Symptoms in gastro-oesophageal reflux disease

Review article: the initial management of uninvestigated dyspepsia in younger patients-the value of symptom-guided strategies should be reconsidered

Several major management guidelines on dyspepsia (upper abdominal pain or discomfort) recommend an initial 'test-and-treat' policy (non-invasive Helicobacter pylori testing with eradication therapy if positive) in uninvestigated patients less than about 45 years old. However, the evidence that this is the optimal strategy is limited. Data from the few available randomized controlled trials provide evidence that this policy improves symptomatology more than a 'test-and-endoscope' approach (in which only H. pylori-positive patients undergo early endoscopy) in those with upper abdominal pain. The balance of cost-effectiveness data from clinical studies and decision analyses indicates that both 'test-and-treat' and empirical anti-secretory therapy approaches are more cost-effective than the 'test-and-endoscope' strategy. Therefore, given concerns about the safety of widespread H. pylori eradication, initial empirical anti-secretory therapy may be a cost-effective alternative to the 'test-and-treat' policy in some younger dyspeptic patients. The effectiveness of such an empirical approach might well be improved by symptom-guided therapy and there is growing evidence that the predominant dyspeptic symptom may provide this guide. The diagnostic, therapeutic and economic utility of this approach merits further clinical investigation.

Diagnosis and treatment of nonsteroidal anti-inflammatory drug-associated upper gastrointestinal toxicity

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in the United States to treat pain and reduce inflammation from chronic inflammatory disorders such as rheumatoid arthritis and osteoarthritis. Approximately 40% of older Americans take NSAIDs. Chronic NSAID use carries a risk of peptic ulcer and other gastrointestinal disturbances. This article reviews the diagnosis of medication-induced ulcers based on clinical presentation, laboratory tests, and endoscopic findings to assist the clinician in early diagnosis and appropriate therapy. Risk factors for NSAID-induced ulcers include old age, poor medical status, prior ulcer, alcoholism, smoking, high NSAID dosage, prolonged NSAID use, and concomitant use of other drugs that are gastric irritants, such as alendronate, a bone resorption inhibitor prescribed for osteoporosis. Appropriate treatment options for patients with medication-induced ulcers include dosage reduction, medication substitution, medication withdrawal, antiulcer therapy, and discontinuation of other gastrotoxic drugs.

Symptomatic benefit 1-3 years after H. pylori eradication in ulcer patients: impact of gastroesophageal reflux disease

OBJECTIVES

Eradication of Helicobacter pylori (H. pylori) infection markedly reduces the recurrence of duodenal and gastric ulcers. However, there is little information regarding its efficacy in resolving dyspeptic symptoms in ulcer patients. The primary aim of this study was to assess the effect of eradicating H. pylori infection on dyspeptic symptoms in ulcer patients. The secondary aim was to identify predictors of symptomatic response to H. pylori eradication.

METHODS

A total of 97 dyspeptic patients with active duodenal and/or gastric ulceration associated with H. pylori infection and unrelated to NSAID use had the severity and character of their dyspeptic symptoms measured before and again 1-3 yr after H. pylori eradication therapy.

RESULTS

Pretreatment, the median dyspepsia score was 12 (4-16). Posttreatment, 55% of those eradicated of H. pylori had resolution of dyspepsia (score <2) compared with 18% of those not eradicated of the infection (95% CI for difference, 11-62%). Of the ulcer patients 31% had symptoms and/or endoscopic evidence of coexisting gastroesophageal reflux disease (GERD) at initial presentation and this influenced the symptomatic response to eradication of H. pylori. Of the 22 patients with heartburn or acid reflux as the predominant presenting symptom, but no endoscopic esophagitis, only 27% experienced resolution of dyspepsia after H. pylori eradication, compared with 68% of the 59 without those as predominant symptoms (95% CI for difference, 18-63%). Only one of the five patients with coexisting endoscopic esophagitis at initial presentation experienced resolution of dyspepsia after H. pylori eradication. Symptomatic benefit was unrelated to time lapsed since the infection was eradicated. Only three of 50 subjects developed de novo GERD symptoms after eradication of H. pylori, whereas 21 of 36 subjects experienced resolution of GERD symptoms after eradication of the infection.

CONCLUSIONS

A substantial proportion of ulcer patients have symptoms and/or signs of coexisting GERD at initial presentation and this reduces the symptomatic benefit from H. pylori eradication. However, we have found no evidence that eradicating H. pylori induces de novo GERD symptoms in ulcer patients.

Recurrent symptoms and gastro-oesophageal reflux disease in patients with duodenal ulcer treated for Helicobacter pylori infection

BACKGROUND

Eradication of Helicobacter pylori has been shown to prevent relapse of endoscopically detected duodenal ulcers. There is controversy regarding symptom improvement after therapy. Some studies have suggested that a substantial number of patients remain symptomatic after eradication therapy. Other studies suggest that gastro-oesophageal reflux disease (GERD) may develop as a result of H. pylori eradication.

AIM

To determine the relationship between symptoms and H. pylori eradication and to determine whether H. pylori eradication results in symptoms or endoscopic findings of GERD.

METHODS

Two hundred and forty-two patients with endoscopically documented duodenal ulcer disease and evidence of H. pylori infection by rapid urease testing and histology were studied in four randomized, placebo-controlled, double-blind trials of H. pylori eradication therapy. All patients underwent symptom assessment and endoscopy with biopsy before therapy and 1 and 6 months after completing therapy. The rapid urease test and histology were used to determine H. pylori status. Interviewers were blinded to H. pylori status after eradication and were unaware of the endoscopic findings (interviews were performed prior to repeat endoscopy).

RESULTS

The presence of epigastric pain was significantly associated with persistent H. pylori infection 1 month after therapy (odds ratio 2.3, 95% CI: 1.02-5.2; P=0.041), as was nausea (OR 7.1, 95% CI: 0.93-55.6; P=0.029). The presence of epigastric pain was significantly associated with ulcer relapse at 6 months (OR 7.5, 95% CI: 3.6-15.7; P < 0.001) as was nausea (OR 5.1, 95% CI: 1.7-16.0; P=0.002). Heartburn was not associated with eradication of H. pylori or ulcer relapse. New onset reflux symptoms were reported by 17% (17 of 101 patients) at 6 months and were not significantly different in patients with (15%) and without (22%) persistent H. pylori infection (P=0.47). Erosive oesophagitis was present at endoscopy in one of the 17 cases that developed new heartburn.

CONCLUSIONS

One month after completion of therapy, the presence of epigastric pain or nausea is associated with persistent infection and these symptoms at 6 months are suggestive of duodenal ulcer relapse. The incidence of GERD is not increased in patients who have eradication of H. pylori.

Diagnostic evaluation in gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) describes the clinical manifestations of reflux of gastric contents and the associated symptoms and patterns of tissue injury. Although its exact prevalence is difficult to determine, there is no doubt the GERD is the most common esophageal disease and probably among the most prevalent conditions seen in the primary care setting. GERD has a wide clinical spectrum, making the diagnostic evaluation challenging and complicated at times. Confirmatory test are rarely needed in patients with typical symptoms of heartburn or regurgitation who have a good clinical response to GERD therapy. This article describes the diagnostic tests necessary for some cases of GERD.

Esophagopharyngeal acid regurgitation: dual pH monitoring criteria for its detection and insights into mechanisms

BACKGROUND & AIMS

A valid technique for the detection of esophagopharyngeal acid regurgitation would be valuable to evaluate suspected reflux-related otolaryngologic and respiratory disorders. The aim of this study was to derive pH criteria that optimally define esophagopharyngeal acid regurgitation and to examine patterns of regurgitation.

METHODS

In 19 healthy controls and 15 patients with suspected regurgitation, dual or quadruple pH sensors were used to monitor pharyngeal and esophageal pH. For each combination of the 2 variables, DeltapH and nadir pH, proportions of pH decreases that occurred during or independent of esophageal acidification were calculated to determine the likelihood that an individual pharyngeal pH decrease was a candidate regurgitation event or a definite artifact.

RESULTS

Overall, 92% of pharyngeal pH decreases of 1-2 pH units and 66% of pH decreases of this magnitude reaching a nadir pH of <4 were artifactual. Optimal criteria defining a pharyngeal acid regurgitation event were a pH decrease that occurred during esophageal acidification, had a DeltapH of >2 units, and reached a nadir of <4 units in less than 30 seconds. Regurgitation occurred more frequently in subjects in an upright (32 of 35) than in a supine (3 of 35 events; P </= 0.0001) position and was more frequently abrupt (synchronous with esophageal acidification) than delayed (P </= 0.05).

CONCLUSIONS

Accepted criteria for gastroesophageal reflux are not applicable to the detection of esophagopharyngeal acid regurgitation, and most regurgitation occurs abruptly and in upright position.

The usefulness of the likelihood ratio in the diagnosis of dyspepsia and gastroesophageal reflux disease

Clinicians are familiar with the concepts of sensitivity and specificity to describe the accuracy of a diagnostic test. These measures do not always express the probability that a patient has a disease with a given test result as this will vary with the prevalence of the disorder in the population. The likelihood ratio is a more clinically relevant method of reporting accuracy, and the probability of having a disease after a positive or negative test can be calculated. The likelihood ratio can be applied to the clinical problem of dyspepsia management. This suggests that Helicobacter pylori (H. pylori) test and treat will detect and treat most peptic ulcers with only 0.5% of H. pylori-negative patients having peptic ulcer disease. Serology is possibly acceptable in populations with an H. pylori prevalence of approximately 50%. The urea breath tests are more appropriate in more extreme prevalence ranges. Once the prevalence of H. pylori falls below 10%, then the urea breath test becomes inaccurate, and screening and treatment may be less appropriate. The absolute probability of having peptic ulcer disease in a largely H. pylori-negative population will be very small, however, and the appropriateness of performing any investigation in these circumstances is debatable. Finally, likelihood ratios indicate that the clinical diagnosis of gastroesophageal reflux disease (GERD) is not straightforward. Traditionally, it is believed that patients with dominant heartburn are likely to have GERD. Likelihood ratios predict, however, that patients with these symptoms have a little over 50% chance of having GERD as defined by 24-h esophageal pH studies.

Management of uninvestigated and functional dyspepsia: a Working Party report for the World Congresses of Gastroenterology 1998

BACKGROUND

The management of dyspepsia is controversial.

METHODS

An international Working Party was convened in 1998 to review management strategies for dyspepsia and functional dyspepsia, based on a review of the literature and best clinical practice.

RESULTS

Dyspepsia, defined as pain or discomfort centred in the upper abdomen, can be managed with reassurance and over-the-counter therapy if its duration is less than 4 weeks on initial presentation. For patients with chronic symptoms, clinical evaluation depends on alarm features including patient age. The age cut off selected should depend on the age specific incidence when gastric cancer begins to increase, but in Western nations 50 years is generally an acceptable age threshold. In younger patients without alarm features, Helicobacter pylori test and treatment is the approach recommended because of its value in eliminating the peptic ulcer disease diathesis. If, after eradication of H. pylori, symptoms either are not relieved or rapidly recur, then an empirical trial of therapy is recommended. Similarly, in H. pylori-negative patients without alarm features, an empirical trial (with antisecretory or prokinetic therapy depending on the predominant symptom) for up to 8 weeks is recommended. If drugs fail, endoscopy should be considered because of its reassurance value although the yield will be low. In older patients or those with alarm features, prompt endoscopy is recommended. If endoscopy is non-diagnostic, gastric biopsies are recommended to document H. pylori status unless already known. While treatment of H. pylori is unlikely to relieve the symptoms of functional dyspepsia, the long-term benefits probably outweigh the risks and treatment can be considered on a case-by-case basis. In H. pylori-negative patients with documented functional dyspepsia, antisecretory or prokinetic therapy, depending on the predominant symptom, is reasonable, assuming reassurance and explanation are insufficient, unless patients have already failed this approach. Other treatment options include antidepressants, antispasmodics, visceral analgesics such as serotonin type 3 receptor antagonists, and behavioural or psychotherapy although these are all of uncertain efficacy. Long-term drug treatment in functional dyspepsia should be avoided; intermittent short courses of treatment as needed is preferred.

CONCLUSION

The management of dyspepsia recommended is based on current best evidence but must be tailored to local factors such as practice setting, the background prevalence of H. pylori and structural disease, and costs.

Predominant symptoms identify different subgroups in functional dyspepsia

OBJECTIVE

Dyspepsia is a common syndrome that often defies diagnosis. Whether the unexplained (or "functional") dyspepsia represents a homogeneous syndrome or includes different subgroups with specific clinical features has not been clarified. The aim of this study was to investigate the relationship between symptom severity, demographic features, and gastric dysmotility in a large series of patients with functional dyspepsia.

METHODS

Severity of individual digestive symptoms, demographic features, and scintigraphic gastric emptying of solids were evaluated in 483 patients with chronic unexplained dyspepsia.

RESULTS

Two main subgroups were identified. The first was characterized by predominant epigastric pain, male gender (61%), and normal gastric emptying. The second subgroup was characterized by predominant nonpainful symptoms, female gender (60%), a high frequency of associated irritable bowel syndrome (30%), and delayed gastric emptying (42%). A third group included approximately one-third of patients who did not present with any predominant symptom, and was characterized by a high frequency of delayed gastric emptying (30%), overlapping irritable bowel syndrome (28%), and gastroesophageal reflux disease (41%).

CONCLUSIONS

Different subgroups exist among patients with functional dyspepsia seen in a referral center. They can be identified by the predominant symptom and are characterized by different demographic, clinical, and pathophysiological features.

Esophageal sensitivity and symptom perception in gastroesophageal reflux disease

Patients with gastroesophageal reflux disease (GERD) experience a wide spectrum of symptoms, varying both in quality and severity. This review summarizes clinical observations of esophageal sensitivity and symptom perception in GERD patients. The Bernstein test, although lacking standardization, remains a useful tool in determining esophageal sensitivity to acid stimuli. Ambulatory 24-hour pH monitoring with symptom event marking and subsequent symptom-reflux correlation between acid reflux events and esophageal symptomatology now provides an alternative method for establishing esophageal acid sensitivity. The intraesophageal balloon distention test (IEBD) was developed to assess esophageal sensitivity to mechanical stimuli. Variants of each of these tests have been applied to the evaluation of uncomplicated GERD patients and patients with esophagitis and Barrett's metaplasia, who generally demonstrate less esophageal sensitivity than the former group. Studies using these methods have demonstrated increased esophageal sensitivity in patients with esophageal chest pain and have also identified a subset of patients with esophageal symptoms yet normal esophageal acid exposure, a condition referred to as "hypersensitive esophagus." The Bernstein test, 24-hour pH monitoring with symptom assessment, and IEBD have each contributed to our understanding of esophageal pain syndromes; it is hoped that future work in this area will lead to improved and more specific therapy for these patients.

Risk factors associated with symptoms of gastroesophageal reflux

BACKGROUND

Although patients with gastroesophageal reflux are often instructed to change their lifestyle, population-based data on the risk factors for reflux in the United States are lacking.

METHODS

We performed a cross-sectional study in an age- and gender-stratified random sample of the population of Olmsted County, Minnesota. Residents aged 25 to 74 years were mailed a valid self-report questionnaire that measured reflux symptoms and potential risk factors. Logistic regression was used to estimate the odds ratios (OR) with 95% confidence intervals (CI) for reflux symptoms (heartburn or acid regurgitation) associated with potential risk factors.

RESULTS

Overall, 1,524 (72%) of 2,118 eligible subjects responded. A body mass index >30 kg/m2 (OR = 2.8; CI, 1.7 to 4.5), reporting an immediate family member with heartburn or disease of the esophagus or stomach (OR = 2.6; CI, 1.8 to 3.7), a past history of smoking (OR = 1.6; CI, 1.1 to 2.3), consuming more than seven drinks per week (OR = 1.9; Cl, 1.1 to 3.3), and a higher psychosomatic symptom checklist score (OR per 5 units = 1.4; CI, 1.3 to 1.6) were independently associated with frequent (at least weekly) reflux symptoms.

CONCLUSION

Obesity is a strong risk factor for gastroesophageal reflux, although the value of weight reduction remains to be proven. That family history was also a risk factor suggests that there may be a genetic component to the disorder.

Reflux esophagitis patients in Singapore have motor and acid exposure abnormalities similar to patients in the Western hemisphere

OBJECTIVE

Endoscopic esophagitis is less common in the East than in the West. The reason for this is unknown. This study examines prospectively the relationship between endoscopic esophagitis and lower esophageal sphincter pressure, distal esophageal contractility, esophageal peristaltic performance, esophageal acid exposure, gastric acid output, and Helicobacter pylori (H. pylori) status in a consecutive series of Asian patients.

METHODS

Esophageal manometry and ambulatory pH monitoring were carried out in 48 patients with endoscopic esophagitis and 208 patients with symptoms suspicious of gastroesophageal reflux disease but without esophagitis. Gastric acid output and H. pylori serology were determined in 22 of the esophagitis group and 36 of the nonesophagitis group.

RESULTS

Compared to the nonesophagitis patients, esophagitis patients had a higher prevalence of hypotensive lower esophageal sphincter (49% vs 24%, p < 0.001), impaired esophageal contractility (45% vs 22%, p < 0.005), poor peristaltic performance (23% vs 12%, p < 0.05), and pathological acid reflux (48% vs 27%, p < 0.005). However, there was no difference in the two groups with respect to gastric acid output and H. pylori positivity.

CONCLUSIONS

Lower esophageal sphincter competence, esophageal peristaltic contractility, and esophageal acid exposure were important factors in the pathogenesis of reflux esophagitis--results identical to Western studies. Gastric acid output per se and H. pylori infection might not be responsible for susceptibility to esophagitis.

Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma

BACKGROUND

The causes of adenocarcinomas of the esophagus and gastric cardia are poorly understood. We conducted an epidemiologic investigation of the possible association between gastroesophageal reflux and these tumors.

METHODS

We performed a nationwide, population-based, case-control study in Sweden. Case ascertainment was rapid, and all cases were classified uniformly. Information on the subjects' history of gastroesophageal reflux was collected in personal interviews. The odds ratios were calculated by logistic regression, with multivariate adjustment for potentially confounding variables.

RESULTS

Of the patients interviewed, the 189 with esophageal adenocarcinoma and the 262 with adenocarcinoma of the cardia constituted 85 percent of the 529 patients in Sweden who were eligible for the study during the period from 1995 through 1997. For comparison, we interviewed 820 control subjects from the general population and 167 patients with esophageal squamous-cell carcinoma. Among persons with recurrent symptoms of reflux, as compared with persons without such symptoms, the odds ratios were 7.7 (95 percent confidence interval, 5.3 to 11.4) for esophageal adenocarcinoma and 2.0 (95 percent confidence interval, 1.4 to 2.9) for adenocarcinoma of the cardia. The more frequent, more severe, and longer-lasting the symptoms of reflux, the greater the risk. Among persons with long-standing and severe symptoms of reflux, the odds ratios were 43.5 (95 percent confidence interval, 18.3 to 103.5) for esophageal adenocarcinoma and 4.4 (95 percent confidence interval, 1.7 to 11.0) for adenocarcinoma of the cardia. The risk of esophageal squamous-cell carcinoma was not associated with reflux (odds ratio, 1.1; 95 percent confidence interval, 0.7 to 1.9).

CONCLUSIONS

There is a strong and probably causal relation between gastroesophageal reflux and esophageal adenocarcinoma. The relation between reflux and adenocarcinoma of the gastric cardia is relatively weak.

The impact of open access 24-h pH-metry on the diagnosis and management of esophageal reflux disease

OBJECTIVE

This study investigates whether the results of 24-h pH-metry can be predicted from clinical information and whether they affect patient management.

METHODS

A total of 200 consecutive patients referred for 24-h pH-metry underwent structured interviews as well as endoscopic and manometric investigations. The most recent 53 patients were prospectively followed to determine the impact of pH monitoring on long term management.

RESULTS

Among a variety of risk factors, the presence of lower esophageal sphincter hypotension (OR = 3.3) and erosive esophagitis (OR = 2.3) were highly predictive of a pathological pH test result. If both abnormalities were present, the risk for an abnormal 24-h pH study increased by a factor of seven. Twenty-four-hour pH monitoring led to an immediate change in management in 42% of all investigated patients. However, such alterations in therapy were maintained for prolonged periods in less than half of them and only 6% of all patients associated changes in management with an improvement of symptoms.

CONCLUSIONS

The results of "open access" 24-h pH-metry are often predictable, and only a minority of patients benefit from this procedure in terms of a change in therapy and an improvement of symptoms.

Treatment of dyspepsia

Dyspepsia is a condition that is commonly seen by family physicians and gastroenterologists in clinical practice. However, there is little consensus on how dyspepsia should be treated. Some of the issues that require consideration are: Who seeks medical help? What types of physicians do patients choose to see? Do different types of physicians see the same types of patients? Do different types of physicians treat dyspepsia differently? What causes dyspepsia? In addition, the definition of dyspepsia and the symptoms associated with it vary from region to region, creating problems when discussing these issues on an international basis. In this review, the above issues are discussed, with particular attention to the impact of Helicobacter pylori infection and gastric dysmotility. Recommendations for treatment are made, and predictions of how dyspepsia will be treated in the future are given.

Barrett's esophagus: the long and the short of it

Specialized intestinal epithelium occurs more frequently at the gastroesophageal junction than previously anticipated. It can occur either within tongues of mucosa (short segment Barrett's) or just beneath a normal z-line (intestinal metaplasia at the gastroesophageal junction). Whether the etiopathogenesis and the natural history of these two conditions are the same is as yet unclear. The role of gastroesophageal reflux disease (GERD), Helicobacter pylori, and inflammation at the gastroesophageal junction in the pathogenesis of short segment Barrett's and intestinal metaplasia at the gastroesophageal junction needs to be carefully documented. Intestinal metaplasia at the gastroesophageal junction, short segment Barrett's, and Barrett's may represent a continuum of the same disease process. Recent evidence suggests, however, that short segment Barrett's shares similar characteristics with Barrett's but may be distinct from intestinal metaplasia at the gastroesophageal junction. It is conceivable that short segment Barrett's may remain steady or even regress if and when the noxious influence wanes but, with continuing stimulation, short segment Barrett's may lengthen further to become what we observe to be Barrett's. If correct, endogenous or exogenous factors that induce progression need to be identified. Acid and bile reflux and H. pylori are possible candidates acting either singly or synergistically. Finally, the true neoplastic potential of short segment Barrett's needs clarification.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease is the most common cause of indigestion in the community, and is usually chronic. Typical symptoms are recurrent retrosternal burning (heartburn) and regurgitation of sour or bitter fluid. In patients with typical symptoms and no alarm symptoms (pain on swallowing, dysphagia, weight loss or anaemia), treatment may be instituted without investigation. Patients with alarm symptoms and those who respond poorly or relapse after initial treatment require investigation (endoscopy and possibly pH monitoring). About 60% of reflux sufferers have no evidence of mucosal injury; their management aims to relieve symptoms. About 40% of reflux sufferers have oesophagitis and/or complications such as Barrett's oesophagus or oesophageal stricture at endoscopy. Drug therapy consists of H2-receptor antagonists, cisapride or proton-pump inhibitors.

Chronic recurrent abdominal pain

Chronic recurrent abdominal pain remains a common medical and surgical problem, frequently dismissed as functional. Instead, these patients should be approached systematically, based on the pattern of recurrent abdominal pain. It is vital to seek out the potential cause of this type of chronic pain because specific and often curative treatment is available.

Functional dyspepsia: New insights into the pathophysiology

The pathogenesis of functional dyspepsia remains poorly understood. There is increasing evidence pointing to a predominant role of gastroduodenal visceral hypersensitivity in the pathogenesis, where patients have abnormally reduced gastric and small intestinal sensory thresholds. Motor abnormalities observed in subgroups of patients include delayed gastric emptying, antral hypomotility, gastric dysrhythmias, abnormal gastrointestinal reflexes and small intestinal dysmotility, but these may be secondary pheno nena. The central nervous system modifies peripheral visceral afferent pathways and, hente, psychological factors may possibly alter symptom status. Other putative mechanisms include Helicobacter pylori gastritis and gastric acid hypersecretion or sensitivity, but the role of these remain controversial.

Patterns of symptoms in functional dyspepsia: role of Helicobacter pylori infection and delayed gastric emptying

OBJECTIVE

Functional dyspepsia (FD) is a syndrome in which several causes are probably involved. Our aim was to investigate the association between specific dyspeptic symptoms and Helicobacter pylori infection or delayed gastric emptying.

METHODS

Nine hundred thirty-five consecutive outpatients with unexplained dyspepsia were studied. After appropriate investigation, 304 patients were diagnosed as affected by chronic FD and were tested for H. pylori infection and gastric emptying of solids by means of 13C-urea and 13C-octanoic acid breath tests. Four dyspeptic symptoms (epigastric pain or burning, postprandial fullness, nausea, and vomiting) were scored as absent, mild, moderate, or severe (0-3) according to their influence on the patients' activities. Symptoms of irritable bowel syndrome and gastroesophageal reflux disease were also assessed. On the basis of symptom scores, three groups were identified: "prevalent pain" (10.5%), "prevalent discomfort" (32.6 %), and "unclassifiable" dyspepsia (56.9%).

RESULTS

Of the 304 patients with FD, 208 (68.4 %) were H. pylori-positive on urea breath test. Gastric emptying was delayed in 99 subjects (32.6%). Patients with "prevalent pain" were infected significantly more often (81.2% vs 59.6%; p = 0.026) and less frequently had delayed gastric emptying (6.2% vs 40.4%; p = 0.0001) than those with "prevalent discomfort." H. pylori infection was independently associated with age > or =40 yr and epigastric pain or burning > or =2 (odds ratio [OR] and 95% confidence interval [CI] 4.09 [2.39-7.00] and 1.70 [1.04-2.77], respectively). Delayed gastric emptying was independently associated with a cumulative score > or =6 for postprandial fullness, nausea, and vomiting (OR [95% CI]: 3.13 [1.06-9.18]). H. pylori status had no influence on gastric emptying. Logistic regression analysis showed that delayed gastric emptying, female sex, and concomitant symptoms of inflammatory bowel syndrome were independently associated with a cumulative score > or =6 for postprandial fullness, nausea, and vomiting (p = 0.0281, p = 0.0387, and p = 0.0316, respectively). Moreover, concomitant symptoms of gastroesophageal reflux disease, female sex, and H. pylori infection were independently associated with epigastric pain or burning > or =2 (p = 0.002, p = 0.0001, and p = 0.0875, respectively).

CONCLUSIONS

Two subsets of FD patients have been identified on the basis of symptoms. One subgroup is mainly characterized by "prevalent pain," H. pylori infection, and normal gastric emptying; the other one demonstrates "prevalent discomfort" and delayed gastric emptying. These findings shed some light on possible etiopathogenetic mechanisms of FD.

Symptomatic gastro-oesophageal reflux in pregnancy: a prospective study among Singaporean women

The present study was undertaken to estimate the prevalence and time course of reflux-type symptoms in Singaporean women and to determine if these symptoms were associated with nausea and vomiting of pregnancy. Consecutive pregnant women in the first trimester of pregnancy were recruited during attendance at an antenatal clinic in a Singapore teaching hospital. Each was interviewed, using a reliable questionnaire detailing demographic characteristics and symptoms, at four time points during the first, second and third trimesters of pregnancy and postpartum period. A total of 35 of 47 women originally enrolled (response rate 74%) completed the study. Heartburn alone, acid regurgitation alone and both heartburn and acid regurgitation were reported by 5.7, 17.1 and 17.1% of the subjects, respectively. Subjects who had these symptoms were more likely to suffer daily nausea and/or vomiting (78.6%) than those who did not (33.3%, P<0.05). In the majority of subjects, heartburn and/or acid regurgitation began in the first trimester (78.6%) and disappeared during the second trimester (71.4%). Nausea alone and in combination with vomiting similarly came on in the first trimester (100%) and subsided by the second trimester (85.7%) in the majority of the subjects studied. The reported prevalence of heartburn and/or acid regurgitation among Western pregnant women were 48-96% and 62%, respectively. Our data, therefore, showed that reflux-type symptoms were less common in Singaporean pregnant women. Reflux-type symptoms were related to nausea and vomiting, both in frequency and time pattern of onset and disappearance of symptoms. The association suggested either a common mechanism or a cause and effect relationship.

Relevance of gastrointestinal motor disturbances in functional dyspepsia

Gastrointestinal motor abnormalities are frequent findings in patients with functional dyspepsia. However, these abnormalities are rather non-specific and seem to be restricted to a proportion of patients. Furthermore, they are not necessarily time-linked to symptom perception. The relationship of digestive motor derangements and symptoms in functional dyspepsia remains, therefore, unsettled. A variety of methodological and conceptual shortcomings characterize many of the studies investigating the relationship between gastrointestinal motility disorders and dyspeptic symptoms, and this obviously contributes to a higher level of uncertainty in the field. Recent reports suggest that gastrointestinal dysmotility is associated with perception of some dyspeptic symptoms, at least in a subset of patients. Well-conducted studies using appropriate methodology are needed to verify whether gastrointestinal motor disorders play a causal role in functional dyspepsia and whether this is of clinical relevance.

How should new-onset dyspepsia be managed in general and specialist practice?

Managing patients with new-onset dyspeptic symptoms represents a real challenge in clinical decision-making. The major controversy has been over the optimal management strategy of patients with new-onset dyspeptic symptoms who do not present with alarm symptoms. Since unaided clinical diagnosis is unreliable, proposed management strategies have included empirical treatment algorithms, computer-assisted predictive score models and Helicobacter pylori-based strategies such as test-and-scope or test-and-treat algorithms. Endoscopy remains the diagnostic 'gold standard', and the management should ideally be based on endoscopic diagnosis. Because of economic constraints and increasing waiting lists, this is not possible. When precise and comprehensive guidelines have been formulated, future patients will probably be managed in primary care by a Helicobacter test-and-treat policy, leaving only empirical treatment failures for specialist evaluation.

On-demand treatment of gastro-oesophageal reflux symptoms: a comparison of ranitidine 75 mg with cimetidine 200 mg or placebo

AIM

To compare the effects of ranitidine 75 mg with those of either cimetidine 200 mg or placebo given on demand for relief of typical symptoms of gastro-oesophageal reflux disease during a 15-day period.

METHODS

A total of 1336 patients (aged > or = 18 years) with heartburn episodes were recruited and randomly assigned to a ranitidine 75 mg, cimetidine 200 mg or placebo group. Depending on the occurrence or persistence of heartburn, treatment was administered as required up to three times daily, with at least 2 h between drug doses. Antacids were allowed as rescue medication if symptoms persisted for at least 2 h after the third medication on any given day. The primary end-point was defined as the proportion of patients with relief of at least 75% of heartburn episodes during the study period (i.e. relief occurring within 2 h after drug ingestion and lasting for at least 5 h).

RESULTS

Analysis was performed in an intention-to-treat population comprising 504 subjects in the ranitidine group, 515 in the cimetidine group and 270 in the placebo group. Primary end-point success rates were 41, 38 and 28%, respectively, for the three groups (P < 0.001 for ranitidine vs. placebo, P = 0.274 for ranitidine vs. cimetidine). Ranitidine 75 mg was significantly more effective than placebo in providing overall heartburn relief (P < 0.001). The differences between the ranitidine and cimetidine groups were not significant, except for a greater reduction in heartburn frequency in the ranitidine group at the end of the study period (P < 0.05). Drug dose was lower and less rescue medication was used in the ranitidine group than the placebo group. The three treatment groups did not differ in terms of tolerability.

CONCLUSION

On-demand ranitidine 75 mg or cimetidine 200 mg are safe and effective treatment for reflux-related symptoms.

Outcomes of atypical symptoms attributed to gastroesophageal reflux treated by laparoscopic fundoplication

BACKGROUND

The introduction of laparoscopic fundoplication (LF) has lowered the threshold for operation in patients with symptoms attributed to gastroesophageal reflux. We sought to determine whether the outcomes in patients referred for atypical symptoms (pulmonary, pharyngolaryngeal, and pain syndromes) were as good as those referred for correction of heartburn and regurgitation (typical symptoms).

METHODS

Thirty-five of 150 consecutive patients undergoing LF with a minimum of 12 months of follow-up were referred primarily for correction of atypical symptoms. A standard preoperative evaluation included endoscopy, manometry, upper gastrointestinal contrast radiography, and 24-hour pH probe testing (33 of 35 patients with atypical symptoms). Patients completed a symptom questionnaire administered by a study nurse before the operation and 3 and 12 months after the operation. Symptoms were scored from 0 to 10.

RESULTS

Heartburn was relieved by LF in 93% of patients, whereas only 56% of patients had relief of atypical symptoms. Furthermore, the degree of improvement in typical symptoms was greater than that seen for atypical symptoms as measured by the 0 to 10-symptom rating score (improvement in typical symptoms = 6.2 vs improvement in atypical symptoms = 4.4 [p = 0.01]). The response rate for laryngeal, pulmonary, and epigastric/chest pain symptoms was 78%, 58%, and 48%, respectively. Analysis of factors associated with relief of atypical symptoms revealed that response to a preoperative trial of omeprazole or H2-blockers was significantly associated with successful surgical outcome (p = 0.03). Six of seven patients with laryngeal symptoms who had acid reflux above the cricopharyngeal level shown by dual-probe pH testing had relief of the symptoms after LF. Manometric findings (amplitude of esophageal body contractions, propagation of contractions, and lower esophageal sphincter resting pressure) neither predicted nor correlated with relief of atypical symptoms after the operation.

CONCLUSIONS

Relief of atypical symptoms attributed to gastroesophageal reflux by LF is less satisfactory and more difficult to predict than relief of heartburn and regurgitation. The only useful preoperative predictors of relief of atypical symptoms in this study were the response to pharmacologic acid suppression and dual-probe pH testing (only in patients with laryngeal symptoms).

The seroprevalence of cagA-positive Helicobacter pylori strains in the spectrum of gastroesophageal reflux disease

BACKGROUND & AIMS

The role of Helicobacter pylori in the pathogenesis of gastroesophageal reflux disease (GERD) is unknown. We determined the prevalence of cagA-positive (cagA+) H. pylori strains in patients with GERD or its complications compared with controls of similar age.

METHODS

A total of 153 consecutive patients with GERD, Barrett's esophagus, and Barrett's esophagus complicated by dysplasia or adenocarcinoma were compared with 57 controls who underwent upper endoscopy for reasons other than GERD. H. pylori infection and CagA antibody status were determined by histology and enzyme-linked immunosorbent assay.

RESULTS

H. pylori prevalence was lower (34%) in patients with GERD and its sequelae than in the control group (45.6%)(P = 0.15). Regardless of the group, increasing age was associated with higher prevalence of H. pylori (P = 0.003). When compared with controls (42.3%), the prevalence of cagA+ H. pylori strains decreased (P = 0.008) in patients with more severe complications of GERD (GERD, 36.7% [nonerosive GERD, 41.2%; erosive GERD, 30.8%]; Barrett's esophagus, 13.3%; and Barrett's with adenocarcinoma/dysplasia, 0%).

CONCLUSIONS

Prevalence of H. pylori in patients with GERD and its sequelae was lower but not significantly different than that of a control group. However, patients carrying cagA+ strains of H. pylori may be protected against the complications of GERD, especially Barrett's esophagus and its associated dysplasia and adenocarcinoma.

Functional (non-ulcer) dyspepsia: unexplained but not unmanageable

Functional dyspepsia--defined as chronic or recurrent pain or discomfort centred in the upper abdomen, with no clinical or endoscopic evidence of known organic disease--is very common and causes considerable morbidity and loss of productivity. A first priority in management is reassuring patients that they do not have a serious disorder. Few drugs have established benefit and the choice depends on which symptoms predominate--prokinetic drugs may be most beneficial in those in whom discomfort (rather than pain), bloating or nausea is the most bothersome complaint and antisecretory drugs in those with predominant epigastric pain.

Inflammation and intestinal metaplasia of the gastric cardia: the role of gastroesophageal reflux and H. pylori infection

BACKGROUND & AIMS

Whether inflammation of the cardia indicates gastroesophageal reflux disease (GERD) and/or is a manifestation of pangastritis caused by Helicobacter pylori infection is unknown. The aim of this study was to evaluate the relationship between cardia inflammation, H. pylori infection, and cardia intestinal metaplasia in patients with and without GERD.

METHODS

Patients with GERD were compared with controls undergoing endoscopy for a variety of other conditions. Endoscopic biopsy specimens from the distal esophagus and cardia, fundus, and antrum were evaluated for inflammation, H. pylori infection, and intestinal metaplasia.

RESULTS

Neither the prevalence of H. pylori infection (controls, 48%; GERD, 41%) nor cardia inflammation (controls, 41%; GERD, 40%) differed between groups. All 11 controls and 22 of 23 patients with GERD (96%) and cardia inflammation had H. pylori infection. Esophagitis was more common among GERD patients (33%) than controls (7%; P = 0.01). Cardia intestinal metaplasia was more common among controls (22%) than GERD patients (3%; P = 0.01); all had cardia inflammation, 7 had H. pylori infection, and 6 had metaplasia elsewhere in the stomach.

CONCLUSIONS

The prevalence of cardia inflammation is similar in patients with and without GERD and is associated with H. pylori infection (P < 0.001). Cardia intestinal metaplasia is associated with H. pylori-related cardia inflammation (P = 0.01) and intestinal metaplasia elsewhere in the stomach, indicating that it is distinct from Barrett's esophagus.

Management guidelines for uninvestigated and functional dyspepsia in the Asia-Pacific region: First Asian Pacific Working Party on Functional Dyspepsia

Dyspepsia is most optimally defined as pain or discomfort centred in the upper abdomen. The symptom complex may be caused by peptic ulcer disease, gastro-oesophageal reflux, or gastric cancer but is most often due to functional (or non-ulcer) dyspepsia. While upper endoscopy is the method of choice to determine the underlying cause of dyspepsia, it is expensive. A more pragmatic approach is needed in the Asia Pacific region where health services are limited. A detailed treatment algorithm is given for managing patients presenting with new-onset dyspepsia and documented functional dyspepsia after endoscopy, and evidence to support this approach is reviewed. Prompt endoscopy is recommended for patients with alarm features. In patients without alarm features, treatment for 2-4 weeks with an empirical anti-secretory or prokinetic agent, followed by investigation using non-invasive Helicobacter pylori testing and treatment for patients who do not respond or relapse, is recommended. Trials of management strategies are now needed to establish the efficacy and cost-effectiveness of the approaches recommended.

Comparison of the effect of the antacid Rennie versus low-dose H2-receptor antagonists (ranitidine, famotidine) on intragastric acidity

BACKGROUND

Symptoms of functional dyspepsia are common and patients often self-medicate with antacids, or with low-dose H2-antagonists which are available as over-the-counter medications. To date, there has been limited information available comparing the effects on intragastric acidity of these two types of over-the-counter medication. Therefore we studied the effect of the antacid Rennie and two H2-antagonists on the intragastric pH of fasting volunteers.

METHODS

Sixteen healthy, fasting volunteers were randomized into a double-blind, placebo-controlled, four-way crossover study comparing Rennie (calcium-magnesium carbonate) 1360 mg, ranitidine 75 mg, famotidine 10 mg and placebo. Their effect on gastric pH was monitored by a 4-h gastric pH-metry. The primary efficacy parameter was the time lag before an intragastric pH > 3.0 was reached after drug administration.

RESULTS

The median time lag before pH > 3.0 was reached after drug administration was 5.8 min for Rennie, 64.9 min for ranitidine, 70.1 min for famotidine and 240.0 min for placebo. The percentage of time with values of pH > 3.0 was 10.4% for Rennie, 61.4% for ranitidine, 56.6% for famotidine and 1.4% for placebo.

CONCLUSION

The onset of action in fasting volunteers was significantly faster with the antacid than with the two H2-antagonists. The duration of action was significantly longer with an H2-antagonist than with the antacid. This suggests that the two products should be used for different indications: antacids are superior for rapid pain relief, whereas H2-antagonists might be better for symptom prophylaxis--for example for nocturnal dyspepsia.

Dyspepsia: current understanding and management

Dyspepsia, defined as "pain or discomfort centered in the upper abdomen" is reported by one in four adults in Western societies. The most important causes are non-ulcer (functional) dyspepsia, peptic ulcer, gastroesophageal reflux, and, rarely, gastric cancer. Persons with heartburn alone are not considered to have dyspepsia. The division of dyspepsia into symptom-based subgroups (ulcer-like, dysmotility-like, reflux-like, and unspecified dyspepsia) has proven to be of doubtful value for the clinician, as it has a low predictive value for identifying the causes of dyspepsia. Upper endoscopy remains the "gold standard" test; ultrasound and blood tests have a low yield. The role of Helicobacter pylori in peptic ulcer disease is well known, but the clinical role of the infection in non-ulcer dyspepsia remains very controversial. In uninvestigated dyspeptic patients who are H. pylori infected based on a non-invasive test, empiric anti-H. pylori therapy is a reasonable and probably cost-effective option. In documented non-ulcer dyspepsia, prokinetics are superior to placebo while antisecretory therapy is of less certain efficacy.

Placebo-controlled trial of cisapride and nizatidine in unselected patients with functional dyspepsia

OBJECTIVE

Patients in most trials of pharmacotherapy for nonorganic dyspepsia have been groups referred selectively for endoscopy, which could have led to a selection bias of nonresponders, explaining the negative outcome of most controlled treatment trials in nonorganic dyspepsia. The aim of this study was to evaluate the effects of cisapride and nizatidine in patients with nonorganic dyspepsia who were recruited directly from primary care settings, and to evaluate the therapeutic implications of dyspepsia subgrouping.

METHODS

A consecutive series of patients who consulted their general practitioner with dyspepsia were invited to an interview and endoscopy. Before endoscopy, symptoms were classified as reflux-like, dysmotility-like, ulcer-like, or unclassifiable. A total of 330 patients with either minor or no abnormalities at endoscopy were randomized to double blind treatment with cisapride 10 mg t.i.d., nizatidine 300 mg at night, or placebo for 2 wk.

RESULTS

A symptomatic response was found in 62% of patients on cisapride (therapeutic gain cisapride vs placebo: 0.1% [95% confidence interval -14% to 14%]) and in 54% of patients on nizatidine (therapeutic gain nizatidine vs placebo: -8% [95% confidence interval -22% to 7%]). Response to treatment was independent of symptom classification.

CONCLUSIONS

The effects of a 2-wk course of cisapride or nizatidine in unselected patients with dyspepsia recruited from primary care were not superior to those of placebo. Symptom subgrouping was not predictive of response to therapy.

Gastroesophageal reflux disease during pregnancy

Pregnant patients with symptomatic GERD should be managed aggressively with lifestyle modification and dietary changes. Antacids and antacids/alginic acids combination or sucralfate should be considered first-line medical therapy. If symptoms are not adequately relieved or complications develop, treatment with cimetidine or ranitidine should be considered; these H2 receptor antagonists are preferred during pregnancy. Nizatidine cannot be recommended. Proton-pump inhibitors should be used with caution because little human experience is available. Despite this caveat, both proton-pump inhibitors are likely to be safe during pregnancy.

Trends in the management of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease is common, with up to 10% of the general population experiencing heartburn on a daily basis. It is a chronic condition and follow-up studies indicate the presence of symptoms at least 20 years after initial diagnosis. In addition to lifestyle modifications, management usually involves the use of an acid suppressant from the H2-receptor antagonist or proton pump inhibitor groups or a prokinetic agent at some stage. In terms of initial symptom resolution and mucosal healing the proton pump inhibitors are consistently superior to the other available agents. However, while it is possible to keep the majority of patients in remission while taking medications, almost all patients have a recurrence of symptoms within six months of stopping medications. The introduction of laparoscopic fundoplication has produced promising initial results but the long-term benefits of this procedure remain to be established. The role of Helicobacter pylori eradication in the management of gastro-oesophageal reflux disease needs further evaluation.

Dyspepsia: how should we measure it?

This study developed and validated a multidimensional measure of dyspepsia. A questionnaire was administered to 126 patients with dyspepsia who presented for care at a VA outpatient clinic and a family physician's private office. Dyspepsia-specific health was measured by self-report using: (1) an existing dyspepsia scale that produces an aggregate score by summing ratings across pain and non-pain symptoms; (2) adaptations of two scales originally designed to measure back pain; and (3) a new scale measuring satisfaction with dyspepsia-related health. Generic health was measured using the SF-36. Results from factor analysis revealed four dimensions of dyspepsia-related health: pain intensity, pain disability, non-pain symptoms, and satisfaction with dyspepsia-related health. After refinements, scales representing the four dimensions conformed to psychometric standards for reliability, and convergent and discriminant validity. The importance of measuring dyspepsia using a multidimensional approach was confirmed by demonstrating that classification of dyspepsia severity depended on the dimension that was assessed. We conclude that dyspepsia is best measured using a multidimensional approach.

Body mass index and risk of adenocarcinomas of the esophagus and gastric cardia

BACKGROUND

Incidence rates have risen rapidly for esophageal adenocarcinoma and moderately for gastric cardia adenocarcinoma, while rates have remained stable for esophageal squamous cell carcinoma and have declined steadily for noncardia gastric adenocarcinoma. We examined anthropometric risk factors in a population-based case-control study of esophageal and gastric cancers in Connecticut, New Jersey, and western Washington.

METHODS

Healthy control subjects (n = 695) and case patients with esophageal squamous cell carcinoma or noncardia gastric adenocarcinoma (n = 589) were frequency-matched to case patients with adenocarcinomas of esophagus or gastric cardia (n = 554) by 5-year age groups, sex, and race (New Jersey only). Classification of cases by tumor site of origin and histology was determined by review of pathology materials and hospital records. Data were collected using in-person structured interviews. Associations with obesity, measured by body mass index (BMI), were estimated by odds ratios (ORs). All ORs were adjusted for geographic location, age, sex, race, cigarette smoking, and proxy response status.

RESULTS

The ORs for esophageal adenocarcinoma rose with increasing adult BMI. The magnitude of association with BMI was greater among the younger age groups and among nonsmokers. The ORs for gastric cardia adenocarcinoma rose moderately with increasing BMI. Adult BMI was not associated with risk of esophageal squamous cell carcinoma or noncardia gastric adenocarcinoma.

CONCLUSIONS

Increasing prevalence of obesity in the United States population may have contributed to the upward trends in esophageal and gastric cardia adenocarcinomas.

Management of dyspepsia in general practice. A critical assessment

The International Gastro Primary Care Group (IGPCG) Upper Gastrointestinal Disease Management Plan is mainly characterised by the proposal that management of patients with upper gastrointestinal syndromes be based on the predominant symptom, rather than on symptom clusters. Although no study has directly tested this hypothesis in general practice, some data indirectly support the proposal. Classification based on the relevance of specific symptoms could identify distinct subgroups of patients with functional dyspepsia with at least partially different features. Data obtained from the literature are discussed and evaluated in relation to the suggested algorithm. Overall, this management plan for patients with dyspepsia seems to be both safe and effective. However, there is a need for prospective studies evaluating its actual validity.

Heartburn without oesophagitis: efficacy of omeprazole therapy and features determining therapeutic response

BACKGROUND

Data are limited on the value of effective antisecretory therapy in the relief of heartburn in patients without oesophagitis.

METHODS

Patients with heartburn, without endoscopic signs of oesophagitis, were randomized to double-blind treatment with omeprazole, 20 or 10 mg once daily, or placebo, for 4 weeks (n = 509). Pre-treatment oesophageal acid exposure was assessed using 24-h intra-oesophageal pH monitoring. Heartburn was assessed at 2 and 4 weeks.

RESULTS

At 4 weeks the proportion of patients with complete absence of heartburn was 46% (95% confidence interval, 39-53%) with 20 mg omeprazole, 31% (25-38%) with 10 mg omeprazole, and 13% (7-20%) with placebo. Satisfaction with therapy was reported by 66%, 57%, and 31% of the patients, respectively.

CONCLUSION

Omeprazole, 20 and 10 mg once daily, provides rapid relief of heartburn in patients without endoscopic oesophagitis.

Effect of smoking on the results of esophageal pH measurement in clinical routine

Because data on the effects of smoking on gastroesophageal reflux are controversial, we evaluated the effect of smoking on the results of esophageal 24-hour pH-metry in clinical routine. Participants were 280 consecutive patients with symptoms suggestive of reflux disease, 78 smokers, and 202 nonsmokers. Of the smokers, 45 actually smoked during the pH measurement and 33 abstained from smoking. The frequency of reflux episodes, the fraction of time pH was < 4, and the percentage of abnormal 24-hour pH-metry results were compared among actual smokers, abstaining smokers, and nonsmokers. In actual smokers, the effect of smoking on gastroesophageal reflux was further analyzed by comparing the reflux frequency and the fraction of time that pH was < 4 for a 10-minute period before, during, and after smoking. We found no difference in reflux frequency and fraction of time that pH was < 4 among actual smokers, abstaining smokers, and nonsmokers, regardless of a normal or an abnormal pH-metry result. The percentage of patients with a pH-metry result indicating disease was similar in the three groups, at 53%, 52%, and 50%, respectively. Gastroesophageal reflux was not increased during smoking a cigarette or in the postsmoking period compared with the presmoking period. Neither being a smoker nor actually smoking a cigarette had a negative influence on gastroesophageal reflux. Thus smoking or abstaining from smoking does not modify the results of pH-metry in clinical routine.

Review article: current practice and future perspectives in the management of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is primarily due to incompetence of the lower oesophageal sphincter (LOS) and crural diaphragm, with transient LOS relaxation frequently accounting for daytime reflux. In the absence of drugs that adequately correct the motility defects of GERD, treatment is directed towards decreasing gastric acidity. Oesophageal healing is related to control of 24-h intragastric acidity, the degree of acid suppression and duration of treatment. H2-receptor antagonists are generally less effective in GERD than in peptic ulcer disease. While providing symptomatic relief in non-erosive GERD, they are often ineffective in healing erosive oesophagitis. Proton pump inhibitors provide more rapid and complete healing and symptom resolution. They are superior to H2-receptor antagonists in the long-term management of erosive oesophagitis and in reducing recurrence of oesophageal stricture following mechanical dilatation. In Barrett's oesophagus, high-dose proton pump inhibitors in combination with laser/photodynamic ablation therapy can produce metaplastic regression, although this does not preclude future emergence of adenocarcinoma. Surgical morbidity and mortality rates in GERD generally remain higher than those associated with long-term pharmacotherapy. However, direct comparisons between laparascopic anti-reflux surgery and proton pump inhibitor maintenance therapy remain to be performed. Although there is no evidence that H. pylori infection worsens the severity of oesophagitis or that H. pylori is carcinogenic in the metaplastic oesophageal mucosa. It has been suggested that H. pylori-positive patients requiring long-term proton pump inhibitor therapy receive bacterial eradication therapy to reduce the risk of developing atrophic gastritis.

Ranitidine effectively relieves symptoms in a subset of patients with functional dyspepsia

BACKGROUND

Acid secretion inhibitors are of dubious value to most patients with functional dyspepsia but might be effective in a subset. The aims of the trial were to compare the effect of ranitidine with that of placebo in selected subsets of patients.

METHODS

Two hundred and twenty-six patients with functional dyspepsia were included in a double-blind multi-crossover (MCO) trial. After 6 weeks an effect score (Xs) with a range of 0-5 was calculated. They were then stratified in accordance with their score and randomized to 4 weeks' double-blind treatment with ranitidine or placebo. Overall symptoms were scored on a 100-mm visual analogue scale, and the change in score (measured in millimetres) was the primary effect measure.

RESULTS

Two hundred and six patients completed the study. The effect of ranitidine and placebo in the 'responders' (76 patients with Xs of 4-5 after the MCO period) was 28 mm and 5 mm, respectively (P < 0.001), and in all patients 19 mm and 12 mm, respectively (P < 0.03). No effect was seen in 'nonresponders' (130 patients with Xs of 0-3 after the MCO period). The clinical improvement, as judged by the patients given ranitidine during the last 4-week period was statistically significantly different in favour of responders compared with nonresponders. We were unable to characterize the responders on the basis of demographics, symptoms, and signs.

CONCLUSIONS

Ranitidine has a good and clinically significant effect in a subset of patients with functional dyspepsia.

Treating the symptoms of gastro-oesophageal reflux disease: a double-blind comparison of omeprazole and cisapride

BACKGROUND

Few studies have specifically addressed the management of the symptoms of gastro-oesophageal reflux disease, and there are no comparative data in this respect for acid pump inhibitors and prokinetic agents.

METHODS

Following endoscopy 424 patients presenting with heartburn as the predominant symptom of gastro-oesophageal reflux disease were randomized to treatment with omeprazole 20 or 10 mg once daily, or cisapride 10 mg four times daily, in a double-blind, double-dummy, parallel group, multicentre study. Symptoms and quality of life were assessed at 4 weeks. Patients still experiencing heartburn continued therapy for a further 4 weeks and the assessments were repeated.

RESULTS

At 4 weeks, heartburn was resolved in 65% (95% CI: 57-73%), 56% (48-64%) and 41% (32%-49%) of patients treated, respectively, with omeprazole 20 mg and 10 mg once daily, and cisapride. Both omeprazole doses were significantly more effective than cisapride (P < 0.01). The same order of efficacy was observed regardless of the presence of erosive oesophagitis. Regurgitation and epigastric pain also improved to a greater degree with omeprazole than with cisapride. Quality of life was improved in all treatment groups, and the improvement in the reflux dimension of the Gastrointestinal Symptom Rating Scale (GSRS) score was significantly different between groups (P = 0.002).

CONCLUSIONS

Omeprazole 20 or 10 mg once daily is significantly more effective than cisapride in the resolution of heartburn, regardless of the presence of erosive oesophagitis, and this is accompanied by an improvement in patient quality of life.

Prognostic factors influencing relapse of oesophagitis during maintenance therapy with antisecretory drugs: a meta-analysis of long-term omeprazole trials

BACKGROUND

This meta-analysis investigated factors that may affect the risk of relapse of oesophagitis, and evaluated the predictive value of symptoms for the presence of relapse during long-term treatment.

METHODS

Individual data from 1154 patients included in five independently conducted, randomized, long-term clinical trials of the efficacy of different dosage regimens of omeprazole, standard ranitidine treatment and placebo for the prevention of relapse of oesophagitis were pooled for this meta-analysis. The therapeutic regimens studied were omeprazole 20 mg o.m. (OME20) in 366 patients, omeprazole 10 mg o.m. (OME10) in 225 patients, omeprazole 20 mg weekends (OMEW) in 235 patients, ranitidine 150 mg b.d. (RAN) in 179 patients, or placebo (PLA) in 149 patients.

RESULTS

OME20 maintained 82.4% (95% CI: 78.2-86.6%) of patients in endoscopic remission over the 6-month period compared to 71.9% (95% CI: 65.5-78.3%) for OME10, 52.3% (95% CI: 44.4-60.1%) for RAN, 42.7% (95% CI: 35.8-49.5%) for OMEW, and 10.6% (95% CI: 5.0-16.3%) for PLA. A Cox's regression analysis of time to recurrence of oesophagitis showed that four factors were associated with a higher relapse rate during placebo and active maintenance therapy: (a) pre-treatment severity of oesophagitis (P < 0.0001), (b) young age (P = 0.01), (c) non-smoking (P = 0.02) and (d) moderate/severe regurgitation before entry into the trials (P = 0.03). Asymptomatic relapse of oesophagitis was uncommon, being found in only 8.6% of the patients.

CONCLUSIONS

Maintenance treatment with omeprazole 10 and 20 mg daily is superior to all other regimens tested, and is only marginally influenced by the pretreatment severity of oesophagitis. Age contributes to the factors that influence the outcome during long-term treatment with omeprazole. Symptom relief is highly predictive for the maintenance of healing.

Long-term comparison of antireflux surgery versus conservative therapy for reflux esophagitis

OBJECTIVE

The purpose of the study was to evaluate the long-term symptomatic and endoscopic outcome in gastroesophageal reflux disease with erosive esophagitis, comparing conservative with operative management.

METHODS

The study comprised 105 of 120 patients consecutively referred for severe reflux symptoms to the gastroenterologic outpatient department of a teaching hospital, where erosive esophagitis was confirmed endoscopically. If conservative management (modified lifestyle and medication) failed to relieve symptoms and heal the esophagitis, antireflux surgery (Nissen fundoplication) was undertaken. Follow-up (median, 10.9 years) evaluation of all patients included comprehensive, standardized interviews; self-scoring of symptoms at the time of referral and currently; and observations at endoscopy.

RESULTS

Nissen fundoplication was performed on 37 of the 105 patients. At follow-up of these 37 patients, (31) 84% had no or only occasional mild heartburn, (33) 89% were free from erosive esophagitis, and (2) 5% were taking H2 antagonists or omeprazole. The corresponding figures in the 68 patients with only conservative treatment were (36) 53%, (31) 45%, and (14) 21%. The mean change in symptom score between referral time and follow-up was 5.7 in the surgically treated group and 1.7 in the nonsurgically treated group. Fifteen new cases of Barrett's metaplasia were found at follow-up.

CONCLUSIONS

In gastroesophageal reflux disease with erosive esophagitis, surgical treatment gave results subjectively and objectively superior to those from conservative management.

Esophageal manifestations of rheumatic disorders

This study was performed to review information on functional and anatomic esophageal manifestations in patients with rheumatic disorders and to outline their pathogenesis, diagnosis, and treatment in light of the current medical, endoscopic, and surgical advances. A MEDLINE search of English-language articles published between 1985 and 1995, reviews of the bibliographies of textbooks, and a manual search of the reference lists of relevant articles formed the data sources, all combined with our own clinical experience. Primary research and review articles addressing the pathogenesis, diagnosis, treatment, prognosis, and complications of esophageal disease occurring in a rheumatic context were selected, with emphasis on recently developed medical, endoscopic, and surgical methods for diagnosis and management. Study design and quality were assessed, with particular attention paid to methods and aims. Relevant data on frequency, clinical presentation, and relationship to underlying rheumatic disorder, prognosis, and clinical management were analyzed. Esophageal manifestations are common in patients with rheumatic diseases and range in nature and severity from functional myopathic or neuropathic esophageal dysmotility to extrinsic lumenal compression and esophageal mucosal damage from gastroesophageal acid reflux or opportunistic infection. The primary symptoms of heartburn, dysphagia, odynophagia, chest pain, and bleeding may be directly related to the underlying rheumatic disease or may be the unwanted effects of therapy with nonsteroidal antiinflammatory drugs, immunosuppressants, or disease-modifying agents. Easily over-looked in the context of a multisystemic disease, these esophageal symptoms may be amenable to simple treatments, but frequently require a thorough assessment by modern, sophisticated diagnostic tools. In many instances, functional and structural involvement of the esophagus in patients with rheumatic disorders requires a high index of suspicion for an early diagnosis, correct assessment, intensive surveillance, and aggressive therapy to avoid end-organ damage and decline in quality of life. Significant recent advances in the understanding of esophageal pathophysiology, the development of diagnostic techniques, progress in diagnostic and therapeutic endoscopy, and minimally invasive surgery allow early detection and effective long-term therapy for esophageal dysfunction associated with rheumatic diseases.

Diagnostic value of histology in non-erosive gastro-oesophageal reflux disease

BACKGROUND

In the absence of oesophageal erosions longterm pH monitoring is the present gold standard for diagnosing gastro-oesophageal reflux disease (GORD). This method, however, is invasive, time consuming, expensive, and not generally available.

AIMS

As histological changes have been described in GORD, this study looked at the possibility of whether the diagnosis of non-erosive reflux disease could be made by histological examination routinely during endoscopy.

SUBJECTS

A total of 24 prospectively selected patients with symptoms suggestive of GORD and seven healthy volunteers.

METHODS

Oesophageal erosions and other peptic lesions were excluded by oesophago-gastroduodenoscopy. Oesophageal pinch biopsy specimens were taken 2 cm and 5 cm above the oesophagogastric junction and evaluated blindly for the histological parameters cellular infiltration, basal zone hyperplasia, and papillary length. Twenty four hour pH monitoring was used as gold standard for the definition of reflux disease. It was abnormal in 13 patients (reflux patients) and normal in 11 patients (symptomatic controls) and in seven healthy volunteers.

RESULTS

Sparse infiltration of the epithelium with lymphocytes in at least one biopsy specimen was found in all patients and volunteers, with neutrophils in three reflux patients, and with eosinophils in two reflux patients and in two healthy volunteers. The basal zone thickness was increased in three reflux patients, in one symptomatic control, and in one healthy volunteer. The papillary length was greater than two thirds of total epithelium in six of 13 reflux patients in contrast with none in 11 symptomatic controls (p < 0.05) and to one healthy volunteer. The sensitivity of the parameter papillary length hence was only 46%.

CONCLUSIONS

Although gastro-oesophageal reflux produces slight histological changes apart from oesophageal erosions in a few subjects, none of the established histological parameters can fulfil the for the diagnosis of GORD in patients without visible oesophageal erosions.