oesophagus when compared with 0% (zero of 60) of controls [P = 0.0006, corrected P = 0.0171, OR = 25.67]. Subgroup analysis revealed that the HLA-B7 allele was confined almost exclusively to Indians with Barrett's oesophagus, 43% (nine of 21) vs. 0% (zero of 19) Indian controls (P = 0.0014, corrected P = 0.0406, OR = 29.64). No class II associations, protective human leucocyte antigens or extended haplotypes for disease susceptibility were identified.

CONCLUSIONS

Barrett's oesophagus in Asians, particularly Indians, is strongly positively associated with HLA-B7; reinforcing a genetic component to gastro-oesophageal reflux disease. A larger sample size and different ethnic populations should be genotyped to further confirm this association and identify possible additional risk factors in the human leucocyte antigen locus.

Empirical treatment for the management of patients presenting with uninvestigated reflux symptoms: a prospective study in an Asian primary care population

BACKGROUND

Data on Asian patients who present with reflux symptoms to their primary care physicians are limited.

AIM

To determine whether empirical therapy without endoscopy is appropriate for patients who present to their primary care physicians with uninvestigated reflux symptoms without alarm symptoms.

METHOD

Forty-seven patients presenting with uninvestigated, dominant reflux symptoms but without alarm features to their primary care physicians underwent endoscopy within 2 weeks of referral. Their endoscopic findings were compared with those of 162 primary care patients presenting with uninvestigated dominant dyspepsia. All patients, except those with ulcers, were treated with esomeprazole 20 mg b.d. for 2 weeks. Their treatment response was assessed at 2 weeks using a symptom score.

RESULTS

Among patients with dominant reflux symptoms, 14 (30%) had erosive oesophagitis. No other clinically significant endoscopic findings were detected among them. In contrast, erosive oesophagitis and peptic ulcer were found in 13 (8%, P < 0.001 vs. reflux group), and 12 (7%, P = 0.06 vs. reflux group), respectively, of patients with dominant dyspepsia. Thirty-seven of forty-five (82%) of those with dominant reflux symptoms and 109 of 139 (78%; P = N.S. vs. reflux group) of those with dominant dyspepsia reported > or = 50% resolution of symptoms after esomeprazole treatment.

CONCLUSIONS

Empirical proton pump inhibitor without endoscopy is reasonable for uninvestigated patients who present to primary care physicians with dominant reflux symptoms.

Diagnosis of gastroesophageal reflux disease using a new questionnaire

BACKGROUND AND AIM

An early and accurate evaluation by a general practitioner is needed to screen out non-gastroesophageal reflux disease (GERD) patients. A recent questionnaire (QUEST) highlighted problems with specificity and complexity, so the aim of the present study was to design a simplified questionnaire.

METHODS

When admitted to hospital to undergo an upper gastrointestinal endoscopy for suspected GERD, 333 patients completed a 50-item questionnaire requiring 'yes/no' answers to different combinations of questions relating to symptoms of upper gastrointestinal tract conditions (e.g. GERD, ulcers and functional dyspepsia) and psychosomatic symptoms. The endoscopic diagnosis was then correlated with the rate of positive answers to each question.

RESULTS

Based on the analysis of the 50 items, the 8-10 questions most often answered affirmatively by each of the GERD and non-GERD groups were chosen for the simplified questionnaire. Three draft questionnaires were compiled. After calculating the sensitivity, specificity and accuracy in relation to the diagnosis of GERD and other conditions, it was found that questionnaire B (selection of persons answering 'yes' to at least one of questions 1-5 and exclusion of persons answering 'yes' to at least three of questions 7-10) had a high sensitivity, high specificity and low false positive rate.

CONCLUSION

A novel questionnaire was developed. It was designed to detect the symptoms of GERD while simultaneously excluding non-GERD patients. This simplified nine-item simplified questionnaire had a sensitivity of 79.8%, a specificity of 53.6% and an accuracy of 63.4%.

Catheter-based pH monitoring: use in evaluation of gastroesophageal reflux disease symptoms (on and off therapy)

Tube-based ambulatory pH testing has rapidly evolved in the past 3 decades to become the standard by which other diagnostic approaches to gastroesophageal reflux disease are judged. Acid exposure 5 cm above the manometrically determined lower esophageal sphincter is the standard for documentation of pathologic acid exposure of the distal esophagus. Proximal esophageal or hypopharyngeal monitoring is an evolving technique that may shed light on patients with supraesophageal symptoms. The ability to simultaneously monitor esophageal and gastric acidity (usually in patients with persistent symptoms despite therapy) is another advantage of this technique. Whether the new system that allows simultaneous pH and impedance monitoring and the system that uses an implantable tubeless monitoring capsule will supplant this older but well-established technology remains to be determined.

Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Asan-si, Korea

BACKGROUND AND AIMS

This study estimated the prevalence and clinical spectrum of gastroesophageal reflux disease (GERD) in Asan-si, Korea, as the prevalence is believed to be lower than in Western countries.

METHODS

A cross-sectional survey, using a reliable and valid questionnaire, was performed on randomly selected 2,240 Asan-si residents aged between 18 and 69 yr. All respondents were interviewed at their homes or offices by a team of interviewers.

RESULTS

Of the 1,902 eligible subjects, 1,417 (78.4%: male 762; female 655) were surveyed. The prevalence of heartburn occurring at least once a month, at least once a week, and at least twice a week was 4.71% (95% confidence interval (CI), 3.6-5.8), 2.0% (95% CI, 1.2-2.7), and 1.3% (95% CI, 0.7-1.9), respectively. The corresponding figures for acid regurgitation were 4.4% (95% CI, 3.3-5.5) and 2.0% (95% CI, 1.3-2.8), respectively. The prevalence of GERD, defined as heartburn and/or acid regurgitation experienced at least weekly, was 3.5% (95% CI, 2.6-4.5). No significant difference was detected between sexes. The prevalence of heartburn was associated with increasing age (p < 0.001). Nineteen percent of our population reported at least one of the atypical symptoms, for instance, chest pain, dysphagia, globus sensation, asthma, bronchitis, pneumonia, or hoarseness. The frequency of frequent GERD among subjects reporting any of the atypical symptoms was 12.6%, which was higher than that of the subjects without atypical symptoms. Patients with typical reflux symptoms were more common among those with atypical symptoms, compared to those without such symptoms (p < 0.001). Using a logistic regression model after adjusting for age and sex, typical reflux symptoms were associated with chest pain (odds ratio (OR), 9.3; 95% CI, 5.9-14.7), dysphagia (OR, 6.4; 95% CI, 2.8-14.7), globus sensation (OR, 3.9; 95% CI, 1.5-9.7), hoarseness (OR, 4.3; 95% CI, 1.4-13.1), asthma (OR, 2.6; 95% CI, 1.4-4.8), and bronchitis (OR, 1.2; 95% CI, 0.6-2.3).

CONCLUSION

The prevalence of GERD was 3.5% in this Korean population. Heartburn and acid regurgitation were significantly associated with chest pain, dysphagia, globus sensation, hoarseness, and asthma.

Differences in clinical characteristics between patients with endoscopy-negative reflux disease and erosive esophagitis in Japan

OBJECTIVE

Helicobacter pylori infection and atrophic gastritis are inversely related to erosive esophagitis. Whether these factors affect the pathogenesis of endoscopy-negative reflux disease is not clear. We aimed to elucidate the differences in clinical characteristics between endoscopy-negative erosive disease and erosive esophagitis.

METHODS

253 subjects (89 with endoscopy-negative reflux disease and 164 with erosive esophagitis) were studied. Gastric atrophy was assessed by measurement of serum pepsinogen. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (CI) of endoscopy-negative reflux disease compared with erosive esophagitis.

RESULTS

Among GERD patients, female gender (OR = 2.27, 95% CI, 1.25-4.10), smoking (OR = 0.45, 95% CI, 0.22-0.91), and the presence of hiatal hernia (OR = 0.30, 95% CI, 0.17-0.56) were significantly associated with endoscopy-negative reflux disease compared with male gender, not smoking, and absence of hiatal hernia, respectively. Body mass index (BMI) was also significantly associated with a decreased OR for endoscopy-negative reflux disease. Although H. pylori infection and gastric atrophy were significantly more common in patients with endoscopy-negative reflux disease, these associations did not persist in a multiple-adjustment model. After adjustment for gender, BMI, smoking, and hiatal hernia, a decrease in serum pepsinogen I/II ratio was significantly associated with an increased OR for endoscopy-negative reflux disease (p for trend = 0.018).

CONCLUSIONS

Female gender, low BMI, not smoking, absence of hiatal hernia, and severity of gastric atrophy were positively associated with endoscopy-negative reflux disease compared with erosive esophagitis among Japanese patients.

Prevalence of functional gastrointestinal disorders in a population of subjects consulting for gastroesophageal reflux disease in general practice

AIMS

To establish the prevalence of functional gastrointestinal (GI) disorders in adult patients with symptoms of gastroesophageal reflux disease (GERD) and to assess the impact of GERD treatment on functional GI disorders in medical practice in France.

METHODS

3318 patients with GERD symptoms (mean age 53 yr; 1726 women and 1592 men) were involved in the survey. A questionnaire on demographic data, GERD features, presence of functional GI disorders and their features, and impact of GERD treatment on functional GI disorders was performed by the physician. The size of the different groups was compared using either a chi2 test or a Mantel-Haenszel analysis, on a case by case basis.

RESULTS

Seventy-two percent of patients with GERD had associated functional GI disorders, with a mean of 4.1 +/- 1.9 functional digestive symptoms per patient. Gas, flatulence, transit disorders and abdominal distension were the most commonly reported symptoms. Among patients with functional GI symptoms, 27% had symptoms suggestive of irritable bowel syndrome (IBS), 16% were suggestive of dyspepsia while 57% had both upper and lower functional digestive symptoms. According to the patients, GERD treatment had a positive impact (significant to complete improvement) on their functional GI disorders in about one-third of patients particularly in those with dyspeptic-type symptoms.

CONCLUSIONS

Functional GI disorders are particularly common in adult patients suffering from GERD, with a three times higher prevalence than in the general population.

[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.

Prevalence of gastroesophageal reflux disease and gastroesophageal reflux disease symptoms in Japan

BACKGROUND AND AIM

Epidemiological studies have shown that 10-48% of people in developed countries have gastroesophageal reflux disease (GERD) symptoms such as heartburn and acid regurgitation. The present study aimed to examine the prevalence of GERD symptoms and GERD in Japanese subjects.

METHODS

A cross-sectional study of Japanese subjects who visited a clinic for a routine health check up was carried out. Subjects were asked to fill out a self-report questionnaire. GERD was defined as the presence of heartburn and/or acid regurgitation at least twice per week.

RESULTS

Of the 6035 eligible subjects, 2662 (44.1%) reported having had heartburn and/or acid regurgitation during the past year: 124 (2.1%) daily, 275 (4.6%) twice per week, 773 (12.8%) twice per month and 1490 (24.7%) less than twice per month. Three hundred and ninety-nine (6.6%) subjects were diagnosed as having GERD and there was no relationship between the prevalence of GERD and either sex or age. The prevalence of bothersome GERD symptoms was significantly higher in subjects with GERD than in those without GERD.

CONCLUSION

Approximately 6.6% of Japanese have GERD and most persons with GERD described heartburn or acid regurgitation as bothersome.

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.

Impact of 24-h esophageal pH monitoring on the diagnosis of gastroesophageal reflux disease: defining the gold standard

BACKGROUND AND AIMS

The tests that are currently available for the diagnosis of gastroesophageal reflux disease (GERD) lack the desired diagnostic accuracy. To date, only pH monitoring has been shown to have a good sensitivity and specificity, but recent studies have failed to confirm this. Thus there is a need to find a test with acceptable sensitivity and specificity for diagnosing GERD. The present study aimed to find a single test or a combination of tests that could serve as a gold standard for the diagnosis of GERD and to identify an evidence-based diagnostic work-up for GERD in clinical and research settings.

METHODS

A prospectively conducted masked study was carried out in which 109 GERD patients were recruited on the basis of symptom score evaluation (heartburn and/or regurgitation). After informed consent was given, the patients underwent various tests, including esophagogastroduodenoscopy with biopsy from the lower esophageal mucosa during the first visit, followed by omeprazole challenge test (OCT), radionuclide scintigraphy, barium swallow and finally 24-h esophageal pH monitoring. A positive concordance of three or more tests was taken as the gold standard.

RESULTS

The results of all six tests were available for 70 patients. As a single diagnostic test, pH testing had the best combination of sensitivity and specificity (Youden's J = 0.69). Even in cases of endoscopy-negative reflux disease, pH monitoring was the most sensitive and specific test (93.3% and 90.4%, respectively; J = 0.83). OCT, endoscopy and histopathology also had good sensitivity (84.4%, 64.4%, 82.2%, respectively). A combination of OCT, endoscopy and histopathology achieved a sensitivity of 100%.

CONCLUSIONS

A combination of OCT, endoscopy and histology will identify all cases of GERD. As these investigations are easily available, they should form the diagnostic work-up in clinical situations. 24-h esophageal pH testing, despite being the gold standard, has no utility in routine clinical settings and hence its availability should be limited to tertiary care settings.