Evaluation of elevation of the head of the bed, bethanechol, and antacid form tablets on gastroesophageal reflux

Wake up to gastro-oesophageal reflux disease: The interplay between arousal and night-time reflux

This review examines the temporal association between nocturnal gastro-oesophageal reflux and sleep-arousal cycles. Most nocturnal gastro-oesophageal reflux events occur during the awake cycle, and arousals precede most nocturnal gastro-oesophageal reflux events, indicating that arousal from sleep predisposes to nocturnal gastro-oesophageal reflux. This sheds light on the complex relationship between nocturnal gastro-oesophageal reflux and sleep, and has implications for managing nocturnal gastro-oesophageal reflux symptoms. The appearance of symptoms and the pathophysiology of nocturnal gastro-oesophageal reflux are influenced by sleep hygiene, sleep disturbances and the misalignment of circadian rhythms. Nocturnal gastro-oesophageal reflux and its related sleep disorders are prevalent and negatively impact the quality of life. There is conflicting evidence on whether nocturnal gastro-oesophageal reflux and sleep disturbances are causally linked, and whether sleep disturbances drive nocturnal gastro-oesophageal reflux. Poor sleep quality increases oesophageal hypersensitivity and overall acid exposure. The nocturnal gastro-oesophageal reflux is linked to the more severe forms of gastro-oesophageal reflux disease, especially with atypical/extra-oesophageal manifestations and complications of mucosal damage such as oesophagitis and stricture, Barret's oesophagus, and oesophageal adenocarcinoma. This review highlights the role of sleep problems in presenting nocturnal gastro-oesophageal reflux, and the potential benefits of treating sleep disturbances in enhancing patient care and quality of life.

The Medical Management of Gastroesophageal Reflux Disease: A Narrative Review

OBJECTIVE

The medical management of gastroesophageal reflux disease (GERD) continues to evolve. Our aim was to systematically assess the literature to provide an updated review of the evidence on lifestyle modifications and pharmacological therapy for the management of GERD.

BACKGROUND

The cornerstones of GERD medical management consist of lifestyle modifications and pharmacologic agents. Most recently, evidence has emerged linking anti-reflux pharmacologic therapy to adverse events, such as kidney injury, metabolic bone disease, myocardial infarction, and even dementia, among others.

METHODS

A systematic search of the databases of PubMed/MEDLINE, Embase, and Cochrane Library was performed for articles on the medical management of GERD between inception and March 1, 2021.

CONCLUSION

Although pharmacological therapy has been associated with potential adverse events, further research is needed to determine if this association exists. For this reason, lifestyle modifications should be considered first-line, while pharmacologic therapy can be considered in patients in whom lifestyle modifications have proven to be ineffective in controlling their symptoms or cannot institute them. Naturally, extra-esophageal causes for GERD-like symptoms must be considered on suspected high-risk patients and excluded before considering treatment for GERD.

Nocturnal Gastroesophageal Reflux Disease (GERD) and Sleep: An Important Relationship That Is Commonly Overlooked

Gastroesophageal reflux disease (GERD) is a prevalent, chronic medical condition that affects 13% of the adult population globally at least once a week. Sleep disturbances are frequently encountered in up to 25% of the GERD patients, likely due to nocturnal gastroesophageal reflux (GER). With advance in diagnostic techniques allowing for an improved understanding of involved physiological mechanisms of nocturnal reflux, there is growing evidence of a bidirectional relationship between GERD and sleep disturbances. Furthermore, nocturnal GER is associated with more complicated GERD. Obstructive sleep apnea (OSA) and GERD also have been linked, but to what degree remains controversial. Treatment of nocturnal GER has been shown to improve both subjective and objective sleep measures. The therapeutic approach includes lifestyle modifications and medication individualization and optimization with proton-pump inhibitors serving as the mainstay of treatment. Antireflux surgery and newer endoscopic procedures have been demonstrated to control nocturnal GER.

Association between body positioning and gastroesophageal reflux in paediatric age

AIM

Postural measures are frequently recommended for gastroesophageal reflux (GER) symptoms, despite limited evidence. This was the first study to assess the impact of upright and recumbent body positions on GER episodes in children and adolescents, not just infants.

METHODS

We retrospectively assessed the pH-impedance parameters of paediatric patients referred for possible GER-related symptoms to two hospitals in Naples and Rome, Italy, from September 2016 to September 2018. Data were separately obtained for the time that the patients spent in upright and recumbent positions.

RESULTS

Data from 187 patients under the age of 18 were collected, at a mean age of just over seven years. We found that the acid exposure time was stable irrespective of changes in body position (P > .05). The mean number of reflux episodes per hour was 2.99 during the upright position and 1.21 during the recumbent position (P < .05), and the mean oesophageal acid clearance time was 44.4 and 93.4 seconds, respectively (P < .05).

CONCLUSION

Most paediatric patients experienced reflux in the upright rather than recumbent position, probably as a result of frequent transient lower oesophageal sphincter relaxations while they were awake. In particular, our findings provide new insights into postural measures for reflux in children and adolescents.

Impact of head of bed elevation in symptoms of patients with gastroesophageal reflux disease: a randomized single-blind study (IBELGA)

BACKGROUND

The clinical impact of head-of-bed elevation in patients with gastro-oesophageal reflux disease is unclear, because of inconsistency and methodological limitations of previous studies.

PATIENTS AND METHODS

A randomised single-blind single-centre controlled clinical trial with a 2x2 cross-over design, in 39 pharmacologically treated patients with gastro-oesophageal reflux disease. Active intervention was to use a head-of-bed-elevation of 20cm for 6 weeks and then to sleep without inclination for 6 additional weeks, with a wash-out of 2 weeks between periods. The primary outcome was a change ≥10% in RDQ score and secondary outcomes were a change ≥10% in SF-36 score, patient preference and frequency of adverse events.

RESULTS

27 (69.2%) patients who used the intervention reached the primary outcome vs 13 (33.3%) patients in the control group (RR: 2.08; 95 CI%: 1.19 - 3.61). No effect was found in SF-36 score (RR: 1.11; 95% CI: 0.47 - 2.60). Preference favouring the intervention was 77.1% and adverse event proportion was 54.0%.

CONCLUSION

Head-of-bed elevation improved reflux symptoms but there was no effect on quality of life. The finding of a non-optimal risk-benefit ratio warrants additional studies before this intervention can be recommended (IBELGA, ClinicalTrials.gov identifier NCT02706938).

Comparison of a Dimethicone/Antacid (Asilone Gel) with an Alginate/Antacid (Gaviscon Liquid) in the Management of Reflux Oesophagitis

Fifty-three patients with symptomatic reflux oesophagitis were entered into a single centre randomized study comparing the effects of a dimethicone/antacid (Asilone Gel) and an alginate/antacid (Gaviscon liquid) on symptoms and endoscopic changes over an 8-week period. Both treatments significantly improved heartburn, acid regurgitation and flatulence. Dimethicone/antacid but not alginate/antacid, produced a significant improvement in oesophagitis, oesophageal ulceration and histological grade of inflammation over the 8-week treatment period so that 14 patients treated with dimethicone/antacid and 10 with alginate/antacid had normal endoscopic oesophageal appearances at the end of the study. The difference in improvement between the two patient groups did not reach significance however, except for dimethicone/antacid improving histological changes (P less than 0.05). These findings suggest that dimethicone/antacid and alginate/antacid are equally effective in treating symptomatic reflux oesophagitis although dimethicone/antacid may have an advantage in improving oesophageal histological appearances.

Treatment of laryngopharyngeal reflux using a sleep positioning device: A prospective cohort study

OBJECTIVE

Laryngopharyngeal reflux (LPR) symptoms are often resistant to management and cause significant quality of life impairment to patients with this disease. This study assesses the utility of a sleep-positioning device (SPD) in treating LPR.

DESIGN

Single center prospective cohort study.

SETTING

Tertiary medical center PARTICIPANTS: 27 adult patients with diagnosed laryngopharyngeal reflux.

INTERVENTION

An SPD consisting of a two-component wedge-shaped base pillow and a lateral positioning body pillow (Medcline, Amenity Health Inc.) was given to patients with a diagnosis of LPR. Subjects slept using the device for at least 6h per night for 28 consecutive nights.

MAIN OUTCOMES

Primary outcomes were Nocturnal Gastroesophageal Reflux Symptom Severity and Impact Questionnaire (N-GSSIQ) and the Reflux Symptoms Index (RSI) survey instrument. Each was collected at baseline, after 14, and after 28days of SPD use.

RESULTS

27 patients (19 female and 8 male; age 57.1±12.8, BMI 29.0±8.1) were recruited. At baseline mean N-GSSIQ was 50.1±22.4 and mean RSI of 29.6±7.7. Repeated measure analysis showed that subjects' total N-GSSIQ scores decreased by an average of 19.1 (p=0.0004) points by two weeks and 26.5 points by 4weeks (p<0.0001). RSI decreased an average of 5.3 points by 2weeks (p=0.0425) and an average of 14.0 points by 4weeks (p<0.0001).

CONCLUSIONS

In patients with LPR, SPD treatment significantly improves self-reported symptoms of nocturnal reflux as well as symptoms specific to LPR. These results support the therapeutic efficacy of a SPD for patients with LPR.

Use of a positional therapy device significantly improves nocturnal gastroesophageal reflux symptoms

The aim of this study was to measure the efficacy of a positional therapy device (PTD) at reducing proton pump inhibitor (PPI) refractory nocturnal GERD symptoms. Among patients with GERD, nocturnal symptoms are very common. A recent study demonstrated a decrease in nocturnal acid exposure and reflux episodes in healthy volunteers who slept using a PTD. This is a single-center prospective trial involving patients on anti-secretory medications with continued nocturnal heartburn and regurgitation. Patients completed the Nocturnal GERD Symptom Severity and Impact Questionnaire (N-GSSIQ) and GERD health-related quality of life questionnaire (GERD-HRQL) at enrollment. Patients were instructed to sleep on the PTD for at least 6 hours a night during the two week study period; subjects continued their baseline anti-secretory medication dose. After 2 weeks, the questionnaires were repeated. A total of 27 patients (16 females and 11 males; age 57.8 ± 15.1) were recruited. After 2 weeks of PTD use, N-GSSIQ scores significantly improved from baseline, with a mean total score improvement of 39.5 (mean 57.7 [pre] vs. 18.2 [post], P < 0.001). Significant improvement from baseline was also observed for the GERD-HRQL questionnaire (29.8 vs. 16.7, P < 0.001). No adverse events were reported. At 3 months after the trial period, 91% of the subjects continued to use the PTD on a nightly basis. Use of the PTD significantly decreased nocturnal GERD symptoms and improved GERD-HRQL. The PTD was well tolerated during the study period and for 3 months after enrollment.

Proxy study on minimizing risk of sacral pressure ulcers while complying with ventilator-associated pneumonia risk reduction guidelines

Bed positioning poses a subtle, yet important, tradeoff in the competing needs of hospitalized patients, particularly those susceptible to lower respiratory tract infections and/or pressure ulcers. Although it is widely held that a minimum 30° incline is necessary to mitigate risk of ventilator-acquired pneumonia, it is unclear what effect semirecumbent positioning has on the risk of pressure ulcerations. The authors test several hypotheses with the objective of elucidating the relationship between bed incline, posture, and incline, pursuant to a more evidence-based recommendation for practice in clinical care. To this end, interfacial pressures from 40 healthy subjects were analyzed following observation in both supine and sidelying positions, at shallow (30°) and moderate (45°) bed-angle incline. Summarily, the authors report that supine postures reduce pressure signatures associated with pressure ulceration versus sidelying position: 15% increase area of contact (P = 1.3×10), and 17% decrease in ratio of peak to average pressure (P = 3.1×10). Within supine posture, the authors found significant increases in 4 measures of local pressure, including average pressure (10.4% decrease, P = .005) and coefficient of pressure variation (22.1%, P = 2.2×10) at moderate incline. The authors conclude that supine bed positionings at moderate incline appear to reduce predictors of pressure ulceration.

A Novel Sleep Positioning Device Reduces Gastroesophageal Reflux: A Randomized Controlled Trial

GOAL

We hypothesized that sleeping left-side down with the head/torso elevated reduces recumbent gastroesophageal reflux (GER).

BACKGROUND

Previous studies show that sleeping with head of bed elevated or on wedge reduces GER and lying left-side down reduces GER versus right-side down and supine. No prior studies have evaluated the potential compounding effects of lying in an inclined position combined with lateral positioning on GER.

STUDY

We evaluated a sleep-positioning device (SPD) consisting of an inclined base and body pillow that maintains lateral position while elevating the head/torso. This was a single institution, randomized controlled trial involving 20 healthy volunteers receiving 4 six-hour impedance-pH tests. After placement of reflux probe, subjects returned home, ate standardized meal, and lay down in randomly assigned positions: SPD right-side down (SPD-R), SPD left-side down (SPD-L), standard wedge any position (W), or flat any position (F). A wireless accelerometer documented position during each study. Number of reflux episodes (RE) and esophageal acid exposure (EAE) were calculated over 6 hours.

RESULTS

Significantly less EAE occurred during sleeping SPD-L versus sleeping W, SPD-R, and F. The most EAE occurred during sleeping SPD-R despite use of the positioning device. RE were significantly less SPD-L than SPD-R. Patients sleeping SPD-L and SPD-R spent the majority of first 2 hours and greater than half of 6 hours in assigned position. Patients sleeping W and F averaged more time supine than right or left.

CONCLUSIONS

The sleep positioning device maintains recumbent position effectively. Lying left-side down, it reduces recumbent esophageal acid exposure.

Hiatal hernia predisposes to nocturnal gastro-oesophageal reflux

BACKGROUND

Nocturnal reflux has been associated with severe complications of gastro-oesophageal reflux disease and a poorer quality of life. Hiatal hernia predisposes to increased oesophageal acid exposure, but the effect on night reflux symptoms has never been investigated. The aim of the study was to investigate if hiatal hernia is associated with more frequent and severe night reflux symptoms.

METHODS

A total of 215 consecutive patients (110 male, mean age 52.6 ± 14.7 years) answered a detailed questionnaire on frequency and severity of specific day and night reflux symptoms. Subsequently, all patients underwent upper endoscopy and were categorized in two groups based on the endoscopic presence of hiatal hernia.

RESULTS

Patients with hiatal hernia were more likely to have nocturnal symptoms compared to those without hiatal hernia (78.6 vs. 51.8%, p = 0.0001); 59.2% of patients with hiatal hernia reported heartburn and 60.2% regurgitation compared to 43.8 and 39.3% of those without hiatal hernia, respectively (p = 0.033 and p = 0.003). The proportions of patients with day heartburn or regurgitation were not significantly different between the two groups. Night heartburn and regurgitation were graded as significantly more severe by patients with hiatal hernia (4.9 ± 4.2 vs. 3.2 ± 3.7, p = 0.002, and 3.8 ± 4.2 vs. 2.2 ± 3.5, p = 0.001, respectively). Patients with hiatal hernia had more frequent weekly night heartburn and regurgitation compared to those without hiatal hernia (p = 0.004 and p = 0.008, respectively).

CONCLUSIONS

More patients with hiatal hernia reported nocturnal reflux symptoms compared to those without hiatal hernia. Furthermore, nocturnal reflux symptoms were significantly more frequent and graded as significantly more severe in patients with presence of hiatal hernia rather than in those without hiatal hernia.

Laryngopharyngeal reflux: Current opinion

The increasing importance of LPR is being recognized day by day in ENT practice. LPR has a significant negative impact in the quality of lives of the patients. Although its impact is similar in some respects to that of laryngopharyngeal disease, LPR has a more significant impact on patient's social functioning and vitality.([23]) All ear, nose and throat practitioners need to be sensitised to the presence of LPR and the need for starting treatment wherever required. Lot of hitherto symptoms of unknown aetiology are being increasingly of treating patients with atypical reflux symptoms such as hoarseness (unexplained cause), globus, throat clearing, cough, etc., with antireflux therapy.([24]).

Alginate controls heartburn in patients with erosive and nonerosive reflux disease

AIM: To evaluate the effect of a novel alginate-based compound, Faringel, in modifying reflux characteristics and controlling symptoms.

METHODS: In this prospective, open-label study, 40 patients reporting heartburn and regurgitation with proven reflux disease (i.e., positive impedance-pH test/evidence of erosive esophagitis at upper endoscopy) underwent 2 h impedance-pH testing after eating a refluxogenic meal. They were studied for 1 h under basal conditions and 1 h after taking 10 mL Faringel. In both sessions, measurements were obtained in right lateral and supine decubitus positions. Patients also completed a validated questionnaire consisting of a 2-item 5-point (0-4) Likert scale and a 10-cm visual analogue scale (VAS) in order to evaluate the efficacy of Faringel in symptom relief. Tolerability of the treatment was assessed using a 6-point Likert scale ranging from very good (1) to very poor (6).

RESULTS: Faringel decreased significantly (P < 0.001), in both the right lateral and supine decubitus positions, esophageal acid exposure time [median 10 (25th-75th percentil 6-16) vs 5.8 (4-10) and 16 (11-19) vs 7.5 (5-11), respectively] and acid refluxes [5 (3-8) vs 1 (1-1) and 6 (4-8) vs 2 (1-2), respectively], but increased significantly (P < 0.01) the number of nonacid reflux events compared with baseline [2 (1-3) vs 3 (2-5) and 3 (2-4) vs 6 (3-8), respectively]. Percentage of proximal migration decreased in both decubitus positions (60% vs 32% and 64% vs 35%, respectively; P < 0.001). Faringel was significantly effective in controlling heartburn, based on both the Likert scale [3.1 (range 1-4) vs 0.9 (0-2); P < 0.001] and VAS score [7.1 (3-9.8) vs 2 (0.1-4.8); P < 0.001], but it had less success against regurgitation, based on both the Likert scale [2.6 (1-4) vs 2.2 (1-4); P = not significant (NS)] and VAS score [5.6 (2-9.6) vs 3.9 (1-8.8); P = NS]. Overall, the tolerability of Faringel was very good 5 (2-6), with only two patients reporting modest adverse events (i.e., nausea and bloating).

CONCLUSION: Our findings demonstrate that Faringel is well-tolerated and effective in reducing heartburn by modifying esophageal acid exposure time, number of acid refluxes and their proximal migration.

Effect of bed head elevation during sleep in symptomatic patients of nocturnal gastroesophageal reflux

BACKGROUND AND AIM

Nocturnal gastro-esophageal reflux causes heartburn and sleep disturbances impairing quality of life. Lifestyle modifications, like bed head elevation during sleep, are thought to alleviate the symptoms of gastroesophageal reflux. We tested the hypothesis that bed head elevation might decrease recumbent acid exposure compared to sleeping in a flat bed.

METHODS

Patients of symptomatic nocturnal reflux and documented recumbent (supine) reflux verified by esophageal pH test entered the trial. On day 1, baseline pH was measured while the patient slept on a flat bed. Then patients slept on a bed with the head end elevated by a 20-cm block for the next 6 consecutive days from day 2 to day 7. The pH test was repeated on day 2 and day 7. Each patient acted as his own control.

RESULTS

Twenty of 24 (83.3%) patients with mean age of 36 ± 5.5 years completed the trial. The mean (± SD) supine reflux time %, acid clearance time, number of refluxes 5 min longer and symptom score on day 1 and day 7 were 15.0 ± 8.4 and 13.7 ± 7.2; P = 0.001, 3.8 ± 2.0 and 3.0 ± 1.6; P = 0.001, 3.3 ± 2.2 and 1.0 ± 1.2; P = 0.001, and 2.3 ± 0.6 and 1.5 ± 0.6; P = 0.04, respectively. The sleep disturbances improved in 13 (65%) patients.

CONCLUSIONS

Bed head elevation reduced esophageal acid exposure and acid clearance time in nocturnal (supine) refluxers and led to some relief from heartburn and sleep disturbance.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

A systematic review of the definitions, prevalence, and response to treatment of nocturnal gastroesophageal reflux disease

BACKGROUND & AIMS

More than half of patients with chronic gastroesophageal reflux (GERD) report nocturnal symptoms. We performed systematic literature review to define nocturnal heartburn and to determine potential causality between nocturnal reflux and extraesophageal manifestations.

METHODS

We performed a search of literature published from 1974-2007. Each study was examined by 2 reviewers and rated on the basis of study type and outcome.

RESULTS

Screening of 445 trials identified 59 (13%) studies relevant for analysis. Twenty-two (5%) of the trials described potential changes in sleep parameters resulting from treatment of heartburn. In most studies, nocturnal reflux was defined as heartburn symptoms that impacted sleep quality and duration. On the basis of 5 large population studies, the mean +/- standard deviation prevalence of nocturnal heartburn was 54% +/- 22%. Consequences of nocturnal reflux included poor sleep quality, daytime fatigue, difficulty initiating sleep or arousals from sleep, and impaired work productivity. The strength of the association between the occurrence of nocturnal reflux and late evening meals was flawed as a result of the confounding effect of the evening meal content. There was no evidence supporting causality between nocturnal heartburn and asthma or obstructive sleep apnea. Subjective, but not objective, measures of sleep improved with antireflux therapy. Head of bed elevation, proton pump inhibitor therapy, H(2)-receptor antagonists, and Nissen fundoplication alleviated nocturnal heartburn and associated sleep disturbances.

CONCLUSIONS

Nocturnal GERD is common and is associated with adverse sleep parameters. It can be effectively managed with medical and surgical therapy.

Medical management of gastroesophageal reflux disease

Gastroesophageal reflux disease is a common worldwide disorder. Most patients have typical symptoms of heartburn, regurgitation and exacerbation of symptoms with large meal volumes, fatty meals, recumbency or bending forward. Patients who show typical symptoms for under 10 years may be treated empirically with lifestyle and dietary modifications plus acid-suppressing medications. The recent decrease in cost, established safety and wide availability of proton pump inhibitors make them the best choice for monotherapy. Other medical therapies include antacids, H(2) receptor antagonists and prokinetic agents. Patients who have alarm symptoms or long-standing symptoms should have an esophagoscopy to evaluate for complications of reflux. Patients who do not respond to therapy should have a test to confirm the diagnosis of gastroesophageal reflux disease.

Impedance monitoring shows that posture and a meal influence gastro-oesophageal reflux composition and frequency

Impedance monitoring determines reflux composition as liquid and/or gas, and we assess with impedance the effect of posture and a meal on reflux composition. Twenty-nine gastro-oesophageal reflux disease (GORD) patients and 10 normal volunteers underwent simultaneous impedance, manometry and pH for three 40-min periods, each 20-min upright, 10-min left side and 10-min right side. One period was fasting, and two postprandial. We found that reflux event composition on the right side was liquid-only near exclusively (93%). In contrast, 85% of reflux on the left side and 74% upright was gas-only or liquid and gas (P < 0.001). More gas-only reflux occurred fasting (80%) than postprandial (P < 0.01). Reflux composition was similar in the study groups and two postprandial periods (P > 0.25). After confirming gas reflux suppression on the right side, a pilot study assessed gastric anatomy as a cause. Five achalasia patients had fluid injected into the stomach at endoscopy, and the EG junction was submerged below liquid-only on the right side. We conclude that reflux is nearly always liquid-only on the right side where the EG junction may be below fluid. Reflux fasting is usually gas-only. Different posture and fasting times may (i) explain variations in acid exposure during pH monitoring and (ii) promote or prevent GORD symptoms.

An effective management regimen for laryngeal granuloma caused by gastro-esophageal reflux: combination therapy with suggestions for lifestyle modifications

According to our previous study, lifestyle modification in combination with drug therapy is much more effective than drug therapy alone in cases of laryngopharyngeal reflux (LPR). Most patients with LPR will have chronic gastro-esophageal reflux diseases (GERD) and require long-term medical therapy for control, resulting in high total expenditure on pharmacologic agents. We combined pharmacologic management with lifestyle modifications for the management of GERD with successful outcomes in patients with GERD-related laryngeal granulomas. Although further studies are needed, guidance concerning lifestyle modifications in combination with PPI therapy may be not only a clinically effective but also a cost-effective method for the management of laryngeal granulomas caused by gastro-esophageal reflux.

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.

Night-time gastro-oesophageal reflux disease: prevalence, hazards, and management

Patients who complain of symptoms of gastro-oesophageal reflux disease (GORD) that occur at night require special attention. Night-time GORD can profoundly impair quality of life by causing pain, disturbing sleep, and interfering with next-day mental and physical functioning. Sleep impairs oesophageal acid clearance resulting in a prolongation of acid mucosal contact, and nocturnal reflux portends a greater risk of erosive oesophagitis and other significant complications of gastro-oesophageal reflux. Lifestyle changes such as elevating the head of the bed and adjusting the sleeping position can relieve night-time heartburn, and instituting some dietary changes along with occasional use of histamine H2 blockers can also be helpful. Relief of night-time reflux and its attendant symptoms usually requires a medication with acid-suppressing properties that extend into the sleeping interval. In most instances, more powerful acid suppression in the form of proton-pump inhibitors will be required. Clinical studies have shown that 40 mg esomeprazole provides better control of night-time GORD symptoms than 20 mg omeprazole or 30 mg lansoprazole. Furthermore, 40 mg pantoprazole offers even faster relief than 40 mg esomeprazole for night-time GORD symptoms. Of the several proton-pump inhibitors available on the market, esomeprazole and pantoprazole appear to have some advantages, which have been documented in recent studies. Esomeprazole has been shown to be more effective than lansoprazole in relieving GORD symptoms, and esomeprazole and pantoprazole appear to be equally effective in resolving GORD symptoms in a comparative study. Pantoprazole has pharmacokinetic properties that document a longer half-life compared with the other proton-pump inhibitors, and pantoprazole has the slowest inhibition recovery rate. These properties lend credence to pantoprazole as an effective treatment for associated symptoms of night-time reflux.

An evaluation of the antireflux properties of sodium alginate by means of combined multichannel intraluminal impedance and pH-metry

BACKGROUND

Alginate-based preparations act as mechanical antireflux barrier, which can reduce both acid and non-acid reflux events and limit the proximal migration of oesophageal refluxate.

AIM

To evaluate all the above features with a novel technique, multichannel electrical impedance and pH-metry.

METHODS

Ten reflux patients underwent stationary impedancemetry and pH-metry after eating a refluxogenic meal. They were studied 1 h in basal conditions and 1 h after taking 10 mL of Gaviscon Advance. In both sessions, measurements were obtained in right lateral and supine decubitus.

RESULTS

Alginate preparation was able to decrease significantly (P < 0.05) the number of acid reflux events and the percentage time pH < 4.0 compared with baseline. There was no effect of the drug on non-acid refluxes. Gaviscon Advance was also significantly effective (P < 0.05) in reducing the height of proximal migration of reflux events compared with baseline in both decubitus positions.

CONCLUSIONS

Our findings explain how Gaviscon Advance controls acid reflux episodes, limits the proximal migration of refluxed material and thereby decreases symptoms in clinical practice.

Review article: diagnosis and management of night-time reflux

Symptoms of gastro-oesophageal reflux disease (GERD) range from mild to severe and, when they occur during night-time hours, can interfere with sleep patterns and reduce overall quality of life. The clinical presentation of GERD is characterized by oesophageal as well as supra-oesophageal symptoms, including otolaryngologic and pulmonary complications. However, GERD may be overlooked as the cause of a patient's supra-oesophageal symptoms because these complaints can occur in the absence of oesophageal symptoms or endoscopic changes. The role of available tools used for GERD diagnosis, including endoscopy, oesophageal pH monitoring and an empirical course of proton pump inhibitor therapy, is discussed. Interventions available to achieve the therapeutic goals of symptom relief and prevention include specific lifestyle modifications and over-the-counter as well as prescription pharmacological agents. Patient-initiated, as-needed treatment may not be the best choice for managing persistent night-time reflux because it requires patient arousal from sleep. Proton pump inhibitor therapy remains the treatment of choice for patients with more severe symptoms and those with erosive oesophagitis. Few studies have specifically evaluated the role of pharmacological agents in the management of night-time reflux and comparisons are difficult due to the variability in study design and endpoints assessed.

Review article: the patient with gastro-oesophageal reflux disease--lifestyle advice and medication

Gastro-oesophageal reflux disease (GERD) is a highly prevalent disorder in all Western countries. Interestingly, prevalence rates appear to be increasing in these countries, with a remarkable increase of GERD-related lethal and nonlethal complications. However, these complications are rare on a global scale. This review aims to summarize the current concepts of genetic, lifestyle and environmental factors that need to be considered whilst caring for patients with these disorders. GERD is defined by the augmented exposure of oesophageal mucosa to acidic content, and is associated with specific symptoms or mucosal lesions. A number of factors may contribute to the manifestation of GERD. Although recent studies emphasize the role of genetic factors, there are many other risk factors that play a pivotal role in the development of GERD and GERD complications. Some nutritional factors are believed to aggravate acidic reflux either by delaying gastric emptying or diminishing the pressure of the lower oesophageal sphincters. Patients are often advised to sleep with their heads elevated, but this advice is not easy to follow and has not been proven effective with regard to long-term outcome. Other lifestyle modifications include changes to the patient's diet, which are important but not frequently sufficient. Thus, medication is usually necessary for symptom control. Proton pump inhibitors are now mainstream treatment for the reduction of acid secretion in patients with severe manifestations and 4-week healing rates are approaching 90%.

Management strategies for gastroesophageal reflux disease

In the treatment of gastroesophageal reflux disease (GERD), the most effective treatment option is the use of proton pump inhibitor (PPI), which minimizes the effect of gastric acid on the distal esophagus. Both the step-up and step-down treatment strategies have advantages and disadvantages. Most physicians would like to choose the step-down therapy rather than the step-up therapy. The 'No-step' PPI therapy (i.e. continuous PPI therapy) is another relevant option. After an initial remission, long-term PPI therapy is an appropriate form of maintenance therapy in many patients. As a treatment plan for non-erosive reflux disease, a standard dose of PPI for 4-8 weeks followed by either the step-down strategy or the on-demand treatment strategy is acceptable. When treating erosive esophagitis, PPI is better than H(2) receptor blockers in healing mucosal breaks and relieving symptoms. Long-term maintenance PPI therapy is reported to be very effective in maintaining the remission of reflux esophagitis for up to 5 years. On-demand PPI is also another good option for a maintenance therapy in erosive esophagitis. In Barrett's esophagus, symptoms seem to be well-controlled with PPIs. Unfortunately, however, PPIs have no effect on the shortening of Barrett's esophagus or in preventing the progression to dysplasia and adenocarcinoma. In summary, after reviewing existing guidelines a rather simple guideline on the management of GERD is suggested - PPI should be given for 4-8 weeks followed by either on-demand or maintenance PPI therapy according to the clinical severity.

Management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic condition requiring long-term treatment. Simple lifestyle modifications are the first methods employed by patients and, because of their low cost and simplicity, should be continued even when more potent therapies are initiated. Potent acid-suppressive therapy is currently the most important and successful medical therapy. Whereas healing of the esophageal mucosa is achieved with a single dose of any proton pump inhibitor (PPI) in more than 80% of cases, symptoms are more difficult to control. Patients with persistent symptoms on therapy should be tested (preferably with combined multichannel intraluminal impedance and pH) for association of symptoms with acid, nonacid, or no GER. Long-term follow-up studies indicate that PPIs are efficacious, tolerable, and safe medication. So far, promotility agents have shown limited efficacy, and their side-effect profile outweighs their benefits. Antireflux surgery in carefully selected patients (ie, young, typical GERD symptoms, abnormal pH study, and good response to PPI) is as effective as PPI therapy and should be offered to these patients as an alternative to medication. Still, patients should be informed about the risks of antireflux surgery (ie, risk of postoperative dysphagia; decreased ability to belch, possibly leading to bloating; increased flatulence). Endoscopic antireflux procedures are recommended only in selected patients and given the relative short experience with these techniques, patients treated with endoscopic procedures should be enrolled in a rigorous follow-up program.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is a common, usually lifelong, disorder resulting from chronic abnormal exposure of the lower esophagus to gastric contents. Motor dysfunction of the lower esophageal sphincter is the primary cause of this disease. At this writing, no medical therapies can completely resolve abnormal lower esophageal sphincter function; therefore, the treatment of gastroesophageal reflux disease centers on suppression of intragastric acid secretion. Available acid-suppressant medications include proton pump inhibitors, H2-receptor antagonists, and antacids. Of these, the proton pump inhibitors are recognized generally as the mainstays of both short-term and long-term therapy for gastroesophageal reflux disease. All have a low incidence of side effects and are well tolerated by most patients. Five proton pump inhibitors are available currently for patients with gastroesophageal reflux disease. Of these, esomeprazole has shown greater efficacy in controlling intragastric acidity than the others. For patients with erosive esophagitis, esomeprazole has demonstrated higher healing rates and more rapid sustained resolution of heartburn than omeprazole or lansoprazole after up to 8 weeks of once-daily treatment. Because new therapies for gastroesophageal reflux disease are highly effective, patients can be reassured that their disease will be well controlled and their symptoms resolved with a safe and appropriate treatment.

Medical management of nocturnal symptoms of gastro-oesophageal reflux disease in the elderly

Elderly patients with nocturnal symptoms of gastro-oesophageal reflux disease (GORD) usually experience a more aggressive and complicated disease course compared with younger patients, resulting in impaired quality of life. The severity of disease and possible complications should be evaluated with upper endoscopy once the diagnosis is suspected. Elderly patients with nocturnal symptoms of GORD and evidence of endoscopic complications (oesophagitis, Barrett's oesophagus, etc.) and those with severe endoscopically negative reflux disease (ENRD) should be treated with proton pump inhibitors. Histamine H(2) receptor antagonists are suitable for mild-to-moderate ENRD. Antacids and lifestyle modifications may be incorporated into the management as adjuncts to more potent and durable therapeutic agents. Effective treatment of nocturnal GORD symptoms in the elderly will result in relief of symptoms, healing of oesophagitis and improved quality of life, and should be maintained indefinitely to prevent relapses of the disease.

Noncardiac chest pain: evaluation and treatment

Noncardiac chest pain is a heterogeneous condition for which diagnosis and treatment are challenging. Research is needed to streamline evaluation to minimize unnecessary invasive testing and costs. Chest pain clinics to assess chest pain patients are popular in the United States and may be of value in reassuring patients and reducing presentation to hospital; however, recently this has been contended [111]. Options for the effective treatment of NCCP are dependent on the risk of an adverse outcome and the cost-effectiveness of the management algorithm that is followed. Most (64%) of those presenting to the emergency department with chest pain are classified as having NCCP [112,113]. GERD is probably the most important cause and application of a test of acid suppression with a high-dose PPI for 1 to 2 weeks seems to be a useful diagnostic tool. In those patients with GERD-related NCCP, short-term and potentially long-term therapy with a PPI (commonly higher than standard dose) is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon in patients with NCCP and evaluation by esophageal manometry might be limited to rule out achalasia. Chest wall syndromes are common but probably often missed. Many patients with NCCP have psychologic or psychiatric abnormalities, as either the cause or an effect of the chest pain, but diagnosis here depends on techniques not applied easily in the acute situation. Pain modulators seem to offer significant improvement in chest pain symptoms for non-GERD-related NCCP. Finally, trials of management strategies to deal with this problem are required urgently, because the earlier discharge of patients with NCCP may exacerbate the problem. Fig. 2 provides a flow chart for diagnosis and treatment of NCCP.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

[Aspects of sleep effects on the digestive tract]

BACKGROUND

During sleep the gastrointestinal system function is markedly reduced most of the time.

OBJECTIVES

In this revision we described the effect of sleep on the digestive system. Salivation, swallowing rate, upper esophageal sphincter pressure and number of primary esophageal contractions have all been shown to be reduced during sleep.

DATA SOURCES

Gastric emptying is slow during sleep but the REM sleep is associated with faster gastric emptying. During the night we have a more regular intestinal motility than during the day. During sleep, phase II of the migrating motor complex cycle is virtually absent, both during diurnal or nocturnal sleep. The nocturnal velocity of migrating motor complex propagation in the proximal small bowel is slower than the diurnal velocity. The colon has a decrease in tonus and contractions. The anal canal pressure is lower and rectum activity is higher during sleep than during the awake state, but the anal pressure is still higher than the rectum pressure and the rectum contractions are most frequently retrograde.

DATA SYNTHESIS

Transient lower esophageal sphincter relaxation is the most frequent cause of gastroesophageal reflux. The frequency of this transient relaxation is very low during sleep. Gastroesophageal reflux during sleep is more frequently associated with a low lower esophageal sphincter pressure.

CONCLUSIONS

In this situation the disease is worse because the patient is in the supine position, so gravity does not help the acid esophageal clearance, salivation is decreased and the primary esophageal contraction is not frequent, a fact causing a prolongation of acid clearance during sleep. The right lateral position during sleep causes more reflux episodes than the left lateral position. The gastroesophageal reflux may be associated with nocturnal wheezing, chronic nocturnal cough and sleep apnea.

Upright versus supine reflux in gastroesophageal reflux disease

BACKGROUND

Postural measures are early recommendations in the management of heartburn, and are aimed at preventing acid reflux through an incompetent lower esophageal sphincter (LES). However, LES incompetence is found in only a minority of patients, and transient LES relaxations, primarily in the upright position, are currently recognized as the main pathophysiological abnormality in gastroesophageal reflux disease (GERD). We investigated the importance of supine acid reflux in patients with GERD.

METHODS

Upon review of their clinical, manometric, pH monitoring and endoscopic characteristics, 85 patients with reflux symptoms were classified into three groups: Group A (n=22), consisting of symptomatic patients without esophagitis or pathological reflux; group B (n=38), symptomatic patients with reflux but no endoscopic esophagitis; and group C (n=25), symptomatic patients with both ulcerative or complicated esophagitis and pathological reflux.

RESULTS

All groups were similar in age distribution. Groups B and C had a higher prevalence of hiatal hernia and reflux symptoms. Manometry revealed similar LES pressures in groups A and B, but lower LES pressure in group C (P < 0.005). In groups A and B, supine reflux, in terms of percentage of time with pH < 4, was less pronounced than upright reflux (P < 0.0001). In contrast, group C supine reflux was as pronounced as the upright reflux.

CONCLUSIONS

The majority of patients reflux in the upright position. Only patients with complicated esophagitis have significant bipositional acid reflux. These findings suggest that unless the patient has severe reflux disease, postural measures may not be indicated.

The role of age and salivation in acid clearance in symptomatic patients with gastro-oesophageal reflux disease

BACKGROUND

Cisapride has been shown to have not only prokinetic effects, but also salivary stimulating effects. Both of these mechanisms play an important role in the acid clearance of the oesophagus.

AIM

To access the efficacy of cisapride in facilitating acid clearance in patients with symptomatic gastro-oesophageal reflux disease.

METHODS

Fifteen older adults and 15 younger adults with symptomatic gastro-oesophageal reflux disease completed the study. The acid clearance test was accomplished by infusing 15 mL of 0.1 N HCl into the distal oesophagus, and the number of swallows was determined to achieve an oesophageal pH of 4.0. This was accomplished under baseline conditions and salivary stimulation with a peppermint lozenge. After 1 week of treatment with cisapride (10 mg, q.d.s.), the acid clearance test was repeated.

RESULTS

The lozenge produced a significant decrease in the number of swallows compared to baseline in both groups (P < 0.01). There was a significant decrease in the number of swallows after the treatment with cisapride compared to baseline in both groups (P < 0.01). No significant difference was found in the number of swallows when comparing cisapride with lozenge.

CONCLUSIONS

Cholinergic stimulation of salivation is an effective means of facilitating oesophageal acid clearance. Drugs, such as 5 hydroxytriptamine (5-HT)4-receptor agonists, should be considered as potentially important compounds in the treatment of gastro-oesophageal reflux disease.

Strategies for medical management of reflux disease

Management of gastro-oesophageal reflux disease (GORD) patients must consider two issues: (i) how to optimize the treatment of a presenting symptom complex, and (ii) how to manage risk of adenocarcinoma associated with GORD. In most cases the need for, and potency of, pharmacological therapy used is decided by symptom assessment. Considering cost effectiveness, the three increments of pharmacological therapy are: (i) generic histamine(2)receptor antagonists, (ii) standard dose proton pump inhibitors, and (iii) higher dose proton pump inhibitors. Endoscopy is warranted if there is doubt regarding the diagnosis of GORD or if the patient relays alarm symptoms suggesting more ominous diagnoses (dysphagia, bleeding, weight loss, odynophagia). The other major indication for endoscopy is to screen for adenocarcinoma or Barrett's metaplasia in the patient with chronic symptoms. In most patients, the need for maintenance medical therapy is determined by the rapidity of symptom recurrence during a trial period off the medication.

Gastroesophageal reflux disease and Barrett's esophagus

GERD has emerged as an important medical issue by virtue not only of its high prevalence, but also by the concern that it may predispose to adenocarcinoma of the esophagus. It generally is classified into erosive and nonerosive forms. Nonerosive GERD tends to remain as such in most patients, and treatment is based on symptom relief. In contrast, erosive GERD mandates aggressive lifelong treatment based on its inevitable relapse without appropriate treatment. Two excellent therapies are available for GERD. Proton-pump inhibitors are highly efficacious and have an excellent long-term (> 10 years) safety profile. Laparoscopic fundoplication offers a new and easier method of delivering a standard reliable procedure also with excellent long-term efficacy. The occurrence of Barrett's esophagus among reflux patients has emerged as an important problem mostly because of the rapidly rising incidence of adenocarcinoma of the esophagus in the population. All patients with long-standing reflux symptoms should be screened for Barrett's and subsequently followed regularly with surveillance endoscopy if Barrett's is detected. Although there are no data to show that aggressive medical or surgical treatment alters the malignant potential of this disease, patients need lifelong therapy.

Laryngopharyngeal reflux: state of the art diagnosis and treatment

Gastroesophageal reflux has been implicated in the pathogenesis of a wide variety of otolaryngologic disorders. Patients with otolaryngologic disorders associated with gastroesophageal reflux infrequently have the classic symptoms of gastroesophageal reflux, such as heartburn. Clinical presentation of laryngopharyngeal reflux is commonly characterized by chronic intermittent symptoms. A meticulous synthesis of the information obtained from a complete otolaryngologic examination, diagnostic tests, and response to treatment is essential for the efficient management of patients with otolaryngologic disorders associated with laryngopharyngeal reflux.

Review article: alginate-raft formulations in the treatment of heartburn and acid reflux

Alginate-based raft-forming formulations have been marketed word-wide for over 30 years under various brand names, including Gaviscon. They are used for the symptomatic treatment of heartburn and oesophagitis, and appear to act by a unique mechanism which differs from that of traditional antacids. In the presence of gastric acid, alginates precipitate, forming a gel. Alginate-based raft-forming formulations usually contain sodium or potassium bicarbonate; in the presence of gastric acid, the bicarbonate is converted to carbon dioxide which becomes entrapped within the gel precipitate, converting it into a foam which floats on the surface of the gastric contents, much like a raft on water. Both in vitro and in vivo studies have demonstrated that alginate-based rafts can entrap carbon dioxide, as well as antacid components contained in some formulations, thus providing a relatively pH-neutral barrier. Several studies have demonstrated that the alginate raft can preferentially move into the oesophagus in place, or ahead, of acidic gastric contents during episodes of gastro-oesophageal reflux; some studies further suggest that the raft can act as a physical barrier to reduce reflux episodes. Although some alginate-based formulations also contain antacid components which can provide significant acid neutralization capacity, the efficacy of these formulations to reduce heartburn symptoms does not appear to be totally dependent on the neutralization of bulk gastric contents. The strength of the alginate raft is dependant on several factors, including the amount of carbon dioxide generated and entrapped in the raft, the molecular properties of the alginate, and the presence of aluminium or calcium in the antacid components of the formulation. Raft formation occurs rapidly, often within a few seconds of dosing; hence alginate-containing antacids are comparable to traditional antacids for speed of onset of relief. Since the raft can be retained in the stomach for several hours, alginate-based raft-forming formulations can additionally provide longer-lasting relief than that of traditional antacids. Indeed, clinical studies have shown Gaviscon is superior to placebo, and equal to or significantly better than traditional antacids for relieving heartburn symptoms. Alginate-based, raft-forming formulations have been used to treat reflux symptoms in infants and children, and in the management of heartburn and reflux during pregnancy. While Gaviscon is effective when used alone, it is compatible with, and does not interfere with the activity of antisecretory agents such as cimetidine. Even with the introduction of new antisecretory and promotility agents, alginate-rafting formulations will continue to have a role in the treatment of heartburn and reflux symptoms. Their unique non-systemic mechanism of action provides rapid and long-duration relief of heartburn and acid reflux symptoms.

Morbidity, mortality, and risk factors for esophagitis in hospital inpatients

Esophagitis is a common endoscopic finding, although its prevalence and contribution to morbidity and mortality in hospital inpatients has not been systematically evaluated. This study aimed to determine the prevalence of esophagitis among hospital inpatients referred for upper gastrointestinal endoscopy, to assess factors associated with the presence of esophagitis, and to determine the mortality of patients with esophagitis. All inpatients referred for upper gastrointestinal endoscopy in a district general hospital were assessed prospectively for one year. The reason for referral, endoscopy findings, and one-month mortality were determined together with a history of nasogastric intubation, periods spent supine, and drug use. Of 595 inpatients who underwent gastroscopy, 58% were referred for investigation of acute upper gastrointestinal bleeding. Esophagitis was found in 196 (33%). Esophagitis was significantly associated with wide-bore nasogastric intubation (p = 0.021; relative risk, 2.61; 95% CI, 0.64-6.06) but not with fine-bore nasogastric intubation. Esophagitis was also significantly associated with being nursed supine (p = 0.015; relative risk, 1.41; 95% CI, -1.75-6.72). There was no association between esophagitis and specific drug therapy. Mortality among patients with esophagitis was higher than those without esophagitis (p = 0.04; relative risk, 1.38; 95% CI, 0.34-3.22). Reflux esophagitis is common in hospital inpatients who are endoscoped. Although the underlying diseases are likely to account for the high mortality, the associations of wide-bore nasogastric intubation and being nursed supine should alert caregivers to an increased risk. If nasogastric intubation is required for feeding only, fine-bore tubes should be considered.

Medical therapy of supraesophageal gastroesophageal reflux disease

Medical therapy of supraesophageal gastroesophageal reflux disease (GERD) is based on the principals for treating patients with heartburn and erosive esophagitis, observations from the few available clinical trials, and clinical experience. In general, patients with supraesophageal GERD require higher doses of antireflux therapy, principally with proton pump inhibitors, for longer periods of time to effectively relieve symptoms compared with patients with heartburn and/or erosive esophagitis. This article reviews the current literature and discusses a suggested approach to medical management of these often complex patients.

Overview of medical therapy for gastroesophageal reflux disease

There appears to be a hierarchy in the efficacy of therapies that are directed against GERD. A summary of this hierarchy, including therapies [table: see text] not approved by the U.S. Food and Drug Administration, is presented in Table 4. The individual practitioner must evaluate the appropriate point at which to place each patient on this hierarchy. Whether it is best to begin with the drug with the highest efficacy and step-down as possible for maintenance, never to step down, or to start with a less efficacious therapy and step up must also be individualized because there are no clear data to support a universal approach to all or even most GERD patients.

Dyspepsia and heartburn

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

Gastroesophageal reflux and asthma

The medical literature has been deluged with articles on the relation between gastroesophageal reflux (GER) and asthma. In an effort to piece together the complex puzzle, investigators from all disciplines have gathered their patients with wheezing and heartburn and studied the epidemiology, the possible cause or effect mechanisms and the therapeutic response to GER treatment. Indeed, since humans first began to hunker down and work together to discuss interesting observations, the world has begun to breathe easier. Epidemiological evidence for a GER/asthma association suggests that about three-fourths of asthmatics, independent of the use of bronchodilators, have acid GER, increased frequency of reflux episodes, or heartburn; and 40% have reflux esophagitis. Physiological studies suggest that 2 separate mechanisms are involved in the GER/asthma relationship: (1) a vagally mediated pathway and (2) microaspiration. In any given patient, however, there is no acceptable diagnostic method available to confirm the presence or absence of GER-induced asthma. Clinical trials, using antireflux medical therapy and antireflux surgery have begun to provide some clues about GER-related pulmonary symptoms. The trials of medical therapy using acid suppressing drugs (e.g. histamine-2 receptor antagonists) have ranged from no benefit to modest improvement of only nocturnal asthma symptoms. Studies with proton-pump inhibitors are underway. In uncontrolled surgical studies, antireflux surgery has resulted in partial or complete remission of asthma symptoms in a large proportion of patients. Despite the uncontrolled nature of these studies, many patients have had dramatic subjective improvement in pulmonary symptoms. It appears for now that clinical trials are the only available means to assess whether medical or surgical treatment of GER in patients with both GER and asthma improves the symptoms of asthma and decreases the need for pulmonary medications. One conclusion is certain: We no longer can ignore the important co-existent nature of these 2 afflictions.