Relaxation training reduces symptom reports and acid exposure in patients with gastroesophageal reflux disease

Biobehavioral approach to distinguishing panic symptoms from medical illness

Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.

The association between symptoms of gastroesophageal reflux disease and perceived stress: A countrywide study of Sri Lanka

BACKGROUND/AIMS

Stress is a known associated factor for gastroesophageal reflux disease (GERD). However, the dynamics between stress and GERD are not fully studied, especially in Sri Lanka. Our objective was to assess it.

METHODS

For this cross-sectional descriptive study, 1200 individuals (age ranged 18-70 years, mean 42.7 years [SD 14.4 years], 46.1% males), were recruited using stratified random cluster sampling from all 25 districts of Sri Lanka. An interviewer-administered questionnaire, which included a country-validated GERD symptom screening tool, and the Perceived Stress Scale (PSS), was used to assess GERD symptoms and stress. Probable GERD was defined as those having heartburn and/ or regurgitation at least once per week which is on par with globally accepted criteria. Those who did not fulfill these criteria were considered as controls.

RESULTS

PSS score was higher in those with probable GERD (mean 13.75 [standard deviation (SD) 6.87]) than in controls (mean 10.93 [SD 6.80]), (p <0.001, Mann-Whitney U test). The adjusted odds ratio for GERD symptoms was 1.96 times higher (95% confidence interval 1.50-2.55) in the moderate to high-stress level compared to the low-stress level participants. PSS score correlated significantly with the GERD screening tool score (R 0.242, p <0.001). Heartburn, regurgitation, chest pain, cough, and burping were significantly frequent in those with moderate to high-stress levels (p <0.001). Those with higher stress scores were more likely to use acid-lowering drugs (p = 0.006).

CONCLUSIONS

Individuals exposed to higher levels of stress are more likely to have GERD symptoms. Therefore, stress reduction should be an important part of GERD symptom management.

Factors that Impact Day-to-Day Esophageal Acid Reflux Variability and Its Diagnostic Significance for Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common disease affecting a significant number of adults both globally and in the USA. GERD is clinically diagnosed based on patient-reported symptoms, and the gold standard for diagnosis is ambulatory reflux monitoring, a tool particularly utilized in the common scenario of non-response to therapy or atypical features. Over the past 20 years, there has been a shift toward extending the duration of reflux monitoring, initially from 24 to 48 h and more recently to 96 h, primarily based on a demonstrated increase in diagnostic yield. Further, multiple studies demonstrate clinically relevant variability in day-to-day acid exposure levels in nearly 30% of ambulatory reflux monitoring studies. For these reasons, an ongoing clinical dilemma relates to the optimal activities patients should engage in during prolonged reflux monitoring. Thus, the aims of this review are to detail what is known about variability in daily acid exposure, discuss factors that are known to influence this day-to-day variability (i.e., sleep patterns, dietary/eating habits, stress, exercise, and medications), and finally provide suggestions for patient education and general GERD management to reduce variation in esophageal acid exposure levels.

Postoperative Gastrointestinal Complaints After Laparoscopic Nissen Fundoplication

PURPOSE

To investigate the postoperative gastrointestinal complaints and their effects on the satisfaction level of patients after laparoscopic Nissen fundoplication (LNF).

MATERIALS AND METHODS

Over a 7-year period, 553 patients who underwent "floppy" LNF were evaluated for preoperative and postoperative complaints. For this purpose, a set of questions derived from gastroesophageal reflux disease-health-related quality-of-life questionnaire (GERD-HRQL) was used. A P-value of <0.05 was considered to show a statistically significant result.

RESULTS

The present study included 215 patients with a mean follow-up of 60 months. Reflux-related symptoms [regurgitation (17.7%), heartburn (17.2%), and vomiting (3.7%)] and nonspecific symptoms [bloating (50.2%), abdominal pain (15.3%), and belching (27%)] showed a significant decrease (P<0.001) after the surgery. Inability to belch (25.1%) and early satiety (29.3%) were the newly emerged symptoms. The percentage of patients with flatulence increased from 23.3% to 38.1% after LNF. There was no significant difference for dysphagia (25.6%) and diarrhea (15.3%) in the postoperative period. Of the patients, 15.3% had recurrent preoperative complaints and 9.8% were using drugs for that condition. Satisfaction level and preference for surgery were 82.8% and 91.6%, respectively. There was no significant difference in GERD-HRQL score according to body mass index.

CONCLUSIONS

This is the first study in which postoperative reflux-related and nonspecific gastrointestinal complaints are analyzed together for a long follow-up period. We found a significant decrease in many reflux-related and nonspecific symptoms. Although some disturbing complaints like inability to belch, early satiety, and flatulence emerged, the preference for surgery did not change.

Anxiety Disorders and Medical Comorbidity: Treatment Implications

Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).

Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus

OBJECTIVE

Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus.

METHODS

A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations.

RESULTS

A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer.

CONCLUSIONS

These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region.

The Proton Pump Inhibitor Non-Responder: A Clinical Conundrum

Gastroesophageal reflux disease (GERD) is a highly prevalent chronic condition where in stomach contents reflux into the esophagus causing symptoms, esophageal injury, and subsequent complications. Proton pump inhibitors (PPI) remain the mainstay of therapy for acid suppression. Despite their efficacy, significant proportions of GERD patients are either partial or non-responders to PPI therapy. Patients should be assessed for mechanisms that can lead to PPI failure and may require further evaluation to investigate for alternative causes. This monograph will outline a diagnostic approach to the PPI non-responder, review mechanisms associated with PPI failure, and discuss therapeutic options for those who fail to respond to PPI therapy.

The stomach-brain axis

The stomach has distinct functions in relation to the ingestion and handling of solids and liquids. These functions include storage of the food before it is gradually emptied into the duodenum, mechanical crushing of larger food particles to increase the surface area, secretion of an acidic enzyme rich gastric juice and mixing the ingested food with the gastric juice. In addition, the stomach 'senses' the composition of the gastric content and this information is passed via the vagal nerve to the lateral hypothalamus and the limbic system, most likely as palatability signals that influence eating behaviour. Other sensory qualities related to the stimulation of gastric tension receptors are satiety and fullness. Receptors that respond to macronutrient content or gastric wall tension influence appetite and meal related hormone responses. The ingestion of food - in contrast to an infusion of nutrients into the stomach - has distinct effects on the activation of specific brain regions. Brain areas such as thalamus, amygdala, putamen and praecuneus are activated by the ingestion of food. Gastric nutrient infusion evokes greater activation in the hippocampus and anterior cingulate. The brain integrates these interrelated neural and hormonal signals arising from the stomach as well as visual, olfactory and anticipatory stimuli that ultimately influence eating and other behavioural patterns. Furthermore, there is now good evidence from experimental studies that gastric afferents influence mood, and animal studies point towards the possibility that gastric dysfunction may be a risk factor for mood disorders such as anxiety and depression. The stomach is also not only colonised by Helicobacter pylori but a large array of bacteria. While there is sufficient evidence to suggest that H. pylori may alter caloric intake and mood, the role of other gastric microbiome for the brain function is unknown. To address this appropriate targeted gastric microbiome studies would be required instead of widely utilised opportunistic stool microbiome studies. In summary, it is now well established that there are important links between the brain and the stomach that have significant effects on gastric function. However, the stomach also influences the brain. Disturbances in the crosstalk between the stomach and the brain may manifest as functional GI disorders while disturbances in the stomach-brain communication may also result in an altered regulation of satiety and as a consequence may affect eating behaviour and mood. These observations may enable the identification of novel therapies targeted at the gastroduodenum that positively alter brain function and treat or prevent conditions such as obesity or functional gastrointestinal disorders.

Nonmedical therapeutic strategies for nonerosive reflux disease

There has been a marked decline over the last several years in drug development for gastroesophageal reflux disease and specifically for nonerosive reflux disease (NERD), despite there being many areas of unmet need. In contrast, we have seen a proliferation, during the same period of time, in development of novel, nonmedical therapeutic strategies for NERD using cutting-edge technology. Presently, compliance and lifestyle modifications are readily available noninvasive therapeutic interventions for NERD. Other nonmedical therapies include, the Stretta procedure, transoral incisionless fundoplication, and the magnetic sphincter augmentation device (LINX). Antireflux surgery, in experienced hands, has been repeatedly shown to be efficacious in resolving NERD-related symptoms. Psychological therapeutic interventions and alternative medicine techniques, such as acupuncture, continue to show promise, especially in NERD patients who failed antireflux treatment.

Psychological modulation in patients surgically intervened for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) has been related with certain psychological dimensions. The influence of mood, emotional intelligence, and perceived quality of life on clinical symptoms and outcome of antireflux surgery was evaluated in GERD patients with and without hiatal hernia. The study included 61 patients who were diagnosed with GERD between 2003 and 2008: 16 of them without hiatal hernia (group A) and 45 of them with hiatal hernia (group B). All of these patients had undergone laparoscopic antireflux surgery. Patients were clinically examined and evaluated with the following instruments: Short Form (SF)-36 Health Survey, Gastrointestinal Quality of Life Index, Hospital Anxiety and Depression (HAD) Scale, and Trait Meta-Mood Scale (TMMS)-24. Proportions were compared by using the chi-squared test; averages were compared by using the Student's t-test (with Bonferroni's correction). In general, our patients intervened for GERD showed results lower than normal or close to the lower limit of normal in the administered tests. Patients in the group without hernia were younger (P < 0.001) and with lower American Society of Anaesthesiologists risk. They showed higher scores in the SF-36 dimensions: Physical Functioning, Physical Role and Emotional Role, and lower scores in the Social Role (P < 0.001). They showed lower scores in the Emotional dimension of Gastrointestinal Quality of Life Index (P = 0.0068) and worse results in the Hospital Anxiety and Depression subscales of Anxiety (P < 0.001) and Depression (not significant). Men in the group without hernia showed higher scores than men in the group with hernia in the TMMS subscales corresponding to Emotional Clarity and Emotional Repair (P < 0.001). Women in the group with hernia showed higher scores than women in the group without hernia regarding Emotional Clarity (P = 0.0012). GERD patients showed poor results in all the tests, and patients without hiatal hernia compared with patients with hernia showed higher levels of anxiety, which interfered with their social life. Moreover, they showed lower tolerance to stress and higher frustration, fear, and worry. On the basis of such unfavorable phychoemotional results observed with GERD patients (especially those without hernia) in the different tests, we propose that improving our knowledge of the psychological profile of GERD patients - particularly those without hiatal hernia - could help in designing individualized medical and psychological therapies and increase success rates.

Medical treatments of GERD: the old and new

The mainstay of pharmacological therapy for GERD is gastric acid suppression with proton pump inhibitors (PPIs), which are superior to histamine-2 receptor antagonists for healing erosive esophagitis and achieving symptomatic relief. However, up to one-third of patients may not respond to PPI therapy, creating the need for alternative treatments. Potential approaches include transient lower esophageal sphincter relaxation inhibitors, augmentation esophageal defense mechanisms by improving esophageal clearance or enhancing epithelial repair, and modulation of sensory pathways responsible for GERD symptoms. This review discusses the effectiveness of acid suppression and the data on alternative pharmacological approaches for the treatment of GERD.

Functional esophageal disorders: a review of diagnosis and management

Functional esophageal disorders are a group of conditions that present with symptoms presumed to originate in the esophagus and otherwise not detected in an objective manner with available diagnostic tests. The diagnosis is typically made after the exclusion of gastroesophageal reflux disease and a primary esophageal motility abnormality such as achalasia or distal esophageal spasm. Functional heartburn, functional chest pain of presumed esophageal origin, functional dysphagia and globus are the four functional esophageal disorders as defined in the ROME III consensus criteria. The dietary, pharmacological and psychological therapies that are used for managing these difficult-to-treat conditions are based on limited evidence as of this date. Although diagnostic algorithms can separate hypersensitive esophagus from functional esophageal disorders, a therapeutic and most likely a pathophysiologic overlap between these conditions may exist. In this comprehensive review, the authors present an overview of diagnostic approaches to each of these functional esophageal disorders and summarize available evidence on existing management strategies.

Functional heartburn: definition and management strategies

Functional heartburn (FH) is a functional gastro-intestinal disorder characterized by symptoms of heartburn not related to gastro-esophageal reflux. The absence of evidence of reflux-related symptoms relies on absence of esophagitis at endoscopy (including biopsies to exclude eosinophilic esophagitis), a normal esophageal acid exposure during esophageal pH-monitoring together with a negative symptom-reflux association analysis and an unsatisfactory response to proton pump inhibitor therapy. Addition of impedance measurement to pH-monitoring is likely to increase the number of patients with recognized reflux-related symptoms. The pathophysiology of functional heartburn remains largely unknown but involves disturbed esophageal perception and psychological factors such as depression, anxiety and somatization. The treatment of FH remains largely empirical and an individual approach is therefore recommended. The clinician should provide reassurance and refrain from performing too many invasive tests or therapeutic procedures. The use of pain modulators is recommended by most experts despite the lack of appropriate clinical trials to support it.

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.

Functional chest pain responds to biofeedback treatment but functional heartburn does not: what is the difference?

BACKGROUND

Patients with functional esophageal disorders represent a challenging treatment group. The purpose of this study was to evaluate the role of biofeedback in the treatment of patients with functional esophageal disorders.

METHODS

In this prospective study, patients with typical/atypical symptoms of gastroesophageal reflux disease underwent upper endoscopy and 24-h pH monitoring. All patients filled out gastroesophageal Reflux Disease Symptom, Hospital Anxiety and Depression, and Symptom Stress Rating questionnaires. Patients with functional heartburn and those with functional chest pain were offered biofeedback treatment. A global assessment questionnaire was filled out at the end of treatment and then 2.8 (range 1-4) years later.

RESULTS

From January 2006 to December 2009, 22 patients with functional esophageal diseases were included in the study. Thirteen had functional heartburn and nine had functional chest pain. Six patients from each group received biofeedback treatment. After treatment for 1-4 years, patients with functional chest pain showed significant improvements in symptoms compared with those who were not treated. Patients with functional heartburn showed no improvement. Patients with functional chest pain had a longer time of esophageal acid exposure than those with functional heartburn.

CONCLUSION

Patients with functional chest pain have different central and intraesophageal factors associated with symptom generation in comparison with patients with functional heartburn. Biofeedback is a useful tool in the treatment of patients with functional chest pain, but not for those with functional heartburn.

Endoscopic esophagitis is more severe in gastroesophageal reflux patients with a positive family history

BACKGROUND

The role of genetic factors in the etiology of gastroesophageal reflux disease (GERD) is still uncertain.

AIM

To define whether the presence of reflux symptoms in first-degree relatives can affect the severity of the endoscopic picture of patients with GERD and disease evolution during follow-up.

PATIENTS/METHODS

A total of 1930 consecutive patients with GERD were referred for endoscopy from Trikala prefecture, had an entry endoscopy and a follow-up if needed. Before endoscopic evaluation, all patients and their first-degree relatives completed Reflux Symptom Questionnaire. Patients were followed up for 4 years with Reflux Symptom Questionnaire every 6 months.

RESULTS

A total of 258 (62.9%) patients with positive and 724 (47.6%) with negative family history of GERD had esophagitis (P<0.0001). Seventy-six (74.5%) patients with more than 1 family member with GERD had esophagitis (P<0.0001). During follow-up endoscopic picture was aggravated in 101 (25%) patients with positive and 46 (3%) with negative family history. A total of 359 (24%) of GERD patients with negative and 24 (10%) with positive family history managed to stop proton pump inhibitors during follow-up (P<0.0001). In logistic regression analysis: age, male sex, presence of hiatal hernia, family history of GERD, tranquilizer use, frequency, and duration of reflux symptoms were independently associated with presence of esophagitis.

CONCLUSIONS

Although we cannot overlook the importance of confounding factors such as body weight and/or psychological factors, we found that endoscopic picture is more severe among GERD patients with at least 1 first-degree relative with GERD. During follow-up, patients with negative family history had more chances to wean off proton pump inhibitors after life-style modifications.

The effect of antireflux treatment on patients with gastroesophageal reflux disease undergoing a mental arithmetic stressor

BACKGROUND

Acute stress exacerbates heartburn in gastroesophageal reflux disease (GERD) patients by enhancing the perceptual responses to intraesophageal acid. The aim of the study was to determine if antireflux treatment can still alter stimulus response functions to acid in patients undergoing acute stress as compared with placebo.

METHODS

Symptomatic GERD patients with erosive esophagitis (EE) or an abnormal pH test were included. Patients underwent stimulus response functions to intraesophageal acid perfusion using the mental arithmetic stressor test. Thereafter, patients were randomized (2 : 1 ratio) to either esomeprazole 40 mg once daily or placebo for 8 weeks. On the last day of treatment, subjects underwent stimulus response functions to intraesophageal acid perfusion using a similar stressor as baseline.

KEY RESULTS

A total of 31 patients were randomized into the treatment arm (mean age 48.6 ± 2.8, M/F 21/10) and 16 into the placebo arm (mean age 52.3 ± 4.3, M/F 12/4). In the esomeprazole group, there was a significant increase in lag time to symptom perception (P = 0.02) and decreased in intensity rating (P = 0.01) as well as acid perfusion sensitivity score (P = 0.01). There was no significant difference in any of the stimulus response functions to acid in the placebo group between baseline and treatment. Interpersonal sensitivity was the only independent clinical predictor factor for response to antireflux treatment.

CONCLUSIONS & INFERENCES

Long-term antireflux treatment with a proton pump inhibitor is effective in reducing esophageal perception responses to acid during acute stress.

Do patients with globus sensation respond to hypnotically assisted relaxation therapy? A case series report

Globus sensation is a bothersome and difficult symptom to treat. The aims of this study were to evaluate the acceptability and utility of hypnotically-assisted relaxation (HAR) in decreasing the perception of globus sensation and the effect of HAR on interdeglutitive upper esophageal sphincter (UES) pressure. Sixteen subjects with persistent globus sensation unresponsive to therapy for reflux disease and with normal esophageal/laryngeal imaging studies were invited to participate in a 7-session clinical protocol. Before and after HAR, subjects completed standard questionnaires including the esophageal symptoms questionnaire. High-resolution manometric assessment of respiratory augmentation and average resting UES pressure were assessed before and after HAR. Ten of the 16 subjects agreed to participate in the protocol. All participants were women with median age 51.5 (range 30-72 years). The participants found HAR acceptable and completed the entire 7-session trial. Globus symptom severity varied widely pre-treatment (median=52.5, range 16-72), and 9 of 10 subjects reported a reduction in globus symptomatology following treatment (median=14.0, range 3-19; P=.007). Only 1 subject exhibited abnormal respiratory augmentation of UES pressure (>27 mm Hg) prior to treatment and was normal following treatment (9.9 mm Hg). Resting UES pressure was normal in all subjects (<118 mm Hg). Group respiratory augmentation and average resting UES pressure were unaffected by HAR (P=.48, .89). This case series suggests that HAR can provide a substantial improvement in globus sensation irrespective of cause. UES function was unaffected. We suggest that HAR therapy is an acceptable and useful intervention for patients with globus sensation.

Prevalence of temporomandibular disorders in patients with gastroesophageal reflux disease: a case-controlled study

PURPOSE

The present study estimated the prevalence of temporomandibular disorders (TMDs) in patients with gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

A study group consisting of 60 adult patients (34 women and 26 men) diagnosed with GERD was matched by age and gender to a control group of 60 patients without any signs or symptoms of GERD. The diagnosis of TMD was established using the Research Diagnostic Criteria for Temporomandibular Disorders.

RESULTS

Of the 60 patients in the study group, 22 (36.6%) had TMD compared with 11 (18.3%) in the control group (P = .025). Most patients with TMD in both groups were diagnosed with myofascial pain: 19 (31.7%) in the study group versus 9 (15%) in the control group (P = .031).

CONCLUSIONS

The increased TMD prevalence in patients with GERD should be explored further to better characterize the association between TMD and GERD. The physicians treating the 2 disorders should consider the clinical implications of this association.

Does acute psychological stress increase perception of oesophageal acid?

Gastro-oesophageal reflux disease (GORD) patients often report an increase in their reflux symptoms during stressful situations. The aim of this study was to assess the influence of acute psychological stress on oesophageal acid perception. In 15 healthy volunteers and 10 GORD patients with a positive symptom-reflux association an oesophageal acid perfusion test was performed, once with and once without the presence of an acute psychological stressor (IQ test). The order of the measurements was randomized. The time from onset of the acid infusion to first acid perception, discomfort and pain was noted. Blood pressure was measured to assess the effect of the stress task. In healthy volunteers, the time to first perception (control task: 617 +/- 174 s vs stress task: 561 +/- 162 s), discomfort (control task: 969 +/- 158 s vs stress task: 940 +/- 151 s) or pain (control task: 1393 +/- 122 s vs stress task: 1366 +/- 121 s) did not differ significantly between both measurements. In GORD patients, no significant differences between both measurements were found either in time to first perception (control task: 63 +/- 26 s vs stress task: 43 +/- 15 s), discomfort (control task: 153 +/- 44 s vs stress task: 249 +/- 62 s) or pain (control task: 558 +/- 139 s vs stress task: 633 +/- 118 s). Systolic blood pressure rose significantly during the stress task in both the healthy volunteers (6 +/- 1 mmHg) and the GORD patients (9 +/- 2 mmHg). Neither in the healthy volunteers nor in the GORD patients, the acute psychological stress induced by an IQ test increased oesophageal acid perception. The observed increase in systolic blood pressure shows that the experimental stressors were effective.

Review article: gastro-oesophageal reflux disease and psychological comorbidity

BACKGROUND

A growing number of studies have shown the impact of psychological comorbidities on gastro-oesophageal reflux disease (GERD) patients' symptom reports and healthcare-seeking behaviour.

AIM

To review the reported relationship between GERD and psychological comorbidity.

METHODS

Review of the literature on GERD and psychological comorbidity.

RESULTS

Psychological comorbidity is common among GERD patients and appears to afflict all GERD phenotypes. Sexual and physical abuse is also common in GERD patients. Stress enhances perception of oesophageal acid exposure. Treatment for GERD, especially in those who are not responsive to antireflux treatment, may require further evaluation for psychological comorbidity.

CONCLUSIONS

Psychological comorbidity is very common in GERD patients and is likely to play an important role in response, or failure of response, to proton pump inhibitor treatment.

The effect of auditory stress on perception of intraesophageal acid in patients with gastroesophageal reflux disease

BACKGROUND & AIMS

Most patients with gastroesophageal reflux disease (GERD) report that stress exacerbates their symptoms, yet mechanisms underlying this association remain unknown. We sought to determine the effect of an acute laboratory stressor on perceptual and emotional responses to intraesophageal acid perfusion in healthy controls and patients with GERD.

METHODS

Forty-six patients with heartburn and 10 healthy controls underwent upper endoscopy and, if negative, pH monitoring. Assessment of psychologic factors and health-related quality of life was done by a questionnaire. Perceptual and emotional responses to intraesophageal acid at baseline, during auditory stress, and during an auditory control condition were determined using a randomized crossover design. Plasma levels of norepinephrine, adrenocorticotropic hormone, and cortisol were assessed.

RESULTS

Twenty-nine subjects were identified as nonerosive reflux disease and 17 as erosive esophagitis. Quality of life, psychologic profile, and personality assessment variables were similar among the 2 patient groups and the controls. There was a significant reduction in mean lag time to initial symptom perception and an increase in mean intensity rating and mean acid perfusion sensitivity score in the 2 patient groups during the stress period, which was not seen during the control condition. Healthy controls demonstrated lack of a significant change in all parameters of stimulus response functions to acid, regardless of condition.

CONCLUSIONS

Acute auditory stress can exacerbate heartburn symptoms in GERD patients by enhancing perceptual response to intraesophageal acid exposure. This greater perceptual response is associated with greater emotional responses to the stressor.

The influence of psychological factors on the outcomes of laparoscopic Nissen fundoplication

Background

Psychological factors play a role in a variety of gastrointestinal illness, including gastroesophageal reflux disease (GERD). Their impact on the surgical outcomes of antireflux surgery is unknown.

Methods

This is a single institution prospective controlled trial, comparing patients undergoing a laparoscopic Nissen fundoplication for GERD (LNF Group, n = 17) to patients undergoing an elective laparoscopic cholecystectomy for biliary colic (Control Group, n = 10). All patients had a psychological assessment before surgery, at 3 months and 6 months after surgery (i.e. Symptom CheckList-90-R somatization subset (SCL-90-R), Depression Anxiety Stress Scales, Anxiety sensitivity index, Illness attitude scale and Beck Depression Inventory II). GERD symptoms were recorded in the LNF Group using a standardized questionnaire (score 0–60). Patients with post-operative GERD symptoms score above 12 at 6 months were evaluated specifically. Statistical analysis was performed using a Student T test, and statistical significance was set at 0.05.

Results

There was no significant difference in preoperative and postoperative psychological assessment between the two groups. In the LNF Group, 7 patients had persisting GERD symptoms at 6 months (GERD score greater than 12). The preoperative SCL-90-R score was also significantly higher in this subgroup, when compared to the rest of the LNF Group (18.2 versus 8.3, p < 0.05) and to the Control Group (18.2 versus 7.9, p < 0.05). There was no significant difference for the other psychological tests.

Conclusion

The SCL-90-R Somatization Subset, reflecting the level of somatization in a patient, may be useful to predict poor outcomes after antireflux surgery. Cognisance of psychological disorders could improve the selection of an optimal treatment for GERD and help reduce the rate of ongoing symptoms after LNF.

Assessment of dietary nutrients that influence perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease symptoms are most commonly reported postprandially, suggesting that some diet components are likely to induce symptoms more than others.

AIMS

To determine which of the various dietary nutrients is a strong predictive factor for symptom generation in association with an acid reflux event.

METHODS

Subjects with typical heartburn symptoms were evaluated by the gastro-oesophageal reflux disease Symptom Checklist, demographics questionnaire, upper endoscopy and pH testing. During the pH study, patients completed a detailed 24-h dietary intake record. This included time of meals, description of food components and the amount and type of food preparation.

RESULTS

Fifty gastro-oesophageal reflux disease patients completed all stages of the study. A total of 112 (78%) symptoms were considered as sensed reflux event. Body mass index did not correlate with having perceived reflux. Patients who consumed more cholesterol, saturated fatty acids and had more percentage calories from fat were significantly more likely to experience a perceived reflux event. Regression analysis and beta-coefficient were specifically significant for cholesterol.

CONCLUSION

Of all dietary nutrients, cholesterol enhances the most the perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease.

Clinical consequences of silent gastroesophageal reflux disease

Silent gastroesophageal reflux disease (GERD) is a very common phenomenon that involves the incidental finding of erosive esophagitis, Barrett's esophagus, and the evolution of esophageal adenocarcinoma in asymptomatic patients. The reasons for having advanced GERD without clearly identifiable symptoms are poorly understood, primarily due to lack of recognition of this important phenomenon. The clinical implications of silent GERD are vast and should provide the impetus for further research into this group of patients. Recent studies have suggested that sleep disturbances and poor quality of sleep could be the needed clues to identify individuals with silent GERD.

Comparative analysis between psychological and endoscopic profiles in patients with gastroesophageal reflux disease: a prospective study based on screening endoscopy

BACKGROUND

Associations between psychological and endoscopic profiles are not clearly validated among the heterogeneous patients with gastroesophageal reflux disease (GERD). The purpose of the present paper was therefore to identify any associations by means of cross-sectional study.

METHODS

Consecutive participants in a health screening program were enrolled. Definition and severity of erosive esophagitis were assessed with Los Angeles classification. Frequency and severity of psychological symptoms were measured with a 30-item Brief Symptom Rating Scale (BSRS) and personality traits with a short form of the Maudsley Personality Inventory (MPI). Statistic analyses were performed based on the presence of GERD symptoms or endoscopic esophagitis.

RESULTS

A total of 4600 participants were recruited. There were 1331 subjects (29%) with manifestations suggesting GERD, including non-erosive reflux disease (NERD) in 488 (10.6%), symptomatic erosive esophagitis (SEE) in 164 (3.6%), and asymptomatic erosive esophagitis (AEE) in 679 (14.8%). The BSRS parameters were significantly higher in symptomatic subjects (i.e. NERD and SEE subjects; P < 0.001); neuroticism scores were also higher (P < 0.001), but extroversion scores (P < 0.001) were lower than those of asymptomatic subjects. Following logistic regression analysis, independent risk factors for GERD symptoms were female gender (odds ratio [OR]: 1.596; 95% confidence interval [CI]: 1.303-1.955) and higher neuroticism scores (OR: 1.046; 95%CI: 1.032-1.06). For erosive esophagitis, independent risk factors were male gender (OR: 2.943; 95%CI: 2.359-3.671) and higher body mass index scores (OR: 1.098; 95%CI: 1.069-1.127).

CONCLUSIONS

Psychological characteristics predict likelihood of GERD symptoms but not structural state of esophagus. Male gender and obesity are risk factors for erosive esophagitis; whereas female gender and neuroticism are more likely to be associated with GERD symptoms.

The effect of psychological stress on symptom severity and perception in patients with gastro-oesophageal reflux

OBJECTIVE

Using an experimental paradigm this investigation explored whether exposure to psychological stress would produce a significant increase in acid-reflux episodes or modify subjective perceptions of gastro-oesophageal reflux (GOR) symptoms.

METHODS

Forty-two patients presenting with heartburn and acid regurgitation underwent 24-h oesophageal pH monitoring. During the last 90 min of this monitoring period, 21 patients received a psychological stressor, while the remaining participants were randomly assigned to a no-stress control condition. State anxiety and subjective GOR symptom ratings were obtained 1 min pretest, 1 min posttest, and 40 min posttest. Cortisol samples were collected at 10-min intervals.

RESULTS

The stressor induced a significant increase in cortisol and state anxiety; however, this was not associated with any increase in reflux. Instead, the experimental group reported a dissociation between objectively measured reflux episodes and subjective symptom ratings. A similar pattern was established for participants who reported greater state anxiety, produced larger cortisol responses, or exhibited certain stress-related personality characteristics.

CONCLUSION

The perception of symptoms in the absence of increased reflux when one is stressed may account for low response rates to traditional treatments. This highlights a need to bridge the gap between psychosomatic research and clinical practice to develop more successful GOR therapies.

Gastroesophageal reflux

Gastroesophageal reflux disease (GERD) is the most common disease of the gastrointestinal system. Heartburn, regurgitation, and dysphagia are the most common symptoms of GERD. However, chest pain, chronic cough, laryngitis, hoarseness, and other otolaryngologic manifestation can be the primary manifestations of the disease. Endoscopy, barium studies, and especially pH monitoring and therapeutic trials may help in establishing the diagnosis of GERD. The introduction of H2 antagonists and especially of proton pump inhibitors (PPI) has brought symptomatic relief in most patients. However, surgical procedures, especially laparoscopic fundoplication, are still required in some patients. Barrett's esophagitis is the most common complication of GERD and is associated with a high prevalence of esophageal adenocarcinoma. Whether or not treatment with either PPIs or H2 antagonists can prevent this complication is still under investigation.

Facilitating treatment of anxiety disorders in patients with comorbid medical illness

Anxiety is a universal human response that usually is adaptive, allowing one to prepare for a perceived threat. This can be a normal coping mechanism when dealing with a medical illness that may require hospitalization, surgery, or painful procedures. It becomes maladaptive when it is persistent and leads to panic attacks, severe physical symptoms, and impairment in functioning. Most of these patients are treated by primary care providers who frequently fail to adequately recognize and treat anxiety disorders in their patients. This leads to increased health care costs and chronic disability. To reach this under-served group of patients, mental health practitioners need to collaborate with their primary care colleagues to provide screening tools and education on diagnosis and effective treatment of these disorders.

Stress and the gastrointestinal tract

Stress, defined as an acute threat to homeostasis, evokes an adaptive or allostatic response and can have both a short- and long-term influence on the function of the gastrointestinal tract. The enteric nervous system is connected bidirectionally to the brain by parasympathetic and sympathetic pathways forming the brain-gut axis. The neural network of the brain, which generates the stress response, is called the central stress circuitry and includes the paraventricular nucleus of the hypothalamus, amygdala and periaqueductal gray. It receives input from the somatic and visceral afferent pathways and also from the visceral motor cortex including the medial prefrontal, anterior cingulate and insular cortex. The output of this central stress circuit is called the emotional motor system and includes automatic efferents, the hypothalamus-pituitary-adrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term alteration in the stress response (plasticity). Corticotropin releasing factor (CRF) is a key mediator of the central stress response. Two CRF receptor subtypes, R1 and R2, have been described. They mediate increased colonic motor activity and slowed gastric emptying, respectively, in response to stress. Specific CRF receptor antagonists injected into the 0 block these visceral manifestations of stress. Circulating glucocorticoids exert an inhibitory effect on the stress response by receptors located in the medial prefrontal cortex and hippocampus. Many other neurotransmitters and neuroimmunomodulators are being evaluated. Stress increases the intestinal permeability to large antigenic molecules. It can lead to mast cell activation, degranulation and colonic mucin depletion. A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress also leads to increased susceptibility to colonic inflammation, which can be adaptively transferred among rats by sensitized CD4(+) lymphocytes. The association between stress and various gastrointestinal diseases, including functional bowel disorders, inflammatory bowel disease, peptic ulcer disease and gastroesophageal reflux disease, is being actively investigated. Attention to the close relation between the brain and gut has opened many therapeutic avenues for the future.

Heart rate variability in patients with different manifestations of gastroesophageal reflux disease

BACKGROUND

Autonomic nervous dysfunction has frequently been observed in patients with gastroesophageal reflux diseases (GERD) and impacts the pathogenesis of GERD. However, the characteristics that distinguish between GERD patients with different manifestations remain unknown.

AIM

To investigate the autonomic nervous function in subgroups of GERD patients.

PATIENTS

Of the 164 participants in this study, 57 were healthy controls, 34 had non-erosive reflux disease (NERD), 40 had symptomatic esophagitis (SE), and 33 asymptomatic esophagitis (AE).

METHODS

Resting autonomic activity was assessed by measuring the 5-min heart rate variability (HRV) and HRV indices including time-domain parameters (standard deviation of normal-to-normal intervals [SDNN] and root mean square of successive differences [RMSSD]) and frequency-domain parameters (low-frequency power [LF; 0.04-0.15 Hz], high-frequency power [HF; 0.15-0.4 Hz], and LF/HF power ratio). Mental stress was assessed by use of a self-reported questionnaire (Brief Symptom Rating Scale [BSRS]).

RESULTS

HF power was (ANOVA, p=0.041) but time-domain parameters, LF power, LF/HF power ratio, and BSRS parameters were not significantly different between the four groups. A higher HF power was found in examinees with NERD than in those with SE and AE (LSD methods: both p=0.02). When split into two groups (erosive vs. non-erosive), nearly all measures of autonomic tonus were significantly lower in the erosive than non-erosive group. Age and the presence of endoscopic esophagitis influenced the RMSSD and HF power results in the regression analysis. Mental stress or gender did not correlate with any HRV index.

CONCLUSION

In comparison with NERD subjects, autonomic tonus in patients with endoscopically confirmed esophagitis (even without symptom) is lower. This finding may suggest that the structural state of esophagus but not symptomatology dictates autonomic function status.

Factors contributing to failure of laparoscopic Nissen fundoplication and the predictive value of preoperative assessment

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has established itself as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). There are, however, few available data on the assessment of long-term failures after LNF.

METHODS

We sought to clarify the mechanisms of failure among a group of patients who reported suboptimal results after LNF. In addition, we attempted to identify specific elements in the preoperative evaluation of GERD patients that might herald a predisposition to anatomical or physiological failure.

RESULTS

One hundred and thirty-one consecutive patients who underwent LNF by a single surgeon were analyzed to identify reasons for surgical failure. Fourteen patients (10.6%) comprised the failure group. Detailed independent statistical analysis identified a hiatus hernia greater than 3 cm at operation (P = 0.003), abnormal preoperative pH analysis in the upright position (P = 0.039), failure to respond to proton pump inhibition preoperatively (P = 0.015), and a preoperative psychiatric history (P = 0.0012) as predictors of subsequent failure.

CONCLUSIONS

In patients who do not respond to proton pump inhibition preoperatively, the evaluating surgeon should be circumspect in advocating antireflux surgery. A detailed assessment of underlying psychiatric or psychological symptoms must also be made. If a large (>3 cm approximately) hiatus hernia is identified or there is abnormal pH analysis in the upright position preoperatively, the surgeon should be guarded about the long-term outcome, and patients should be advised accordingly.

The effect of life stress on symptoms of heartburn

OBJECTIVE

Psychosocial stressors have been associated with exacerbations of symptoms in functional and inflammatory disorders of the gastrointestinal tract. The present longitudinal study tests the general hypothesis that life stressors can exacerbate symptoms in patients with chronic heartburn.

METHODS

Sixty subjects with current heartburn symptoms were recruited by community advertisement and assessed for presence of stressful life events retrospectively over the preceding 6 months and prospectively for 4 months. Symptom severity by daily diary, quality of life, and psychological symptoms of anxiety, depression, and vital exhaustion were also measured.

RESULTS

The presence of a severe, sustained life stress during the previous 6 months significantly predicted increased heartburn symptoms during the following 4 months. In addition, symptoms showed a strong, independent correlation with vital exhaustion. Affective and subjective stress ratings were not strongly related to heartburn severity; however, anxiety showed the strongest relationship to impaired quality of life and depression to heartburn medication use.

CONCLUSIONS

As with other chronic conditions such as irritable bowel syndrome (IBS), heartburn severity appears to be most responsive to major life events and not an accumulation of more minor stressors or fluctuations in mood. In addition, vital exhaustion, which may in part result from sustained stress, may represent the psychophysiological symptom complex most closely associated with heartburn exacerbation. Potential mechanisms for these results include increased level and frequency of esophageal acid exposure, inhibition of gastric emptying of acid, or stress-induced hypersensitivity.

Psychological and emotional aspects of gastroesophageal reflux disease

A synergy exists between the psychological and physiological aspects of esophageal and other gastrointestinal symptoms. Based on a biopsychosocial model of disease, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) has been under study. This article reviews psychological and emotional factors influencing GERD symptoms and treatment.

Non-erosive reflux disease (NERD)--acid reflux and symptom patterns

BACKGROUND

Recent reports suggest that patients with non-erosive reflux disease (NERD) treated with anti-reflux medications show lower symptom improvement rates than patients with erosive oesophagitis treated with the same medications.

AIM

To determine the acid reflux and symptom patterns of patients with NERD in comparison with those with erosive oesophagitis and Barrett's oesophagus, and to identify different NERD subgroups.

METHODS

One hundred and forty-nine consecutive patients seen for classic heartburn symptoms were evaluated for the study. Oesophageal mucosal injury was assessed by upper endoscopy and classified by Hetzel-Dent criteria. Patients with Hetzel-Dent grades 0-1 were considered to have NERD. The extent of oesophageal acid exposure was determined by ambulatory 24-h oesophageal pH monitoring.

RESULTS

Seventy-one patients were found to have NERD, 36 erosive oesophagitis and 42 Barrett's oesophagus. Compared with patients with erosive oesophagitis (75%) and Barrett's oesophagus (93%), those with NERD (45%) were significantly less likely to have an abnormal pH test (P = 0.0001). Patients with Barrett's oesophagus had the highest mean number of acid reflux events (210 +/- 17.7), compared with those with erosive oesophagitis (139.7 +/- 15.2) and NERD (95.3 +/- 9.4) (P = 0.0001); however, the rate of perceived acid reflux events was similar and very low in all groups (NERD, 3.6%; erosive oesophagitis, 2.9%; Barrett's oesophagus, 2.17%). NERD-positive patients (abnormal pH test) had a similar extent of oesophageal acid exposure to those with erosive oesophagitis. NERD-positive patients were more likely to demonstrate a symptom index greater than 75% than NERD-negative patients (normal pH test) (61.9% vs. 10.5%; P = 0.0001). In the NERD-negative group, those with a negative symptom index reported having heartburn at pH < 4 only 12.7% of the time, compared with 70.7% of the time in those with a positive symptom index, despite a similar mean number of heartburn episodes.

CONCLUSIONS

Patients with NERD commonly demonstrate a negative pH test. Acid reflux characteristics and symptom patterns suggest a heterogeneous group of patients.

Gastroesophageal reflux disease: Presentation and assessment of a common, challenging disorder

Although gastroesophageal reflux disease (GERD) is frequently referred to as a continuous spectrum, it is more useful to consider GERD as 2 discrete entities with several subsets that differ in pathophysiology, clinical presentation, natural history, and therapy. One entity is classic severe acid reflux with erosive esophagitis and its complications. Barrett's esophagus is an important subset of this group, with markedly increased acid exposure and an increased risk of adenocarcinoma. The second entity is nonerosive reflux disease (NERD) with minimal or no esophagitis. Patients with NERD do not develop local mucosa complications, like stricture or Barrett's esophagus, but their symptom severity can equal that of erosive esophagitis. Acid is involved in the symptoms of many but not all NERD patients. This acid dependence is evident either as an increase in esophageal acid reflux or a hypersensitivity to acid, and both generally respond well to proton pump inhibitor (PPI) therapy. NERD patients who are not acid-dependent have what is called functional heartburn; GERD-like symptoms are present, but there is no obvious involvement of refluxed acid. An important subset of GERD is refractory GERD, which consists of patients who fail aggressive PPI therapy. Parallel findings with other refractory syndromes can be anticipated; however, there are indications that psychosocial factors play a major role in refractory GERD, and these patients may benefit more from an integrated biopsychosocial approach. Diagnosis of GERD is usually made on clinical grounds, often supplemented by a therapeutic trial with antisecretory agents. Endoscopy is reserved for patients with alarm symptoms, such as dysphagia, anemia, or weight loss, or to detect Barrett's esophagus. Endoscopy is not useful to exclude the diagnosis of GERD because it will be negative in 70% of cases in primary care. Ambulatory 24-hour esophageal pH monitoring is necessary only when the diagnosis is in doubt, the patient fails medical management, or surgery is contemplated.

Functional Heartburn

Functional heartburn is defined as the presence of a retrosternal burning sensation in the absence of pathologic gastroesophageal reflux. The underlying pathophysiology seems to be heterogeneous. In a subset of patients, esophageal hypersensitivity to physiologic esophageal acid exposure is involved, and this is likely to respond to intensive antireflux treatment. Antireflux surgery was not studied systematically in these patients and should be considered only in exceptional cases. In the remaining patients, non-acid reflux, esophageal mechanosensitivity, and psychological factors may be involved. Treatment options in these patients are limited owing to a lack of studies. Emerging therapies include selective serotonin reuptake inhibitors and relaxation therapy.

Review article: gastro-oesophageal reflux disease--pathophysiological issues of clinical relevance

Gastro-oesophageal reflux disease is a multifactorial disorder in which the pathophysiological mechanisms are variably combined in different patients. Motor dysfunction of the lower oesophageal sphincter (LOS) and, possibly, the proximal stomach is a major cause of the increase in the number of reflux episodes. Transient LOS relaxation is the main mechanism of reflux in many patients with endoscopically negative disease, whereas a hypotensive LOS becomes relevant only in patients with oesophagitis. Alterations in primary and secondary peristalsis contribute to the increased oesophageal acid exposure by delaying clearance. The presence of a hiatus hernia, especially when voluminous and/or non-reducible, increases the number of reflux episodes by mechanically weakening the oesophago-gastric junction, and impairs oesophageal clearance. Hypersensitivity to acid is often present and contributes to the clinical manifestations of the disease, whereas oesophageal hypersensitivity, both to chemical and mechanical stimuli, plays a predominant role in a subset of patients. Increased concentrations of noxious compounds in the oesophageal refluxate may contribute to the development of anatomical lesions, but this is still a matter for debate. The clinical relevance of Helicobacter pylori infection and of mucosal defensive factors still needs to be fully elucidated.

Nonerosive reflux disease--current concepts and dilemmas

Nonerosive reflux disease is defined as the presence of typical symptoms of gastroesophageal reflux disease caused by intraesophageal acid in the absence of visible esophageal mucosal injury at endoscopy. Recent studies demonstrate that it is a chronic disease with a significant impact on quality of life, and it is very common in primary care settings. Treatment with acid inhibitory agents is effective, and proton pump inhibitors are the most effective form of therapy.

Gastroesophageal reflux: practical management of a common, challenging disorder

Gastroesophageal reflux (GER) occurs in 2 distinct forms that differ in pathophysiology, clinical presentation, natural history, and therapy: mild GER (with no or minimal esophagitis) and classic, severe reflux (at risk for erosive esophagitis). A minority of subjects (< 20%) have the classic, potentially severe pattern of GER caused by reduced lower esophageal sphincter (LES) pressure and prolonged acid reflux, particularly at night, but also during the day. Evaluation and management must be catered to patients with this pattern of reflux. In contrast, symptoms in mild reflux (the majority) often occur during the day after meals in an upright posture (upright reflux); resting LES pressure is usually normal (reflux episodes are related to transient relaxation of the LES) and little reflux occurs at night. Acid reflux, which occurs mostly during the day, overlaps with the normal range and esophagitis is rare; however, symptoms can be distressing. Optimal management is controversial because no outcome trials have been conducted to address management in primary care settings. However, clinical clues can help differentiate mild and severe reflux and guide management decisions. This article provides a detailed approach to current management of GER syndromes.

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.

Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I Epidemiologic Followup Study. First National Health and Nutrition Examination Survey

PURPOSE

Gastroesophageal reflux disease is an important and increasingly common condition. Both overweight and high fat food consumption have been implicated as causes of reflux disease. We examined the relationship of overweight, high dietary fat intake, and other factors with reflux disease hospitalization.

METHODS

We studied participants in the first National Health and Nutrition Examination Survey, a population-based sample examined in 1971-75 and followed through 1992-93. Persons with a physician-diagnosed hiatal hernia at baseline or reflux disease hospitalization within the first five years of study were excluded. A second analysis included follow-up of 9851 participants free of reflux disease in 1982-84. Ninety-six percent of the baseline cohort were recontacted. Reflux disease cases were persons hospitalized with a diagnosis of esophagitis or uncomplicated hiatal hernia. Hazard rate ratios for reflux disease hospitalization according to body mass index (BMI) (kg/m2), total daily servings of high fat foods and other factors were calculated using Cox proportional hazards analysis.

RESULTS

A total of 12,349 persons were followed for a median of 18.5 years (range 5.0-22.1). Cumulative incidence of reflux disease hospitalization was 5.2% at 20 years. Multivariate survival analysis revealed higher reflux disease hospitalization rates with higher BMI (5 kg/m2) [hazard ratio (HR) = 1.22, 95% confidence interval (CI) = 1.13-1.32]. No relationship was found between higher fat intake and reflux disease hospitalization. Other factors associated with reflux disease hospitalization included age, low recreational activity, and history of doctor-diagnosed arthritis.

CONCLUSIONS

Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization.

Noncardiac chest pain: where does it start?

The pathogenesis of recurrent noncardiac chest pain remains an enigma. The literature suggests that it may be caused by a heightened state of visceral nociperception. Coronary atherosclerosis must first be excluded with a reasonable degree of certainty. The physician can then focus on reassuring the patient and continuing management, bearing in mind the caveat, first do no harm. Polypharmacy and hazardous procedures should be avoided. Aggressive acid suppression is helpful in patients with gastroesophageal reflux disease, and antidepressants have shown promise in otherwise unexplained cases of chest pain. Despite significant morbidity in patients with the disorder, the long-term prognosis is excellent.

Effect of acute stress on oesophageal motility in patients with gastro-oesophageal reflux disease

BACKGROUND AND AIM

Sixty four per cent of people with heartburn believe that it is exacerbated by stress. An alteration in oesophageal motility is one possible mechanism for this apparent change with stress. This study aimed to assess the effect of acute stressors on oesophageal motility in patients with gastro-oesophageal reflux disease (GORD).

METHODS

Sixty patients were studied. Twenty had oesophagitis, 20 had increased oesophageal acid exposure on pH monitoring but no endoscopic oesophagitis, and 20 had neither oesophagitis nor abnormal oesophageal acid exposure. Oesophageal motility was studied in these patients during psychological stress (Stroop test) and physical stress (cold pressor test).

RESULTS

Blood pressure (BP) and heart rate increased in response to both stressors (mean systolic BP increased by > 10 mm Hg, diastolic BP by > 4 mm Hg and heart rate by > 3 beats per minute (p < 0.00001). The amplitude, duration, and velocity of propagation of oesophageal peristaltic contractions were not altered by the stressors. The percentage of simultaneous waves increased in patients with oesophagitis during the cold pressor test (median increase in these patients was 6% (p < 0.05)). This effect was not noted in the patients without oesophagitis.

CONCLUSION

Acute stressors did not induce significant changes in oesophageal motility in patients with GORD but no oesophagitis. For these patients, dysmotility is not likely to be a cause of oesophageal symptoms which are exacerbated by stress. There was, however, a significant increase in simultaneous waves during cold pressor stress in patients with oesophagitis.