Epidemiology and natural history of gastro-oesophageal reflux disease

Long-term gastrointestinal morbidity in patients with congenital diaphragmatic defects

Recent reports indicate a significant incidence of gastroesophageal reflux (GER) and other nonpulmonary problems after the repair of congenital diaphragmatic defects. Reports of follow-up through adulthood are few and based on a small number of patients. From 1948 to 1982, 107 of 164 patients (65%) treated at the authors' institution survived after repair of congenital diaphragmatic hernia or eventration. Sixty of the 107 survivors (56%) (mean age, 29.6 years; SD, 9.0 years) were interviewed and examined clinically. Forty-one of the sixty (68%) underwent upper gastrointestinal endoscopy. Early postoperative GER was recorded for 11 of the 60 patients (18%). Two of them underwent fundoplication because of an esophageal stricture. At the time of the follow-up study, 38 of the 60 (63%) reported symptoms suggestive of GER. Endoscopic or histological GER (esophagitis, Barrett's esophagus) was present in 22 of 41 patients (54%). No significant correlation between the initial severity of the diaphragmatic defect or neonatal postoperative problems and the late GER could be verified. Intestinal obstruction requiring hospital admission occurred in 12 of the 60 patients (20%), eight of whom had surgical treatment between 1 month and 20 years after repair of the diaphragmatic defect. GER and intestinal obstruction are common among patients who have undergone repair of a congenital diaphragmatic defect. Investigations for GER should be performed routinely during the follow-up of these patients.

Natural history of reflux oesophagitis: a 10 year follow up of its effect on patient symptomatology and quality of life

BACKGROUND

Although oesophagitis is the most common diagnosis made at upper gastrointestinal endoscopy, data on the longterm outcome of affected patients are sparse.

AIMS

This study assessed the level of reflux symptoms, quality of life, drug consumption, and complications in patients at least 10 years after diagnosis of oesophagitis at one centre.

PATIENTS

One hundred and fifty two patients with typical reflux symptoms and a first time diagnosis by endoscopy of grade I-III oesophagitis between 1981 and 1984, were followed up using a postal questionnaire and telephone interview.

RESULTS

Eighteen of 152 patients had died, 33 failed to respond, and 101 replied (mean follow up 11 years, range 121-160 months). Over 70% of patients still had heartburn at least daily (32%) or weekly (19%) or required daily acid suppression treatment (20%). Two patients (2%) had developed oesophageal strictures and one had Barrett's oesophagus. Two of eight quality of life scores (physical function and social function) measured by the Short Form-36 were significantly lower than Northern Ireland population scores.

CONCLUSION

Nearly three quarters of patients previously diagnosed as having oesophagitis still had significant morbidity related to gastro-oesophageal reflux disease more than 10 years after diagnosis. Some quality of life scores were significantly lower than those of the general population.

Psychosocial factors and their role in symptomatic gastroesophageal reflux disease and functional dyspepsia

Patients with symptoms of GERD and dyspepsia are among the most common consulters in general practice and are different from their counterparts in the community who choose not to consult although they suffer from similar symptoms. They represent a heterogeneous group with considerable symptom overlap. They have a relatively poor quality of life and endoscopic findings can only explain symptoms in about half of these patients. Thus psychosocial factors which could contribute to their morbidity should be explored. While some studies have methodological shortcomings, main findings are that key psychological factors are anxiety, tension, neuroticism, somatization, fears of malignancy, negative assessment of health, depression, a poor social network and less effective coping strategies. Physical illness is likely to bring on psychological distress due to discomfort or threat of ill health. Cognizance of psychosocial factors will facilitate an understanding of the underlying problems and will improve diagnosis and selection of optimal treatment.

Acid suppression by famotidine 20 mg twice daily or 40 mg twice daily in preventing relapse of endoscopic recurrence of erosive esophagitis

Control of esophageal acid exposure is important in treating patients with gastroesophageal reflux disease (GERD). After complete healing of esophagitis, most patients will relapse within 6 months if left untreated. This multicenter, randomized, double-masked, placebo-controlled trial, conducted in the United States, examined whether two famotidine dosing regimens are effective in extending the time in remission for patients with moderate-to-severe erosive esophagitis. Of 172 patients enrolled, 31 received placebo, 69 received famotidine 20 mg twice daily (BID) , and 72 received famotidine 40 mg BID. Endoscopy was scheduled at baseline and at months 3 and 6. Patients assessed global heartburn and symptom relief at months 3 and 6 relative to the start of the study. Life table (Kaplan-Meier) relapse rates at 6 months were 22% (P < 0.001 vs placebo) for famotidine 20 mg BID, 11% (P < 0.001 vs placebo) for famotidine 40 mg BID, and 62% for placebo. Compared with placebo, patients in the famotidine groups were significantly less likely to note global symptomatic deterioration, as measured by the distribution of global assessment responses. The incidence of clinical and laboratory adverse experiences was similar among treatment groups. For maintenance treatment of GERD, famotidine 20 mg BID and 40 mg BID are more effective than placebo in extending the time in remission.

The natural history of globus pharyngeus

While globus pharyngeus is a common disorder, accounting for 3% to 4% of new otolaryngology outpatient referrals, few long-term follow-up studies have been conducted on patients with this condition. The authors of this study followed 74 patients with a diagnosis of globus pharyngeus for an average of 7 years, 7 months (range: 7 years to 8 years, 10 months). During the follow-up period, 55% of patients were asymptomatic and 45% of patients had persistent symptoms. An in-depth analysis of features at clinical presentation failed to reveal any reliable prognostic indicators. A number of patients developed other conditions during the follow-up period, but no patient developed upper aerodigestive tract malignancy. This study represents the longest follow-up of globus patients to date and, to the authors' knowledge, is the first to address the issue of malignancy in globus.

Heartburn in patients with achalasia

Heartburn, the main symptom of gastrooesophageal reflux disease (GORD), might be expected to occur infrequently in achalasia, a disorder characterised by a hypertensive lower oesophageal sphincter (LOS) that fails to relax. Nevertheless, it is often described by patients with achalasia. The medical records of 32 patients with untreated achalasia who complained of heartburn, and of 35 similar patients who denied the symptom, were reviewed to explore the implications of heartburn in this condition. Data on endoscopic and manometric findings, and on the onset and duration of oesophageal symptoms were collected. Three patterns of heartburn were observed: (1) in 8 patients (25%) the onset of heartburn followed the onset of dysphagia, (2) in 15 patients (47%) heartburn preceded the onset of dysphagia and persisted as dysphagia progressed, and (3) in 9 patients (28%), heartburn preceded the onset of dysphagia and stopped as dysphagia progressed. The mean (SD) basal LOS pressure in the patients with heartburn (38 (16) mm Hg) was significantly lower than that in patients without the symptom (52 (26) mm Hg); the lowest LOS pressure (29 (11) mm Hg) was observed in the subset of patients whose heartburn preceded the onset of dysphagia and then stopped. It is concluded that patients who have achalasia with heartburn have lower basal LOS pressures than patients who have achalasia without this symptom. In some patients with achalasia, the appearance of dysphagia is heralded by the disappearance of longstanding heartburn. For these patients, it is speculated that achalasia develops in the setting of underlying GORD.

Nonsteroidal antiinflammatory drugs and dyspepsia in the elderly

Upper gastrointestinal tract symptoms are common in the elderly and, despite a paucity of data, nonsteroidal antiinflammatory drugs (NSAIDs) are believed to be important risk factors. We aimed to evaluate the association of NSAIDs with dyspepsia and heartburn in a population-based study. An age- and gender-stratified random sample of Olmsted County, Minnesota, Caucasian residents aged 65 years and older was mailed a valid self-report questionnaire; 74% responded (N = 1375). Age- and gender-adjusted (to 1980 US Caucasian population) prevalence rates for NSAID use, dyspepsia (defined as pain located in the upper abdomen or nausea), and heartburn (defined as retrosternal burning pain) were calculated. Logistic regression analysis was used to estimate the association of dyspepsia and heartburn with potential risk factors adjusting for age and gender. The age- and gender-adjusted annual prevalences (per 100) of aspirin and nonaspirin NSAID use were 60.0 (95% CI 57.2, 62.7) and 26.1 (95% CI 23.6, 28.7), respectively. The annual prevalences of dyspepsia and heartburn were 15.0 (95% CI 12.9, 17.0) and 12.9 (95% CI 10.9, 14.8), respectively. Aspirin was associated with dyspepsia and/or heartburn (OR = 1.6, 95% CI 1.2, 2.2) as were nonaspirin NSAIDs (OR = 1.8, 95% CI 1.3, 2.6), but smoking and alcohol were not significant risk factors. Aspirin and nonaspirin NSAIDs are associated with almost a twofold risk of upper gastrointestinal tract symptoms in elderly community subjects.

Gastroesophageal reflux laryngitis resistant to omeprazole therapy

Gastroesophageal reflux disease (GERD) is known to cause a variety of symptoms that lead a patient to seek otolaryngologic care. New advances in the treatment of GERD have enabled otolaryngologists to eliminate most of the signs and symptoms caused by acid reflux. Omeprazole, the most recent pharmacologic advancement, has been reported to be universally successful in controlling acid release from the stomach of patients with GERD. This report describes a series of patients with GERD for whom high-dose omeprazole therapy was not successful in completely reducing gastric acid levels of GERD symptomatology.

Upper gastrointestinal symptoms in the third trimester of the normal pregnancy

OBJECTIVES

To report on the prevalence of well-being, heartburn, nausea, and vomiting related to gestational week, parity, and age in the third trimester of the normal pregnancy.

STUDY DESIGN

Self-administered questionnaire filled in daily by 180 women from 31st gestational week to delivery.

RESULTS

The study was completed by 120 women. The weekly prevalence of well-being decreased from 50% at the 31st gestational week to 24% at the 42nd gestational week (P = 0.00001). The weekly prevalence of heart-burn (approximately 60%), nausea (approximately 16%) and vomiting (approximately 7%) was nearly constant throughout the study period. Well-being was inversely related to parity, (P = 0.006), heartburn positively related to age (P = 0.016), and nausea and vomiting inversely related to age (P = 0.003 and P = 0.044).

CONCLUSION

Discomforts are customary in the third trimester of normal pregnancy. However, heartburn and especially nausea and vomiting appeared occasionally and were not present for longer periods. The findings that heartburn, nausea and vomiting had different relations to age may suggest different etiologies.

A contemporaneous comparison of hospital charges for laparoscopic and open Nissen fundoplication

Surgical treatment of gastroesophageal reflux disease is increasingly recognized as a cost-effective alternative to long-term medical therapy. This fact, coupled with the advent of laparoscopic fundoplication as a safe and efficacious alternative to open surgery, underscores the importance of determining the costs associated with laparoscopic treatment. Hospital costs and charges of patients undergoing open (N = 9) and laparoscopic (N = 11) fundoplication were retrospectively analyzed. Both procedures were performed during the same time period (6/91-6/93), at the same hospital, and by the same surgical team. Operative time, and hospital stay, were recorded in addition to total, operating room, anesthesia, sterile supplies, and hospital room charges. Figures are reported as mean values +/- standard error of the mean. The Wilcoxon signed rank test was used for comparison of groups. Operative time (221 +/- 18 vs 165 +/- 12 min, P = 0.033) was longer in the laparoscopic group, while hospital stay (5.8 +/- 02 vs 8.8 +/- 04 days, P < 0.001) was significantly shorter. Total hospital costs were similar for both groups of patients ($14,615 +/- 863 vs $15,891 +/- 921, P = 0.247). Overall hospital charges were nearly identical ($26,634 +/- 1376 vs $27,189 +/- 1753, P = 0.803). A detailed analysis demonstrated cost shifting, with laparoscopic fundoplication resulting in significantly higher charges associated with events in the operating room. Operating room ($6,064 +/- 252 vs $4,283 +/- 380, P = 0.001), sterile supplies ($6,214 +/- 508 vs $5,403 +/- 390), and anesthesia charges ($1,593 +/- 76 vs $1,122 +/- 95, P < 0.001) were all greater in the laparoscopic group.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality of life in upper gastrointestinal disorders

BACKGROUND

There is increased interest in the concept 'quality of life'. Available instruments are defined and discussed, with special emphasis on reliability and validity. Research on quality of life in patients with upper gastrointestinal disorders is reviewed, and our own results presented.

METHODS

The Psychosocial Adjustment to Illness Scale was used to compare 100 patients with functional dyspepsia and 100 patients with duodenal ulcer in a cross-sectional study, and to monitor the quality of life of 74 duodenal ulcer patients in a longitudinal phase.

RESULTS

The quality of life of patients with functional dyspepsia was more negatively affected than that of patients with duodenal ulcer. After half of the patients had received short-term cognitive psychotherapy and all had received prophylactic H2-blocker treatment after ulcer relapse, quality of life improved in both the treatment group and the control group. Seventy-four patients with recurrent duodenal ulcers reported higher satisfaction with the health care system, improved sexual relationship, and less psychological distress one year after cure of the ulcer disease by the eradication of Helicobacter pylori compared to before.

CONCLUSIONS

Reliable and valid instruments are available to measure quality of life, and will probably gain increased importance in future medical research. In patients with recurrent duodenal ulcer disease, quality of life improves with the eradication of Helicobacter pylori.

The prevalence of gastro-oesophageal reflux disease

Estimation of the prevalence of gastro-oesophageal reflux disease (GORD) is difficult because of the lack of an accepted definition and a gold standard. Based on the occurrence of reflux symptoms and on the use of antacids in the population, the prevalence of GORD may be estimated at about 10%. The 1-year incidence of endoscopic oesophagitis has been shown to be 1.2%. In an endoscopic population study, oesophagitis was found in about 10% of the adult population. However, the criteria used for the diagnosis were disputable. The true prevalence of oesophagitis is probably about 5%, higher in males than in females. The severity of GORD tends to increase with age, with regard to both symptoms and oesophagitis.

Symptoms and disease severity in gastro-oesophageal reflux disease

The definition of criteria relevant to disease severity assessments should be considered in parallel with the long-term aims of treatment in gastro-oesophageal reflux disease (GORD). There is no doubt that the resolution of symptoms is the major management aim. Heartburn and regurgitation are specific for GORD when they are the predominant symptoms, but prove to be insensitive when the diagnosis of GORD is based on the measurement of oesophageal acid exposure. A relationship between the frequency of heartburn and the degree of acid exposure has been reported in GORD patients both with and without oesophagitis. GORD may also, however, cause a wide spectrum of atypical symptoms (e.g. non-cardiac chest pain or respiratory symptoms). To the extent that a causal relationship between these symptoms and reflux episodes has been established, evaluation of symptom severity should also encompass these atypical presentations. The role of symptoms in the prediction of relapse of oesophagitis is controversial, but in several studies the presence of residual symptoms of GORD at the time of healing has indicated a greater probability of relapse. Endoscopy is a useful technique for the evaluation of disease severity. Indeed, even typical symptoms may not predict the presence and severity of oesophagitis in an individual patient. Despite the fact that the interpretation of therapeutic trials is often impeded by differences in the grading systems used, healing rates of oesophageal lesions are inversely proportional to the initial severity of oesophagitis when drugs such as H2-receptor antagonists are used. Differences are less evident with highly effective drugs such as omeprazole.(ABSTRACT TRUNCATED AT 250 WORDS)

Roles of gastric acid and pH in the pathogenesis of gastro-oesophageal reflux disease

In recent years, gastric acid has been shown to play a major role in the pathogenesis of reflux oesophagitis, though it remains possible that defective oesophageal mucosal resistance may also play some part. Abnormally prolonged and/or frequent exposure of the distal oesophagus to a pH of less than 4 is the major defect; this results from frequent gastro-oesophageal reflux, the impact of which is magnified in about half of the patients by slow oesophageal acid clearance. Abnormal oesophageal acid exposure increases in severity from endoscopy-negative reflux disease through worsening grades of reflux oesophagitis. Pepsin activity has been shown to be a major determinant of the aggressiveness of refluxate and, in turn, the full activity of gastric pepsin requires a pH below 3. Thus, gastric acid probably exerts a predominantly indirect effect on the pathogenesis of reflux oesophagitis by determining peptic activity. Although bile and other components of small intestinal juice can injure the oesophageal mucosa, these factors are apparently important only in the exceptional patient with very severe reflux disease. Gastric acid hypersecretion is probably also unimportant in the majority of patients. Peptic activity, and hence the aggressiveness of refluxate, are reduced markedly between pH 3 and 4. Achievement of this threshold, pH 3-4, in the daytime is important as, contrary to traditional beliefs, daytime reflux, triggered by food intake, is of the greatest importance in most patients.(ABSTRACT TRUNCATED AT 250 WORDS)