Clinical consequences of silent gastroesophageal reflux disease

Insight into global burden of gastroesophageal reflux disease: Understanding its reach and impact

The exact worldwide prevalence of gastroesophageal reflux disease (GERD) remains uncertain, despite its recognition as a common condition. This conundrum arises primarily from the lack of a standardized definition for GERD. The gold standard diagnostic tests for GERD, such as pH impedance testing and endoscopy, are cumbersome and impractical for assessing community prevalence. Consequently, most epidemiological studies rely on symptom-based screening tools. GERD symptoms can be both esophageal and extraesophageal, varying widely among individuals. This variability has led to multiple symptom-based definitions of GERD, with no consensus, resulting in prevalence estimates ranging from 5% to 25% worldwide. Most systematic reviews define GERD as experiencing heartburn and/or regurgitation at least once weekly, yielding a calculated prevalence of 13.98%. In 2017, the global age-standardized prevalence of GERD was estimated at 8819 per 100000 people (95% confidence interval: 7781-9863), a figure that has remained stable from 1990 to 2017. Prevalence increases with age, leading to more years lived with disability. GERD significantly impairs quality of life and can lead to multiple complications. Additionally, it imposes a severe economic burden, with the United States alone estimated to spend around 10 billion dollars annually on diagnosis and treatment. In summary, GERD prevalence varies greatly by region and even within different areas of the same province. Determining the exact prevalence is challenging due to inconsistent diagnostic criteria. However, it is well-documented that GERD poses a significant global burden, affecting the quality of life of individuals and creating a substantial healthcare cost.

The prevalence of gastroesophageal reflux disease and laryngopharyngeal reflux in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in post-irradiated patients with nasopharyngeal carcinoma (NPC) is unknown.

MATERIALS AND METHODS

In a cross-sectional study, 31 NPC and 12 control patients completed questionnaires for GERD/LPR before esophageal manometry and 24-h pH monitoring. The DeMeester score and reflux finding score (RFS) were used to define GERD and LPR, respectively. Risk factors were identified.

RESULTS

51.6% of NPC and 8.3% of control patients, and 77.4% of NPC and 33% of control patients, were GERD-positive and LPR-positive, respectively. The GERD/LPR questionnaire failed to identify either condition in patients with NPC. No parameter differences in esophageal manometry or pneumonia incidence were noted between GERD/LPR-positive and GERD/LPR-negative patients. Post radiotherapy duration, high BMI, lack of chemotherapy, and dysphagia were positive risk factors for GERD/LPR.

CONCLUSIONS

A high prevalence of GERD/LPR in patients with post-irradiated NPC exists, but reflux symptoms are inadequate for diagnosis.

Endoscopic Evaluation of Radiologic Distal Esophageal Thickening

GOALS

We aim to determine the incidence of esophagogastroduodenoscopies (EGDs) primarily performed for imaging findings of distal esophageal thickening (DET). We also aim to determine if patients with imaging findings of DET have a higher incidence of cancer, and to evaluate the risk factors associated with findings of malignancy.

BACKGROUND

The growth of diagnostic imaging has led to an increase in incidental findings of DET. This nonspecific finding frequently prompts an EGD for evaluation-many of which demonstrate benign conditions. There may be a misuse of valuable resources.

STUDY

We performed a retrospective chart review of 1080 EGDs from January 2016 to July 2018 at the Veterans Affairs Medical Center, comparing EGDs for the indication of imaging report of DET with EGDs for other indications. Patient demographics, clinical history, imaging, procedure, and pathology reports were collected. Descriptive analysis and biostatistical analysis with χ2, Fisher exact, Wilcoxon rank sum, and Kruskal-Wallis tests were utilized in analyzing the data.

RESULTS

Of the 1080 total endoscopies, 8.2% (n=88) were done specifically because of the imaging findings of DET. Those who had EGDs performed because of DET had a higher percentage of abnormal esophageal findings and of cancer. A history of Barrett's esophagus, tobacco use, and having gastrointestinal symptoms were not significant predictors of abnormal findings or of cancer for EGDs done for DET.

CONCLUSIONS

There may be a role for EGDs performed for radiologic findings of DET. Even those without risk factors for malignancy should have EGDs performed for DET. Radiologists should consider reporting the DET size in order to determine if significant endoscopic findings correlate with wall thickness.

Contemporary diagnosis and management of dental erosion

OBJECTIVE

This article is aimed at providing an overview of the topic of erosive tooth wear (ETW), highlighting the clinical signs, diagnosis, and management of dental erosion.

OVERVIEW

With the increased prevalence of ETW, it is important that oral health professionals are able to recognize the early signs. Early clinical signs of dental erosion are characterized by loss of enamel texture, a silky glossy appearance, and sometimes a dulling of the surface gloss, referred to as the "whipped clay effect, cupping, and restorations 'standing proud'." The progression of ETW should be monitored by means of diagnostic models or clinical photographs. ETW can be as a result of acid attack of extrinsic or intrinsic origin.

CONCLUSION

There is an increase of ETW that is being recognized by the profession. The first step in diagnosing and management is to recognize as early as possible that the process is occurring. At that point a determination of whether the primary etiology is either intrinsic or extrinsic should be made. If these findings are confirmed, appropriate prevention, and management strategies can be adopted followed by appropriate restorative therapy.

CLINICAL SIGNIFICANCE

The prevalence of ETW continues to increase. It is therefore important that oral health care providers have a better understanding of the etiology, pathophysiology, and management of this condition. This review aims to provide the guidelines for diagnosis and management of dental erosion.

When did gastro-esophageal reflux become a disease? A historical perspective on GER(D) nomenclature

BACKGROUND

Within the span of a few decades, gastro-esophageal reflux (GER) evolved from a rare entity to the most commonly diagnosed upper gastro-intestinal disease, i.e. gastro-esophageal reflux disease (GERD). The boundaries of GERD remain matter of controversy and appear to be ever expanding in both children and adults. Our aim is to answer the questions: when did GER become a disease? And when did it become specifically a pediatric disease?

METHODS

We performed a comprehensive historical review of the original medical literature using Medline and Google, along with a compilation of original and secondary texts in English, French and German.

RESULTS

Our finding is that those actively involved in treating the reflux, first surgeons in the 1960s and then gastroenterologists in the 1970s, initiated naming it a disease. In pediatrics, the possible correlation between reflux events and sudden infant death syndrome accelerated the management of reflux associated with respiratory symptoms with surgery in the 1970s. Surgeons were also the first specialists to formulate the term pediatric GERD in 1982.

CONCLUSION

Understanding the genesis of GERD may shed light upon its expansion as a disease category and its persistent controversial nature in pediatrics.

Esophageal Evaluation for Patients Undergoing Lung Transplant Evaluation: What Should We Do for Evaluation and Management

Lung transplantation is a high-risk, but lifesaving, procedure for patients with end-stage lung disease. Although 1-year survival is high, long-term survival is not nearly as high, due mainly to acute and chronic rejection. Bronchiolitis obliterans syndrome is the most common type of chronic rejection and often leads to poor outcomes. For this reason, esophageal testing in the lung transplant population has become a major issue, and this article discusses the evidence behind esophageal testing, the importance of esophageal dysmotility gastroesophageal reflux disease, both acidic and nonacidic reflux, and aspiration and the treatment of these findings.

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.

A population-based survey of gastroesophageal reflux disease in a region with high prevalence of esophageal cancer in China

Background:

The exact relationship between gastroesophageal reflux disease (GERD) and esophageal squamous cell cancer (ESCC) is far from clarification. The aim of this study was to investigate the epidemiology of GERD in a region with high prevalence of ESCC in China.

Methods:

A population-based, cross-sectional study was conducted in a high ESCC prevalent area, Anyang, Henan, China. All subjects fulfilled questionnaires and underwent gastroendoscopy with routine esophageal biopsy. The subjects were divided into GERD subtypes (reflux esophagitis [RE] and non-erosive reflux disease [NERD]) and controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to examine risk factors for RE and NERD.

Results:

A total of 2844 subjects were finally enrolled. The prevalence of GERD (RE + NERD) was 17.3%. Among them, 271 (9.53%) adults were diagnosed with RE. The prevalence of RE increased with age (7.09% in 45–50 years, 8.00% in 51–60 years, and 9.53% in 61–69 years, χ² = 62.216, P < 0.001). Sixty-seven (2.36%) subjects were diagnosed with the silent RE. A total of 221 (7.77%) subjects were diagnosed with NERD. Frequent liquid food consumption (OR [95% CI]: 1.502 [1.076–2.095]) was independent risk factor for RE as well as age, male gender, high body mass index (BMI), ever smoking. Age was independent risk factor for NERD. For silent RE, age, male gender, and frequent liquid food consumption were risk factors.

Conclusions:

In the population with high prevalence of ESCC, a high prevalence of GERD and inverted proportion of RE/NERD were presented. Age was an independent risk factor for GERD. The male gender, high BMI, smoking, and frequent liquid food consumption may be risk factors for RE but not for NERD.

Aerodigestive disorders in dogs evaluated for cough using respiratory fluoroscopy and videofluoroscopic swallow studies

Aerodigestive diseases, hybrid disorders representing a pathologic link between respiratory and alimentary tracts, may manifest with respiratory signs without gastrointestinal signs. These are underdiagnosed in dogs due to poor clinical recognition and diagnostic limitations. We hypothesize that a subset of dogs presenting for cough without gastrointestinal signs would have occult aerodigestive disorders identified using videofluoroscopic swallow study (VFSS). Data were retrospectively obtained from 31 client-owned dogs presenting for cough, with thoracic radiographs, and a VFSS between April 2015 and December 2017. Exclusion criteria were cough of cardiac origin or gastrointestinal signs within 6 months. Swallow study parameters included pharyngeal/esophageal motility, laryngeal obstruction/defects, penetration-aspiration, reflux, excessive aerophagia, megaesophagus (ME), lower-esophageal sphincter achalasia-like syndrome (LES-AS), and sliding hiatal hernia (HH). The median (interquartile range) duration of cough was 4 (2-8) months. Thoracic radiographs were unremarkable in 11 dogs, with aspiration pneumonia suspected in seven. In 25/31 dogs (81%), VFSS abnormalities were detected and some dogs had more than one defect: pharyngeal (n=10) or esophageal hypomotility (n=10), reflux (n=9), penetration-aspiration (n=8), excessive aerophagia (n=6), laryngeal obstruction (n=3), ME (n=3), HH (n=2), and LES-AS (n=1). A respiratory disorder causing cough was identified in 17 dogs with VFSS abnormalities (laryngeal obstruction/defect and airway disease including chronic or eosinophilic bronchitis, tracheal/mainstem bronchial collapse, bronchiectasis, and bronchomalacia). An alimentary disorder identified on VFSS in absence of a discrete respiratory disorder causing cough was diagnosed in eight dogs. In conclusion, canine aerodigestive disorders can manifest as cough without alimentary signs. VFSS is a useful diagnostic to determine the contribution of esophageal/gastrointestinal pathology in dogs with cough.

Plausibility criteria for putative pathophysiological mechanisms in functional gastrointestinal disorders: a consensus of experts

BACKGROUND AND AIMS

The functional gastrointestinal disorders (FGIDs) are extremely common conditions associated with a considerable personal, social and health economic burden. Managing FGIDs in clinical practice is challenging because of the uncertainty of symptom-based diagnosis, the high frequency of overlap between these conditions and the limited efficacy of available therapies. It has often been argued that successful drug development and management of FGIDs requires knowledge of the underlying pathophysiology. Numerous and highly variable candidate pathophysiological mechanisms have been implicated in the generation of FGID symptoms, but there is no current consensus on how to best define the relevance of these disturbances.

METHODS

A group of international experts on FGIDs developed plausibility criteria that should be fulfilled by relevant pathophysiological mechanisms in FGIDs.

RESULTS

Five criteria are proposed: (1) the presence of the abnormality in a subset of patients, (2) temporal association between proposed mechanism and symptom(s), (3) correlation between the level of impairment of the mechanism and symptom(s), (4) induction of the symptom(s) by provoking the pathophysiological abnormality in healthy subjects and (5) treatment response by a therapy specifically correcting the underlying disorder or congruent natural history of symptoms and dysfunction in the absence of specific therapy. Based on strength of evidence for these five criteria according to the Grading of Recommendations Assessment, Development and Evaluation system, a plausibility score can be calculated for each mechanism.

CONCLUSION

Evaluation of the strength of evidence for candidate pathophysiological abnormalities fulfilling these five plausibility criteria will help to identify the most relevant mechanisms to target for novel diagnostic approaches and for the development of new therapies.

Prevalence and Predictors of Silent Gastroesophageal Reflux Disease in Patients with Hypertension

BACKGROUND

Gastroesophageal reflux disease (GERD) without symptoms or silent GERD can be easily missed in patients with hypertension. We aimed to investigate the prevalence of GERD, specifically the prevalence of silent GERD in hypertensive patients, and to explore its possible predictors.

METHODS

Consecutive patients with hypertension referred to the cardiovascular clinic of Suining Central Hospital in 2016 were screened for this study. A Reflux Disease Questionnaire (RDQ) and an esophagogastroduodenoscopy (EGD) were employed for the evaluation of silent GERD. Included patients were divided into silent-GERD group and non-GERD control group. The demographic characteristics and antihypertensive agent prescriptions were collected and compared between the two groups.

RESULTS

The prevalence of silent GERD and GERD in patients with hypertension was 15.1% and 31.4%, respectively. 66 patients were included in the silent-GERD group, and 298 patients were included in the non-GERD control group. Abdominal obesity and untreated hypertension were positive predictors, while controlled hypertension was a negative predictor for silent GERD. The prescription of calcium channel blockers was not a predictor for it.

CONCLUSIONS

High prevalence of GERD, specifically silent GERD, could be found in patients with hypertension. Abdominal obesity and untreated hypertension were positive predictors for silent GERD, while controlled hypertension was a negative predictor for it.

Clinical spectrum and risk factors associated with asymptomatic erosive esophagitis as determined by Los Angeles classification: A cross-sectional study

BACKGROUND

Gastro esophageal reflux disease (GERD) is a chronic and recurrent disease, and it varies in regions. However, to date, there are no reports available on clinical features and the risk factors for the asymptomatic reflux esophagitis in Nepalese adults.

METHODS

Data were gathered from 142 erosive patients who had undergone endoscopy at Bir Hospital, Kathmandu. Los Angeles classification was used to grade the severity of the disease. Patients were interviewed to find out the presence of various reflux symptoms.

RESULTS

Based on the Los Angeles classification, the severity of the disease assessed was; grade A 31.8% (31/142), grade B 39.4% (56/142), grade C 33.8% (48/142), and grade D 4.9% (7/142). One hundred and twenty six (88.7%) subjects had reflux symptoms. Prevalence of asymptomatic esophagitis was 16(11.3%). Age was independently linked to asymptomatic esophagitis (P<0.05), and the odd of being asymptomatic appeared lower in younger adults (P<0.05; OR: 0.118; CI: 0.014-.994).

CONCLUSION

A low prevalence of asymptomatic reflux esophagitis (RE) was seen. Most subjects experienced mild to moderate RE. Age remained an independent factor associated with reflux esophagitis, and the odds of being asymptomatic was lower in younger age.

Adam, Eve and the reflux enigma: age and sex differences across the gastro-oesophageal reflux spectrum

INTRODUCTION

We present demographic differences across the gastro-oesophageal reflux disease (GORD) spectrum in a UK District General Hospital.

PATIENTS AND METHODS

Data were prospectively collected over 37 years. At endoscopy patients were categorized as: erosive oesophagitis (EO), Barrett's oesophagus (BO) or nonerosive reflux disease (NER). Analysis 1: comparison of EO, BO and NER 1977-2001 when the database for GORD without BO closed. Analysis 2: demographic differences in oesophageal adenocarcinoma (OAC) in total BO population diagnosed 1977-2011.

RESULTS

GORD 1977-2001 (n=11 944): sex, male predominance in EO and BO but not NER; male : female ratios, 1.81, 1.65, 0.87, respectively (P<0.0001); mean age at presentation, EO 54 years, BO 62 years, NER 50 years; women were older than men by 10, 7 and 6 years, respectively.BO 1977-2011: prevalent OAC, 87/1468 (6%); male : female ratio, 4.1 (P<0.0001); incident OAC, 54/1381 (3.9%); male : female ratio, 3.5 (P<0.0001). Among all BO, more men developed OAC (3 vs. 0.9%). Within each sex, proportion of OAC higher among men (4.9 vs. 2.3%); at OAC diagnosis women were slightly but not significantly older (69.9 vs. 72.3 years, P=0.322).

CONCLUSION

Two views may explain our findings. First, women have either milder reflux, or reduced mucosal sensitivity hence reflux remains silent for longer. Alternatively, women genuinely develop reflux later, that is, are more protected and for longer from developing GORD and its complications. Early evidence is emerging that female sex hormones may indeed have a protective role in GORD during the reproductive period. We suggest reflux and its consequences may be an example of 'protection' conferred on Eve.

Fundoplication for laryngopharyngeal reflux despite preoperative dysphagia

INTRODUCTION Fundoplication for laryngopharyngeal disease with oesophageal dysmotility has led to mixed outcomes. In the presence of preoperative dysphagia and oesophageal dysmotility, this procedure has engendered concern in certain regards. METHODS This paper describes a consecutive series of laryngopharyngeal reflux (LPR) patients with a high frequency of dysmotility. Patients were selected for surgery with 24-hour dual channel pH monitoring, oesophageal manometry and standardised reflux scintigraphy. RESULTS Following careful patient selection, 33 patients underwent fundoplication by laparoscopy. Surgery had high efficacy in symptom control and there was no adverse dysphagia. CONCLUSIONS Evidence of proximal reflux can select a group of patients for good results of fundoplication for atypical symptoms.

Relevance of sleep disturbance to the integrity and characteristics of secondary peristalsis in patients with gastroesophageal reflux disease

OBJECTIVE

Sleep disturbance is common in patients with gastroesophageal reflux disease (GERD). Secondary peristalsis is important for clearance of the refluxate from the esophagus. We aimed to test the hypothesis whether secondary peristalsis is impaired in GERD patients with sleep disturbance.

METHODS

Secondary peristalsis was stimulated with slow and rapid air injections into mid-esophagus in 8 age-matched health controls and 41 patients with GERD. Sleep disturbance was assessed by the Pittsburg Sleep Quality Index (PSQI). Objective sleep measures were assessed by ambulatory actigraphy.

RESULTS

The threshold volume for inducing secondary peristalsis during slow air injection was significantly higher in GERD patients with sleep disturbance than healthy controls (14.3 ± 1.2 vs. 8.9 ± 0.5 mL, p < .05). GERD patients with sleep disturbance had higher threshold volume of secondary peristalsis during rapid air injection than GERD patients without sleep disturbance (5.1 ± 0.4 vs. 3.9 ± 0.2 mL, p < .05) and healthy controls (5.1 ± 0.4 vs. 3.6 ± 0.2 mL, p < .05). There was a negative correlation between PSQI score and peristaltic frequency during rapid air injection (r = -.39, p = .01). Secondary peristaltic amplitude during rapid air injection was negatively correlated with wake after sleep onset (r = -.34, p = .04).

CONCLUSIONS

Sleep disturbance is associated with secondary peristaltic response to distension-induced esophageal stimulation in patients with GERD. Our study suggests that sleep disturbance per se may adversely influence the effectiveness of esophageal peristalsis and bolus clearance during sleep in patients with GERD.

Sleep disturbance and enhanced esophageal capsaicin sensitivity in patients with gastroesophageal reflux disease

BACKGROUND AND AIM

Esophageal infusion of capsaicin-containing red pepper sauce induced heartburn symptoms in patients with gastroesophageal reflux disease (GERD). We aimed to test the hypothesis whether sleep disturbance modulates esophageal sensitivity to capsaicin infusion in patients with GERD.

METHODS

We enrolled 40 patients with their sleep quality measured by the Pittsburg Sleep Quality Index with > 5 indicating sleep disturbance. Esophageal sensation to capsaicin infusion was documented via measures of lag time to initial heartburn perception, heartburn intensity rating, and sensitivity score by esophageal infusion of capsaicin-containing red pepper sauce. Objective sleep measures were assessed by ambulatory actigraphy.

RESULTS

We found 22 patients with sleep disturbance. The patients with sleep disturbance had shorter lag time to initial heartburn perception (P = 0.03) and greater sensory intensity rating (P = 0.02). The sensitivity score for capsaicin infusion was greater in patients with sleep disturbance when compared with those without sleep disturbance (P = 0.04). Actigraphy measures revealed that patients with sleep disturbance also had poor sleep efficiency (P = 0.04), longer average awakening time (P = 0.03), and greater total activity account (P = 0.04). The lag time for perceiving capsaicin infusion was positively correlated with total sleep time (r = 0.43, P = 0.03).

CONCLUSIONS

We have shown that GERD patients with sleep disturbance have significantly enhanced heartburn perception to capsaicin infusion as compared with those with normal sleep. Our findings suggest that sleep disturbance is associated with esophageal hypersensitivity to capsaicin infusion in patients with GERD.

Effect of asthma and PTSD on persistence and onset of gastroesophageal reflux symptoms among adults exposed to the September 11, 2001, terrorist attacks

BACKGROUND

Little is known about the direction of causality among asthma, posttraumatic stress disorder (PTSD), and onset of gastroesophageal reflux symptoms (GERS) after exposure to the 9/11/2001 World Trade Center (WTC) disaster.

METHODS

Using data from the WTC Health Registry, we investigated the effects of early diagnosed post-9/11 asthma and PTSD on the late onset and persistence of GERS using log-binomial regression, and examined whether PTSD mediated the asthma-GERS association using structural equation modeling.

RESULTS

Of 29,406 enrollees, 23% reported GERS at follow-up in 2011-2012. Early post-9/11 asthma and PTSD were each independently associated with both the persistence of GERS that was present at baseline and the development of GERS in persons without a prior history. PTSD mediated the association between early post-9/11 asthma and late-onset GERS.

CONCLUSIONS

Clinicians should assess patients with post-9/11 GERS for comorbid asthma and PTSD, and plan medical care for these conditions in an integrated fashion. Am. J. Ind. Med. 59:805-814, 2016. © 2016 Wiley Periodicals, Inc.

A Model for Predicting the Future Risk of Incident Erosive Esophagitis in an Asymptomatic Population Undergoing Regular Check-ups

Erosive esophagitis is a major risk factor for Barrett esophagus and esophageal adenocarcinoma. Information regarding the putative risk factors for developing erosive esophagitis is considerably heterogeneous; thus, a risk model is required to clinically predict the incidence of erosive esophagitis. This study was to derive and validate a predictive model for the incidence of developing erosive esophagitis after negative index endoscopy in a population subjected to routine health check-ups. This retrospective cohort study of health check-ups included 11,535 patients who underwent repeated screening endoscopy after >3 years from a negative index endoscopy. We used logistic regression analysis to predict the incidence of erosive esophagitis, and a Simple Prediction of Erosive Esophagitis Development score for risk assessment was developed and internally validated using the split-sample approach. The development and validation cohorts included 5765 patients (675 with erosive esophagitis [11.7%]) and 5770 patients (670 with erosive esophagitis [11.6%]), respectively. The final model included sex, smoking behavior, body mass index, hypertension, and the triglyceride level as variables. This model predicted 667 cases of erosive esophagitis, yielding an expected-to-observed ratio of 1.00 (95% confidence interval [CI], 0.92-1.07). A simplified 5-item risk scoring system based on coefficients was developed, with a risk of erosive esophagitis of 6.2% (95% CI, 5.2-7.1) for the low-risk group (score ≤2), 15.1% (95% CI, 13.5-16.6) for the intermediate-risk group (score ≤3, 4), and 18.2% (95% CI, 15.2-21.3) for the high-risk group (score ≥5). The discriminative performance of the risk-prediction score was consistent in the derivation cohort and validation cohort (c-statistics 0.68 and 0.64, respectively); the calibration was good (Brier score 0.099 and 0.1, respectively). In conclusion, a simple risk-scoring model using putative risk factors can predict the future incidence of developing erosive esophagitis in asymptomatic populations.

Gastroesophageal reflux in asymptomatic obese subjects: An esophageal impedance-pH study

AIM

To investigate the relationship between reflux and body mass index (BMI) in the asymptomatic obese population using the impedance-pH technique.

METHODS

Gastroesophageal reflux is frequent in the obese population. However, the relationship between acid reflux and BMI in asymptomatic obese people is unclear. Forty-six obese (BMI > 25 kg/m(2)) people were enrolled in this prospective study. We evaluated the demographic findings and 24-h impedance pH values of the whole group. Gas, acid (pH < 4), weak acid (pH = 4-7) and weak alkaline (pH ≥ 7) reflux parameters were analyzed.

RESULTS

The mean age of patients was 49.47 ± 12.24 years, and half of them were men. The mean BMI was 30.64 ± 3.95 kg/m(2) (25.14-45.58 kg/m(2)). BMI of 23 was over 30 kg/m(2). Seventeen patients had a comorbidity (hypertension, diabetes mellitus, or ischemic heart disease). Endoscopic examination revealed esophagitis in 13 of the 28 subjects (10 Grade A, 3 Grade B). The subjects were divided into two groups according to BMI (< 30 and > 30 kg/m(2)). Demographic and endoscopic findings, and impedance results were similar in these two groups. However, there was a positive correlation between BMI and total and supine pH < 4 episodes (P = 0.002, r = 0.414; P = 0.000, r = 0.542), pH < 4 reflux time (P = 0.015, r = 0.319; P = 0.003, r = 0.403), and DeMeester score (P = 0.012, r = 0.333).

CONCLUSION

Acid reflux is correlated with BMI in asymptomatic obese individuals.

Atypical symptoms and health-related quality of life of patients with asymptomatic reflux esophagitis

BACKGROUND AND AIM

Asymptomatic reflux esophagitis (RE) is simply regarded as RE without the typical reflux symptoms, but it is unknown whether patients with asymptomatic RE have atypical symptoms. The aim of this study was to examine the clinical characteristics and health-related quality of life (HRQOL) of patients with asymptomatic RE.

PATIENTS AND METHODS

Consecutive patients with RE were enrolled during January 2010 to August 2012, and of them, 41 who had taken acid-suppressing drugs were excluded, leaving 280 patients as the study group. The patients' symptoms were evaluated using a self-completed questionnaire (modified Frequency Scale for the Symptoms of gastroesophageal reflux disease [FSSG]), as well as an HRQOL questionnaire (SF-8). We defined the typical symptoms of RE as heartburn and regurgitation. Asymptomatic RE was defined if the total symptom score was 0 or the minimum (1 point) for typical reflux symptoms in the modified FSSG.

RESULTS

Of the 280 RE patients, 71.8% (n = 201) were symptomatic and 28.2% (n = 79) were asymptomatic. The atypical symptom scores were significantly lower in asymptomatic RE (2.2 ± 2.2) than in symptomatic RE patients (6.9 ± 5.2) (P < 0.0001), and the HRQOL scores were significantly higher in asymptomatic RE than in symptomatic RE (P < 0.0001). Sleep was significantly less disturbed and chronic cough less frequent in asymptomatic RE than in symptomatic RE.

CONCLUSION

Frequency and severity of atypical symptoms in patients with asymptomatic RE were significantly less than in patients with symptomatic RE, and the HRQOL score was significantly higher in those patients. These observations suggest a specific patient cohort that is truly unlikely to manifest symptoms.

Predictive factors of silent reflux in subjects with erosive esophagitis

BACKGROUND

Asymptomatic erosive esophagitis by definition is a condition lacking any reflux symptom.

AIMS

We aimed to investigate the prevalence of asymptomatic erosive esophagitis in a general population undergoing periodic health checkup.

METHODS

Consecutive subjects undergoing a medical checkup were enrolled for evaluation of reflux disease with upper endoscopy and a validated reflux questionnaire. The presence and severity of erosive esophagitis were evaluated. In all subjects, demographic characteristics and biochemical data were recorded, and sleep and psychological characteristics were assessed by means of self-administered Pittsburgh Sleep Quality Index score, Taiwanese Depression Questionnaire score, and State-Trait Anxiety Inventory score.

RESULTS

Of 2568 subjects eligible for this study, erosive esophagitis was found in 676 subjects (26.3%), in whom the proportions of asymptomatic and symptomatic erosive esophagitis were 59.2% (400 subjects) and 40.8% (276 subjects) respectively. At a univariate analysis, it was found that asymptomatic erosive esophagitis subjects were more frequently of female gender, of older age, with a lower level of education. They also showed less alcohol and tea consumption, less depression, less anxiety, lower serum level of triglyceride, and lower prevalence of metabolic syndrome. Multivariate analysis revealed that female sex (OR = 1.645, p = 0.0146) was a positive predictive factor for asymptomatic erosive esophagitis, whereas higher level of education (OR = 0.564, p = 0.044), higher Taiwanese Depression Questionnaire score (OR = 0.922, p < 0.001), and the presence of metabolic syndrome (OR = 0.625, p = 0.0379) were negative predictive factors.

CONCLUSIONS

Asymptomatic erosive esophagitis is a common feature in otherwise healthy subjects and is independently associated with female gender, lower education level, less depression, and lower prevalence of metabolic syndrome.

Prevalence of gastro-oesophageal reflux disease with upper gastrointestinal symptoms without heartburn and regurgitation

BACKGROUND

Symptomatically 'silent' gastro-oesophageal reflux disease (GORD) may be underdiagnosed.

OBJECTIVE

To determine the prevalence of untreated GORD without heartburn and/or regurgitation in primary care.

METHODS

Patients were included if they had frequent upper gastrointestinal symptoms and had not taken a proton pump inhibitor in the previous 2 months (Diamond study: NCT00291746). GORD was diagnosed based on the presence of reflux oesophagitis, pathological oesophageal acid exposure, and/or a positive symptom-acid association probability. Patients completed the Reflux Disease Questionnaire (RDQ) and were interviewed by physicians using a prespecified symptom checklist.

RESULTS

GORD was diagnosed in 197 of 336 patients investigated. Heartburn and/or regurgitation were reported in 84.3% of patients with GORD during the physician interviews and in 93.4% of patients with GORD when using the RDQ. Of patients with heartburn and/or regurgitation not identified at physician interview, 58.1% (18/31) reported them at a 'troublesome' frequency and severity on the RDQ. Nine patients with GORD did not report heartburn or regurgitation either at interview or on the RDQ.

CONCLUSIONS

Structured patient-completed questionnaires may help to identify patients with GORD not identified during physician interview. In a small proportion of consulting patients, heartburn and regurgitation may not be present in those with GORD.

Prevalence of asymptomatic erosive esophagitis and factors associated with symptom presentation of erosive esophagitis

OBJECTIVE

Asymptomatic erosive esophagitis (EE) is incidentally found during endoscopy for health screening. The authors have aimed to investigate the prevalence of asymptomatic EE in subjects undergoing health checkups and factors associated with symptom presentation of EE.

METHODS

Among the consecutive 13,342 adults who underwent esophagogastroduodenoscopy in health checkup programs of Ajou University Hospital from May 2010 to April 2011, 8840 subjects (5683 men and 3157 women; median age, 45 years) who met the enrollment criteria were included in the analysis. They completed a questionnaire that evaluated smoking, medication history, anxiety, depression, esophagopharyngeal symptoms, and dyspeptic symptoms. The mucosal damage of the esophagus was assessed using the Los Angeles classification system. Individuals who had EE but no esophagopharyngeal symptoms were classified into the asymptomatic EE group.

RESULTS

A total of 768 subjects were diagnosed with gastroesophageal reflux disease based on the occurrence of heartburn and/or acid regurgitation at least once a week. The prevalence of symptomatic and asymptomatic EE in 8840 subjects was 4.3% and 3.3%, respectively. About 43% of individuals with EE did not exhibit any esophagopharyngeal symptoms. Male gender and postprandial distress syndrome were independently associated with asymptomatic EE. Male gender, current smoking, anxiety, epigastric pain syndrome (EPS), and postprandial distress syndrome were independently associated with symptomatic EE. Compared with the asymptomatic EE group, anxiety and EPS were independent factors associated with symptomatic EE.

CONCLUSIONS

Asymptomatic EE is common in subjects undergoing a health checkup. The coexistence of anxiety or EPS appears to be the predictors for the symptom presentation of EE.

Laryngeal assessment by videolaryngostroboscopy in patients with rheumatoid arthritis

AIM

To evaluate the larynx involvement in patients with rheumatoid arthritis (RA) in a clinical setting and correlate with the different clinical features related to more aggressive disease.

METHODS

Cross-sectional study including 36 consecutive patients with RA. Reflux symptoms were evaluated by the Reflux Symptom Index (RSI) and vocal cord impairment by the Voice Handicap Index-10 (VHI-10). Laryngeal involvement was done by videolaryngostroboscopy (VLS).

RESULTS

The mean age was 56,3 ± 14 years with a mean disease duration of 2,6 ± 3,1 years (range 0-16 years). Voice use was considered as professional users in 33%. Twenty-four (67%) out of 36 patients had abnormal findings of VLS. One patient had larynx nodules (bamboo nodules). Eleven patients (31%) were diagnosed with muscle tension dysphonia, and there were symptoms and signs of pharyngeal-laryngeal reflux in 23 (64%) patients. No signs of cricoarytenoid joint impairment was found.

CONCLUSIONS

Organic larynx involvement was uncommon in patients with RA. However symptoms and signs of pharyngeal-laryngeal reflux were seen in around 60% of patients. There was no correlation between the clinical phenotype, severity of disease, immunological profile or treatment with VLS findings.

Management of Asymptomatic Erosive Esophagitis: An E-Mail Survey of Physician's Opinions

Background/Aims

The management of asymptomatic erosive esophagitis is controversial. We surveyed physicians' opinions on asymptomatic erosive esophagitis using e-mail.

Methods

All members of the Korean Society of Neurogastro-enterology and Motility were invited to answer the questionnaire on the treatment and follow-up of patients with asymptomatic erosive esophagitis by e-mail.

Results

A total of 73 members answered the questionnaire (response rate, 18%). As initial management, 41% of respondents chose pharmacologic treatment, whereas 59% chose nonpharmacologic treatment. In the case of pharmacologic treatment, proton pump inhibitors were the preferred medication. The most common treatment duration was 4 weeks (43%), followed by 8 weeks (38%), and 6 months (11%). Sixty-two percent of the respondents recommended follow-up endoscopy annually, whereas 29% chose no endoscopic follow-up. Thirty-four percent of the respondents answered that they would talk about reflux-related sleep disturbances. Only 25% of the respondents explained the possibility of Barrett's esophagus or esophageal adenocarcinoma to their patients.

Conclusions

There are substantial practice variations in the management of asymptomatic erosive esophagitis in Korea.

The relationship between existence of typical symptoms and psychological factors in patients with erosive esophagitis

Background/Aims

In Asian countries including Korea, the prevalence of gastroesophageal reflux disease (GERD) is on the rise and its clinical impact has been emphasized. The purpose of this study was to investigate the clinical characteristics of esophagitis patients with or without symptoms, and their association with psychological factors.

Methods

Subjects diagnosed as erosive esophagitis of Los Angeles-A or more in screening by upper gastrointestinal endoscopy were enrolled. Questionnaires regarding GERD symptoms and Symptom Checklist-90-Revision were used to identify the presence of psychological symptoms.

Results

There was no difference between the subjects' general characteristics (gender, age, body mass index, smoking and alcohol intake) according to the existence of typical symptoms in these patients with erosive esophagitis. Patients with typical GERD symptoms were more likely to have atypical symptoms, dyspepsia and higher scores on psychological symptoms (somatization, obsessive-compulsiveness and phobic anxiety) than those without.

Conclusions

Psychological symptoms and other gastrointestinal symptoms should be considered in the patients with erosive esophagitis.

Gastroesophageal reflux disease and airway hyperresponsiveness: concomitance beyond the realm of chance?

Gastroesophageal reflux disease and asthma are both quite common the world over, and they can coexist. However, the nature of the relationship between these two diseases remains unclear. In this study, we review controversial aspects of the relationships among asthma, airway hyperresponsiveness, and gastroesophageal reflux disease in adults and in children.

Clinical feature of asymptomatic reflux esophagitis in patients who underwent upper gastrointestinal endoscopy

BACKGROUND AND AIM

Prevalence of gastroesophageal reflux disease (GERD) varies in regions, but few reports on clinical features and quality of life (QOL) of asymptomatic GERD exist in Japan.

METHODS

Endoscopy was performed in our department between April 2008 and September 2010. Among 6409 cases answering Frequency of Scale for the Symptoms of GERD (FSSG) and SF8 QOL (PCS: physical component summary; MCS: mental component summary), proton pump inhibitor or histamine 2 receptor antagonist users were excluded, and 388 cases diagnosed as reflux esophagitis (RE) (Los Angeles Classification grade A, B, C, D) were analyzed. Asymptomatic cases with FSSG total score = 0 were defined as asymptomatic RE (AsymRE) and FSSG total score ≥ 1 as symptomatic RE (SymRE). Each clinical feature was analyzed.

RESULTS

The frequency of AsymRE was 11.6% of RE (AsymRE, n = 45; SymRE, n = 343). Patient characteristics in AsymRE, SymRE were male/female = 35/10; 239/104 (not significant), mean age (year) = 63.5 ± 14.3; 58.3 ± 12.7 (P < 0.01), body mass index = 23.9 ± 4.3; 23.5 ± 3.7 (ns), respectively. Regarding the grade of RE, grade A 80.0%, B 17.8%, C 2.2% and D 0% in AsymRE, and grade A 72.6%, B 24.8%, C 2.0% and D 0.6% in SymRE (ns). PCS in SF8 was AsymRE; SymRE = 51.8 ± 9.8; 49.0 ± 7.7 (P < 0.01) and MCS in SF8 was AsymRE; SymRE = 51.4 ± 9.4; 48.2 ± 7.6 (P < 0.01), respectively.

CONCLUSION

The prevalence of asymptomatic RE was high, particularly in elderly subjects. Unlike symptomatic RE, QOL was not impaired at all with asymptomatic RE. No differences were seen between groups in clinical features such as endoscopic severity of RE, indicating that asymptomatic RE is a condition that should not be overlooked clinically.

Screening for oesophageal cancer

Oesophageal cancer is a global health problem with high mortality due to the advanced nature of the disease at presentation; therefore, detection at an early stage significantly improves outcome. Oesophageal squamous-cell cancer is preceded by dysplasia and oesophageal adenocarcinoma is preceded by Barrett's oesophagus, which progresses to cancer via intermediate dysplastic stages. Screening to detect these preneoplastic lesions has the potential to substantially reduce mortality and morbidity. However, the risks and benefits of such programmes to individuals and to society need to be carefully weighed. Endoscopic screening is invasive, costly and error prone owing to sampling bias and the subjective diagnosis of dysplasia. Non-endoscopic cell-sampling methods are less invasive and more cost effective than endoscopy, but the sensitivity and specificity of cytological assessment of atypia has been disappointing. The use of biomarkers to analyse samples collected using pan-oesophageal cell-collection devices may improve diagnostic accuracy; however, further work is required to confirm this. The psychological and economic implications of screening as well as the feasibility of implementing such programmes must also be considered.

Distension of the esophagogastric junction augments triggering of transient lower esophageal sphincter relaxation

Patients with gastroesophageal reflux disease show an increase in esophagogastric junction (EGJ) distensibility and in frequency of transient lower esophageal sphincter relaxations (TLESR) induced by gastric distension. The objective was to study the effect of localized EGJ distension on triggering of TLESR in healthy volunteers. An esophageal manometric catheter incorporating an 8-cm internal balloon adjacent to a sleeve sensor was developed to enable continuous recording of EGJ pressure during distension of the EGJ. Inflation of the balloon doubled the cross-section of the trans-sphincteric portion of the catheter from 5 mm OD (round) to 5 × 11 mm (oval). Ten healthy subjects were included. After catheter placement and a 30-min adaptation period, the EGJ was randomly distended or not, followed by a 45-min baseline recording. Subjects consumed a refluxogenic meal, and recordings were made for 3 h postprandially. A repeat study was performed on another day with EGJ distension status reversed. Additionally, in one subject MRI was performed to establish the exact position of the balloon in the inflated state. The number of TLESR increased during periods of EGJ distension with the effect being greater after a meal [baseline: 2.0(0.0-4.0) vs. 4.0(1.0-11.0), P=0.04; postprandial: 15.5(10.0-33.0) vs. 22.0(17.0-58.0), P=0.007 for undistended and distended, respectively]. EGJ distension augments meal-induced triggering of TLESR in healthy volunteers. Our data suggest the existence of a population of vagal afferents located at sites in/around the EGJ that may influence triggering of TLESR.

Old age and male sex are associated with increased risk of asymptomatic erosive esophagitis: analysis of data from local health examinations by the Korean National Health Insurance Corporation

BACKGROUND AND AIMS

Silent gastroesophageal reflux disease (GERD) is often detected during routine screening esophagogastroduodenoscopy (EGD). However, the risk factors and clinical implications of silent GERD remain unclear. In the present study, we investigated the risk factors for asymptomatic erosive esophagitis by analyzing the local area health examination data.

METHODS

The Korean National Health Insurance Corporation provides a bi-annual health examination performed by qualified local hospitals for the early detection of cancer in medical insurance holders over 40 years of age. Participants who completed self-reported questionnaires on health, followed by EGD at the Myongji Hospital (Goyang, Korea), were enrolled in this study.

RESULTS

The data of a total of 5301 participants who underwent EGD between January 2005 and December 2008 were analyzed. The prevalence of erosive esophagitis was 6%. In the multivariate analysis, erosive esophagitis was strongly associated with an age greater than 60 years (odds ratio [OR]: 0.7, 95% confidence interval [CI]: 0.6-1.0), male sex (OR: 2.3, 95% CI: 1.7-3.0), hiatus hernia (OR: 2.9, 95% CI: 2.1-4.0), duodenal ulcer (OR: 1.6, 95% CI: 1.1-2.5), hypertension (OR: 1.5, 95% CI: 1.2-2.0), and smoking (OR: 1.4, 95% CI: 1.0-1.8). Of the 320 participants with erosive esophagitis, 145 (45.3%) were asymptomatic participants, and those who were more frequently greater than 60 years (OR: 1.8, 95% CI: 1.1-3.1) and male (OR: 1.8, 95% CI: 1.1-3.2).

CONCLUSIONS

Asymptomatic erosive esophagitis in adults older than 40 years is strongly associated with old age (≥ 60 years) and male sex compared with symptomatic erosive esophagitis.

Esophageal sensation and esophageal hypersensitivity - overview from bench to bedside

Noxious stimuli in the esophagus activate nociceptive receptors on esophageal mucosa, such as transient receptor potential, acid-sensing ion channel and the P2X family, a family of ligand-gated ion channels responsive to ATP, and this generates signals that are transmitted to the central nervous system via either spinal nerves or vagal nerves, resulting in esophageal sensation. Among the noxious stimuli, gastric acid and other gastric contents are clinically most important, causing typical reflux symptoms such as heartburn and regurgitation. A conventional acid penetration theory has been used to explain the mechanism of heartburn, but much recent evidence does not support this theory. Therefore, it may be necessary to approach the causes of heartburn symptoms from a new conceptual framework. Hypersensitivity of the esophagus, like that of other visceral organs, includes peripheral, central and probably psychosocial factor-mediated hypersensitivity, and is known to play crucial roles in the pathoegenesis of nonerosive reflux disease, functional heartburn and non-cardiac chest pain. There also are esophagitis patients who do not perceive typical symptoms. This condition is known as silent gastroesophageal reflux disease. Although the pathogenesis of silent gastroesophageal reflux disease is still not known, hyposensitivity to reflux of acid may possibly explain the condition.

Esophageal stricture and metaplasia following abdominoplasty

Numerous complications have been reported following abdominoplasty. In this report, the case of a 48-year-old woman who developed an esophageal stricture, and subsequently Barrett's esophagus, secondary to increased intra-abdominal pressure following abdominoplasty is presented.

Erosive esophagitis in asymptomatic subjects: risk factors

INTRODUCTION

Asymptomatic erosive esophagitis is a common yet rarely reported disease. The purpose of this study is to investigate the prevalence of asymptomatic erosive esophagitis and to identify the risk factors for this disease.

MATERIALS AND METHODS

In this study, we investigated 572 asymptomatic subjects undergoing health check-ups after upper gastrointestinal endoscopy. The severity of esophagitis was evaluated by the Los Angeles classification, and the independent risk factors for asymptomatic esophagitis were analyzed by the logistic regression method.

RESULTS

The results showed the prevalence of erosive esophagitis in asymptomatic subjects was 12% (70/572). In all asymptomatic subjects, erosive esophagitis was grade A (71%) or B (29%). Univariate analysis revealed that male gender, high body mass index (BMI), and consumption of tobacco, alcohol, tea, spicy foods, and betel nut were associated with the development of erosive esophagitis. Multivariate analysis revealed that male gender (OR, 3.8, 95% CI, 1.5-9.3) and high BMI (BMI 25-30: OR, 2.3, 95% CI, 1.3-4.2; BMI >30: OR, 3.8, 95% CI, 1.3-10.9) were independent predictors of erosive esophagitis.

CONCLUSION

Our data revealed male gender and high BMI are independent risk factors for asymptomatic erosive esophagitis.

Reflux oesophagitis in Italy (Diomede project)

AIMS

A multicentric observational study was performed to update the available information on reflux oesophagitis in Italy.

METHODS

In phase I, the number and severity of reflux oesophagitis diagnosed in 1 year (2003) were reported together with the associated endoscopic findings. In phase II, oesophagitis patients consecutively referred in a 3-month period were analysed. A multivariate analysis was used to identify the risk factors for severe oesophagitis.

RESULTS

253,992 upper endoscopies were collected. The overall prevalence of oesophagitis was 14.8% and the endoscopic findings associated with oesophagitis were hiatus hernia (46.3%), duodenal ulcer (10.7%), gastric ulcer (3.6%) and Barrett's oesophagus (2.9%). In phase II, 1542 reflux oesophagitis patients were analysed (60.3% males; mean age 50.7 +/-16.6 years). Only 53.4% of patients reported heartburn and/or regurgitation as main complaint. Severe symptoms, age > 50 years, hiatus hernia and male gender were identified as independent predictors of severe oesophagitis.

CONCLUSIONS

Oesophagitis is the most frequent among the peptic diseases of the upper gastro-intestinal tract. Only half of the oesophagitis patients reported typical reflux symptoms as dominant. Advanced age, male gender, severe symptoms and hiatus hernia were independent risk factors for severe disease.

Natural history of aging in Cornelia de Lange syndrome

Observations about the natural history of aging in Cornelia de Lange syndrome (CdLS) are made, based on 49 patients from a multidisciplinary clinic for adolescents and adults. The mean age was 17 years. Although most patients remain small, obesity may develop. Gastroesophageal reflux persists or worsens, and there are early long-term sequelae, including Barrett esophagus in 10%; other gastrointestinal findings include risk for volvulus, rumination, and chronic constipation. Submucous cleft palate was found in 14%, most undetected before our evaluation. Chronic sinusitis was noted in 39%, often with nasal polyps. Blepharitis improves with age; cataracts and detached retina may occur. Decreased bone density is observed, with occasional fractures. One quarter have leg length discrepancy and 39% scoliosis. Most females have delayed or irregular menses but normal gynecologic exams and pap smears. Benign prostatic hypertrophy occurred in one male prior to 40 years. The phenotype is variable, but there is a distinct pattern of facial changes with aging. Premature gray hair is frequent; two patients had cutis verticis gyrata. Behavioral issues and specific psychiatric diagnoses, including self-injury, anxiety, attention-deficit disorder, autistic features, depression, and obsessive-compulsive behavior, often worsen with age. This work presents some evidence for accelerated aging in CdLS. Of 53% with mutation analysis, 55% demonstrate a detectable mutation in NIPBL or SMC1A. Although no specific genotype-phenotype correlations have been firmly established, individuals with missense mutations in NIPBL and SMC1A appear milder than those with other mutations. Based on these observations, recommendations for clinical management of adults with CdLS are made.