ReQuest-- the challenge of quantifying both esophageal and extra-esophageal manifestations of GERD

A nocturnal decline of salivary pH associated with airway hyperresponsiveness in asthma

Salivary pH is associated with esophageal acid reflux and neutralization of esophageal acid. In this study, we assessed the association between nocturnal decline of salivary pH and airway hyperresponsiveness. Salivary pH was serially assessed in 9 patients with mild asthma (7 men and 2 women; mean age 33.3 years; mean %predicted FEV(1.0) 89.4%) and 10 healthy volunteers (6 men and 4 women; mean age 31.2 years) using a pH indicator tape. The buffering capacity of saliva was defined as the median effective dose (ED(50)) for acidification of saliva with 0.01 N HCl, and airway responsiveness was defined as the dose of methacholine producing a 35% fall in Grs (PD(35)-Grs). There was a significant correlation between the values obtained from the pH indicator tape and those obtained from the electrometric pH meter. Using the indicator tape for sequential monitoring, we observed a nocturnal fall (ΔpH) in salivary pH in all subjects. A significant correlation was found between airway hyperresponsiveness (PD(35)-Grs) and either ΔpH or ED(50) in mildly asthmatic patients. Vagal reflux dysfunction might contribute to nocturnal salivary pH as well as to airway hyperresponsiveness in mild asthmatics.

Utility of non-endoscopic investigations in the practical management of oesophageal disorders

The current available methods for diagnosis of GORD are symptom questionnaires, catheter and wireless pH-metry, impedance-pH monitoring and Bilitec(@). Osophageal pH monitoring allows both quantitative analysis of acid reflux and assessment of reflux-symptom association. Impedance-pH monitoring detects all types of reflux (acid and non-acid) and allows assessment of proximal extent of reflux, a relevant parameter for understanding symptoms perception and extraoesophageal symptoms. Bilitec provides a quantitative assessment of duodeno-gastro-oesophageal reflux. Oesophageal motor abnormalities have been associated with GORD symptoms as well as chest pain and dysphagia. High-resolution manometry contributed to re-classify oesphageal motor disorders. However, barium swallows are still essential for evaluation of oesophageal anatomy and combined oesophageal manometry-impedance can assess oesophageal motility and bolus transit simultaneously in a non-radiological way. Still in experimental phase, high-frequency ultrasound allows monitoring of the oesophageal wall thickness and exaggerated longitudinal muscle contraction that might be associated to chest pain and dysphagia. This chapter provides a critical evaluation of the clinical application of these techniques.

Impact of PPIs on patient focused symptomatology in GERD

About half of patients with gastroesophageal reflux disease (GERD) have a normal endoscopy, so symptom assessment is the only appropriate outcome measure for these persons. Symptom assessment is also of great importance in persons with erosive esophagitis. There is currently no fully validated questionnaire to compare symptom response to treatment of patients with GERD. The aim of this review is to consider ReQuest^™ assessment tool to evaluate esophageal, supra-esophageal, and infra-esophageal symptoms, as well as any modification of the patient’s quality of life. The ReQuest^™ may be combined with the Los Angeles classification of esophagitis (LA A–D), to include the normal endoscopic finding in normal endoscopy reflux disease. The ReQuest^™ score declines rapidly towards normal with patient treatment with a proton pump inhibitor. A proportion of patients need more than the usual 8 weeks of therapy. For example, in GERD patients with Los Angeles B–D, the ReQuest^™ score falls more with pantoprazole 40 mg than with esomoprazole 40 mg after 12 weeks of therapy. Now that the simplified ReQuest in Practice^™ is available, this validated brief questionnaire has potential as an instrument for use in GERD patients seen in everyday clinical practice.

Comparison of endoscopic findings with symptom assessment systems (FSSG and QUEST) for gastroesophageal reflux disease in Japanese centres

BACKGROUND AND AIM

We compared endoscopic findings of the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), a written questionnaire developed in Japan, to that for the questionnaire for the diagnosis of reflux esophagitis (QUEST) for the diagnosis of reflux esophagitis.

METHODS

We registered 475 patients with untreated symptoms of upper abdominal pain (male/female: 252/223, average age 52.4 +/- 17.8 years). Subjects were assessed first with the FSSG and QUEST questionnaires, then by endoscopy, before allocation to a gastric ulcer (GU), duodenal ulcer (DU), gastroesophageal reflux disease (GERD) or functional dyspepsia (FD) group.

RESULTS

On the basis of the endoscopic findings the diagnoses for the 475 subjects were as follows: FD 52.2%, DU 7.6%, GU 7.8%, and GERD 32.4% (Grade M 10.1%, Grade A + B 20.2%, Grade C + D 2.3%). There was no difference between the FSSG and QUEST in sensitivity, specificity or accuracy for any condition. The FSSG score rose with increasing endoscopic severity of GERD, but there was no correlation between the QUEST score and endoscopic severity. The FSSG total score was inferior to QUEST in terms of distinguishing GERD from other conditions, but when only the questions relating to reflux symptoms were used, the FSSG was able to distinguish GERD from other conditions as well as QUEST.

CONCLUSIONS

The FSSG score reflects the severity of the endoscopic findings of GERD.

Tradução e validação para a língua portuguesa (Brasil) de instrumentos específicos para avaliação de qualidade de vida na doença do refluxo gastroesofágico

INTRODUÇÃO: Estudos têm demonstrado ser a doença do refluxo gastroesofágico capaz de alterar a qualidade de vida e a produtividade no trabalho dos doentes por ela acometidos. Instrumentos para esse tipo de avaliação são provenientes, em sua maioria, de países de língua inglesa e/ou francesa. A utilização desses instrumentos em nosso meio demanda criterioso processo de tradução e validação. OBJETIVOS: Traduzir para língua portuguesa os questionários GERD-HRQL (Gastroesophageal Reflux Disease - Health Related Quality of Life), HBQOL (Heartburn Specific Quality of Life Instrument) e GSAS (Gastroesophageal Reflux Disease Symptom Assessment Scale) específicos para avaliação de qualidade de vida na doença do refluxo gastroesofágico. Testar suas propriedades psicométricas de confiabilidade e validade. MÉTODOS: Cento e trinta e dois pacientes com doença do refluxo gastroesofágico (idade média 54,9 anos, ± DP 13,9) atendidos no ambulatório de motilidade digestiva da Universidade Federal de São Paulo, SP, e de gastrocirurgia da Faculdade de Medicina de São José do Rio Preto, SP, aceitaram participar do presente estudo, fornecendo termo de consentimento pós-esclarecimento. Destes, 40 pacientes participaram da fase de pré-teste (28 do sexo feminino e 12 do sexo masculino, com idade média de 55,3 anos, ± DP 14,7) e 92 da fase de validação (64 do sexo feminino e 28 sexo masculino, com idade média 54,7 anos e ± DP 13,7). A tradução e adaptação cultural foi realizada de acordo com o método de GUILLEMIN et al., sendo a validação dos questionários traduzidos (GERD-HRQL, HBQOL e GSAS) realizada em relação aos instrumentos genérico SF-36 e sintomático ESDRGE (SQGERD). RESULTADOS: A adaptação cultural implicou na troca de quatro palavras no GERD-HRQL, seis no HBQOL e nove no GSAS. Posteriormente a esta fase, o questionário GSAS foi abandonado por problemas no cálculo do escore, sendo as propriedades de medidas testadas nos dois questionários remanescentes, esses se mostraram reprodutíveis para uso inter e intra-observador com valores de 0,980 e 0,968, respectivamente, para o GERD-HRQL, e valores que variaram de 0,868 a 0,972, respectivamente, para o HBQOL. O questionário HBQOL demonstrou alta consistência interna (>0,70) para três das quatro dimensões avaliadas (aspecto físico, dor, sono). Os resultados encontrados na fase de validação apresentaram bons níveis de correlação com os questionários SF-36 e ESDRGE (SQGERD). CONCLUSÕES: As versões para a língua portuguesa (Brasil) dos instrumentos GERD-HRQL e HBQOL, adaptadas ao padrão cultural brasileiro, configuram-se em opções válidas, confiáveis, com baixo nível de desgaste do paciente e de fácil aplicação para avaliação de qualidade de vida na DRGE em nosso meio. O instrumento HBQOL é a única opção de avaliação multidimensional de qualidade de vida atualmente disponível para uso no Brasil. A versão em português do instrumento GSAS mostrou-se inadequada para avaliação de qualidade de vida na DRGE em nosso meio.

Gastroesophageal reflux disease and irritable bowel syndrome: a common overlap syndrome

Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) are very common disorders in the general population. Symptoms of IBS are commonly encountered in GERD patients, and symptoms of GERD are not uncommon in IBS patients. GERD patients consistently report lower abdominal symptoms, which may be part of the spectrum of GERD symptoms. Alternatively, GERD and IBS may be two distinct manifestations of a similar underlying pathophysiologic process that can affect different levels of the gastrointestinal tract. Although the reason for the overlap observed between GERD and IBS remains to be elucidated, recent studies have demonstrated that GERD patients who also suffer from IBS-like symptoms perceive their GERD-related symptoms as more severe and are less likely to respond to antireflux treatment, as compared with those without IBS.

Review article: quality-of-life issues in gastro-oesophageal reflux disease

The purpose of this review is to explore issues relating to quality of life in gastro-oesophageal reflux disease, examining the range of generic and disease-specific instruments available, their applicability and limitations and to overview the effect of gastro-oesophageal reflux disease on quality of life. Whereas instruments have been developed to assist researchers, there is a paucity of reliable instruments for pragmatic use in the clinical setting. The situation is complicated because there is not necessarily a direct correlation between endoscopic findings and symptom severity and non-erosive reflux disease is now recognized as an important manifestation of gastro-oesophageal reflux disease. However, quality-of-life instruments are useful in evaluating the impact of therapies and interventions, although these are limited, particularly in surgical interventions. Impaired quality of life now forms part of a definition of gastro-oesophageal reflux disease, the impact of which goes beyond the symptoms alone. While the symptoms themselves have a negative effect on sufferers' lives, there are secondary effects caused by impaired physical, emotional and social functioning on productivity. Non-gastrointestinal problems caused by gastro-oesophageal reflux disease also impair quality of life. There is an ongoing need to develop instruments which truly measure the impact of gastro-oesophageal reflux disease and which are readily interpretable to the individual patient and clinician.