Ambulatory reflux monitoring in GERD--which test should be performed and should therapy be stopped?

The Spectrum of Treatment Modalities for Gastroesophageal Reflux Disease (GERD): A Narrative Review

Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disease that is encountered and treated by physicians all over the world. It is a chronic and non-progressive condition. Symptoms can range from mild heartburn to chronic, recurrent, and severe symptoms like constant acid regurgitation, laryngitis, bad breath, otitis media, and severe heartburn, which can be debilitating to the patient. Hence, the administration of appropriate therapy according to the patient's severity of symptoms is imperative, more so because over-the-counter drugs like antacids are very common to treat GERD. Often, in some instances, mere changes in lifestyle prove highly effective in reversing GERD symptomatology. Depending on the severity, response to treatment, and presence or absence of complications, treatment with medical or surgical modalities can be decided. It has now been found that although the gold standard in medical therapy for GERD has been proton pump inhibitors (PPIs), there has been increasing research about their side effects and recurrence after treatment. Hence, newer anti-GERD drugs have been under trial, which has been discussed in detail in the review. The use of surgical fundoplications has drastically decreased and is being widely replaced by incisionless laparoscopic fundoplications and newer endoluminal techniques such as the LINX device. This review aims to compile the vast spectrum of treatment modalities for GERD, ranging from more contemporary diagnostic methods, lifestyle modifications, medical therapy, and surgical and endoluminal techniques, with a particular focus on newer directions.

Evaluation and Treatment of Patients with Persistent Reflux Symptoms Despite Proton Pump Inhibitor Treatment

Despite the exceptional efficacy of proton pump inhibitors (PPIs) in healing reflux esophagitis complicating gastroesophageal reflux disease (GERD), up to 40% of patients who take PPIs for GERD complain of persistent GERD symptoms. There is no clear consensus on the type, dosing, and duration of PPI therapy required to establish a diagnosis of PPI-refractory GERD symptoms, but most authorities do not consider patients "PPI-refractory" unless they have been on double-dose PPIs. This article discusses the mechanisms that might underlie heartburn that does not respond PPIs and an approach to the management of patients with PPI-refractory GERD symptoms.

pH Scores in Hiatal Repair with Transoral Incisionless Fundoplication

Background and Objectives

Transoral incisionless fundoplication is an alternative to traditional laparoscopic fundoplications. Recently, hiatal hernia repair combined with transoral incisionless fundoplication has become an accepted modification of the original procedure; however, outcomes information, particularly objective pH monitoring, has been sparse. We retrospectively review the subjective and objective outcomes of transoral incisionless fundoplication combined with hiatal hernia repair.

Methods

Ninety-seven consecutive patients presenting for reflux evaluation were reviewed for outcomes after evaluation and treatment. Fifty-five patients proceeded to hiatal hernia repair with transoral incisionless fundoplication. Twenty-nine patients (53%) were found to have matched preoperative and postoperative validated surveys and pH evaluations.

Results

There were no serious complications. The mean followup was 296 days (SD, 117 days). The mean Gastroesophageal Reflux Disease Health Related Quality of Life score improved from 33.7 (SD, 22.0) to 9.07 (SD, 13.95), P < .001. The mean Reflux Symptom Index score improved from 20.32 (SD, 13) to 8.07 (SD, 9.77), P < .001. The mean pH score improved from 35.3 (SD, 2.27) to 10.9 (SD, 11.5), P < .001. Twenty-two of the 29 patients were judged to have an intact hiatal repair with transoral incisionless fundoplication (76%). Of the 22 patients with an intact hiatal repair and intact fundoplication, 21 (95%) had normalized their pH exposure.

Conclusions

In this retrospective review, hiatal hernia repair combined with transoral incisionless fundoplication significantly improved outcomes in patients with gastroesophageal reflux disease in both subjective Gastroesophageal Reflux Disease Health Related Quality of Life and Reflux Symptom Index measurements as well as in objective pH scores.

Natural history, pathophysiology and evaluation of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common diseases encountered by both internists and gastroenterologists. GERD can cause a wide variety of symptoms ranging from heartburn and regurgitation to more atypical symptoms such as cough, chest pain, and hoarseness. The diagnosis is often times made on the basis of history and clinical symptomatology. The prevalence of GERD is currently estimated to be 8-33% with the incidence of disease only expected to increase over time. Although most cases of GERD can be diagnosed based on symptoms and clinical presentation, the diagnosis of GERD can be challenging when symptoms are atypical. In this review, we provide a comprehensive summary of the epidemiology, pathophysiology, evaluation and diagnosis of gastroesophageal reflux disease.

The high frequency of esophageal disorders in Iranian patients with non-cardiac chest pain

AIM

The aim of this study was to evaluate the prevalence of gastrointestinal disorders in non-cardiac chest pain (NCCP) Iranian patients.

BACKGROUND

Gastro-esophageal reflux disease (GERD) is the most common cause of NCCP, which accounts for about one third of cases.

METHODS

This was a descriptive study on consecutive NCCP patients who referred to the gastroenterology clinic at the Taleghani Hospital, Tehran, Iran from 2015 to 2017. Medical history, physical examination and esophageal test including upper gastroenterology (UGI) endoscopy, esophageal manometry and 24 hour ambulatory esophageal pH monitoring were done for each participant.

RESULTS

The study included 102 patients, of which 58.9% were women, and the mean age of patients was 41.5 ± 11.2 years. The most common symptoms associated with chest pain were regurgitation in 28.4%, dysphagia in 23.5% and heartburn in 19.6% patients. UGI endoscopy was abnormal in 29.4% cases, esophageal manometry was abnormal in 61.7% cases and ambulatory pH monitoring was abnormal in 37.2% patients. Using UGI endoscopy and combined 24-h pH monitoring determined the prevalence of GERD 44.1% , and based on manometry the most frequent causes of NCCP was ineffective esophageal motility (IEM) in 19.6% patients with NCCP.

CONCLUSION

Detecting etiology of NCCP allows healthcare providers to assure patients of the benign nature of their condition and provide appropriate treatment. It can also help prevent excessive hospital and physician visits as well as the costly and potentially risky testing which often results.

Is the Routine Use of Impedance Analysis for the Diagnosis of Gastro-Esophageal Reflux Disease More Expensive than Conventional pH Monitoring? Cost Analysis of Two Procedures

Conventional 24-h pH monitoring is the gold standard for the diagnosis of non-erosive, non-acidic gastro-esophageal reflux disease. Multichannel Intraluminal Impedance (MII) analysis markedly improves diagnostic accuracy of non-erosive, non-acidic gastro-esophageal reflux disease. However, MII catheters are more expensive than standard catheters. This study aimed to determine the rates of acid or non-acid reflux and by making a retrospective projection, to predict the costs of two algorithms. We retrospectively reviewed the medical data of 102 patients who presented to our hospital with suspected non-erosive GERD and underwent 24 h impedance/pH-monitoring. Demographic characteristics, Demeester scores, number of reflux episodes, and results of impedance analysis were recorded. According to these data, cost was calculated either for the scenario in which impedance measurement was performed solely or following a negative conventional pH monitoring. Thirty-seven of all 102 patients (36.3 %) had a Demeester score greater than 14.7. These patients were assigned as group 1 (acid reflux). The impedance analysis of the remaining 65 patients detected 34 patients (33.3 %) to have more than 50 reflux episodes over a period of 24 h and assigned as Group 2, and 31 patients (30.4 %) had no reflux (group 3). The cost of the single- step algorithm using MII catheter was calculated as $15,300, while the total cost of two-step scenario would have been predicted as $16,890. Our study showed that an initial conventional pH monitoring can make the diagnosis of GERD in only one third of the patients with suspected non-erosive GERD. In nearly two-thirds of patients, however, repeated procedures and use of impedance catheters are needed. It is clear that this algorithm has certain drawbacks with regard to cost, patient comfort, and workforce loss.

The Quality of Care for Gastroesophageal Reflux Disease

Improving the quality of healthcare delivery is a cornerstone of modern medical care shared between all stakeholders. However, effectively improving quality requires both an understanding of the tenets of healthcare quality and how they relate to an individual disease process. This is especially important for common diseases, such as gastroesophageal reflux disease (GERD), where wide variations in practice exist. The high prevalence of GERD coupled with wide variation in clinical approach results in significant economic burden and poor quality of care. Thus, GERD serves as a useful framework to highlight the opportunities and current challenges of delivering high-quality care. In this article, we identify quality metrics in GERD and the areas in need of research to improve the quality of the management of GERD. Additionally, we suggest strategies for improvement as it relates to the proper diagnostic testing utilization and the decision-making process.

Chronic cough: a gastroenterology perspective

PURPOSE OF REVIEW

The purpose of this review is to highlight recent work and provide recommendations on the approach for diagnosis and management of chronic cough in a gastroenterology clinic.

RECENT FINDINGS

Chronic cough is a burdensome symptom affecting a large number of patients and contributes significant cost to the healthcare system. Recent work has shown that select patients may benefit from acid-suppressive therapy and even surgery when there is true pathologic evidence of reflux disease with cough. However, judicious use and proper interpretation of diagnostic testing for gastroesophageal reflux in the setting of cough is important to avoid unnecessary or inappropriate therapy.

SUMMARY

Chronic cough remains a vexing problem for many physicians, including gastroenterologists. It is important that physicians approach refractory cough in a multidisciplinary manner. Future research is needed to better understand the likely central hypersensitivity response mediating reflux-related cough and potential alternative approaches to therapy.