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Wolf U, Wegener M. Proton Pump Inhibitor Prescription in Nursing Home Residents: Prevalence, Appropriateness, and Associated Factors-A Secondary Data Analysis from Three German Regions and the Impact of Guideline Recommendations. Pharmaceuticals (Basel) 2024; 17:1082. [PMID: 39204187 DOI: 10.3390/ph17081082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 07/21/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024] Open
Abstract
Despite reliable evidence of adverse drug effects, the substantially increased prescription rates of proton pump inhibitors (PPIs) remain at a high level. This study analyzed the appropriateness of PPI prescriptions among residents of nursing homes in three regions of Germany. Baseline data of a cluster-randomized controlled trial were used to determine the prevalence of PPI prescriptions, the validity of indications, and the adequacy of the prescribed dosages according to 1. their drug approvals and 2. valid recommendation guidelines. Regression analyses were conducted to assess associated factors. A total of 437 residents in 37 nursing homes were included (mean age 83 ± 9.2 years, 72% women). The PPI prescription prevalence was 44% (n = 193). In 52/193 (27%) there was no adequate indication, and in 54 (39%) of 138 indicated PPI prescriptions it was overdosed. Yet, in only less than one-third (28%) of "adequate" prescriptions, the indication was according to the PPI approvals, whereas the majority (72%) were off-label indications in line with valid guideline recommendations. Non-indicated PPI prescription was associated with the total number of prescribed drugs (OR 1.32; 95% CI 1.18-1.62; p = 0.013). There were no associations with age, level of care dependency, cognitive impairment, prescription of psychotropic drugs, number of chronic diseases, number of physicians' consultations, or study region. To conclude, in 55%, the high prescription prevalence among residents was either not indicated or overdosed. In total, only 20% (39/193) of cases of PPI use complied with the approved indications. There is a need for quality control of 1. PPI administration in German nursing homes, and 2. of guideline recommendations expanding the off-label PPI use by 72% within the indication scale, predominantly from wide prescription for low-dose ASA.
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Affiliation(s)
- Ursula Wolf
- Pharmacotherapy Management, University Hospital Halle (Saale), 06120 Halle (Saale), Germany
- Institute of Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, 06112 Halle (Saale), Germany
| | - Martina Wegener
- Institute of Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, 06112 Halle (Saale), Germany
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2
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Galvarini M, Angeramo CA, Kerman J, Balmaceda R, Debes I, Herbella FAM, Schlottmann F. Outcomes of Endoscopic Antireflux Mucosectomy for the Treatment of Gastroesophageal Reflux Disease: Systematic Review and Meta-analysis. J Clin Gastroenterol 2024:00004836-990000000-00337. [PMID: 39145822 DOI: 10.1097/mcg.0000000000002061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
OBJECTIVE Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders in western countries. Endoscopic procedures have recently emerged as an alternative therapy to surgery for patients with GERD. The aim of this study was to determine outcomes after endoscopic antireflux mucosectomy (ARMS). METHODS A systematic review and meta-analysis were performed to analyze outcomes after ARMS. The main outcomes included patients' satisfaction, GERD health-related quality of life, use of proton pump inhibitors, and DeMeester score. The secondary endpoint was postprocedural adverse events. A meta-analysis of proportions was used to assess the effect of each approach on different outcomes. RESULTS A total of 22 studies comprising 654 patients were included for analysis. The mean age of patients was 51.83 (36 to 59.39) years, and the mean body mass index was 25.06 (23.5 to 27) kg/m2. The weighted pooled proportion of patient satisfaction after ARMS was 65% (95% CI: 52%-76%). The pooled proportion of patients taking proton pump inhibitors decreases from 100% to 40.84% (P < 0.001). The mean GERD health-related quality of life scores (pre 19.48 vs post 7.90, P < 0.001) and DeMeester score (pre 44.99 vs post 15.02 P = 0.005) significantly improved after ARMS. Overall morbidity rate was 27% (95% CI: 13%-47%), with a weighted pooled proportion of perforation, stricture, and bleeding of 3% (95% CI: 2%-6%), 12% (95% CI: 9%-16%), and 6% (95% CI: 2%-17%), respectively. CONCLUSIONS Endoscopic ARMS for GERD is associated with symptomatic improvement, reduction of medical therapy, and enhanced quality of life. Refinements of the technique, however, are needed to decrease morbidity.
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Affiliation(s)
- Martin Galvarini
- Department of Surgery, Sanatorio Argentino of San Juan, San Juan
| | | | - Javier Kerman
- Department of Surgery, Sanatorio Argentino of San Juan, San Juan
| | - Rubén Balmaceda
- Department of Surgery, Sanatorio Argentino of San Juan, San Juan
| | - Ignacio Debes
- Department of Gastroenterology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
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3
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Patel P, Layne S, Leiman DA. Regurgitation, eructation, and supragastric belch: retrograde esophageal motility, disorders, and treatment. Curr Opin Gastroenterol 2024:00001574-990000000-00163. [PMID: 39150445 DOI: 10.1097/mog.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW This review describes pathologic conditions of retrograde flow into the esophagus along with recent therapeutic advances and treatment options. RECENT FINDINGS The esophagus facilitates anterograde and retrograde movement of contents, the latter of which is mediated by transient lower esophageal sphincter relaxations (TLESRs). Gastroesophageal reflux disease (GERD) often includes esophageal-specific symptoms such as heartburn or regurgitation. Volume regurgitation responds less frequently to acid suppression with proton pump inhibitors (PPIs) than heartburn, given its relationship with incompetence of the esophagogastric junction (EGJ) and increased frequency of TLESRs. Therefore, although the refluxate pH can be altered with PPIs, the frequency of reflux episodes is generally not reduced and surgical and endoscopic treatments may be favored. Other instances of abnormal retrograde esophageal flow respond better to medical therapy, or lifestyle interventions. Compared to gastric belching because of increased stomach distension, supragastric belching is caused by intake of air from pharynx into the esophagus followed by rapid expulsion of air. These conditions can be distinguished on esophageal tests such as high-resolution manometry and are likely to respond to behavioral modifications. SUMMARY Retrograde flow into the esophagus can be a normal occurrence, but diagnostic testing to distinguish causes can guide appropriate intervention.
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Affiliation(s)
- Pooja Patel
- Division of Gastroenterology, Duke University
| | | | - David A Leiman
- Division of Gastroenterology, Duke University
- Duke Clinical Research Institute, Durham, North Carolina, USA
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4
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Xie L, Xu Y, Liu W, Zhou C, Guo L, Zhou S, Zhang C, Chen J, Zhu B, Ding S, Li H, Zhang L, Wang L, Xu L, Shao F, Wang L. Absorption, Metabolism, and Excretion of [ 14C]-Labeled Anaprazole: A New Proton Pump Inhibitor, After a Single Oral Administration in Healthy Chinese Male Subjects. Clin Pharmacol Drug Dev 2024. [PMID: 39101494 DOI: 10.1002/cpdd.1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/28/2024] [Indexed: 08/06/2024]
Abstract
Anaprazole is a proton pump inhibitor. This study aims to elucidate absorption, metabolism, and excretion pathways of anaprazole sodium in the human body. A total of 4 healthy Chinese male subjects were administered a single oral dose of 20 mg/100 µCi of [14C]-anaprazole sodium enteric-coated capsules. The whole blood, plasma, and excreta were analyzed for a total radioactivity (TRA) and metabolite profile. The cumulative radioactivity excretion rate was 93.2%, with 53.3% and 39.9% of the radioactive dose excreted in urine and feces, respectively, and 91.6% of dose recovered within 96 hours after dosing. The parent drug, anaprazole, showed good absorption and was extensively metabolized majorly to thioether M8-1 via nonenzymatic metabolism. Overall, 35 metabolites were identified in plasma, urine, and fecal samples. Anaprazole was the most abundant component in plasma followed by the thioether M8-1, accounting for 28.3% and 16.6%, respectively, of the plasma TRA. Thioether carboxylic acid XZP-3409 (26.3% of urine TRA) and XZP-3409 oxidation and dehydrogenation product M417a (15.1% of fecal TRA) were the major metabolites present in urine and feces, respectively. Anaprazole was undetectable in urine, while fecal samples showed traces (0.07% dose). Blood/plasma ratios of the radioactivity (approximately 0.60) remained consistent over time. Anaprazole showed good absorption and was extensively metabolized majorly to thioether M8-1 via nonenzymatic metabolism, and cytochrome P450 3A4 also contributed to its metabolism in healthy individuals.
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Affiliation(s)
- Lijun Xie
- Phase I Clinical Trial Unit, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Yanjun Xu
- Department of Medical Affairs, Xuanzhu Technology Co., Ltd, Shijiazhuang, China
| | - Wei Liu
- Department of Nuclear Medicine, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Chen Zhou
- Phase I Clinical Trial Unit, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Lian Guo
- Department of DMPK Service, Lab Testing Division, WuXi AppTec Co. Ltd., Nanjing, China
| | - Sufeng Zhou
- Phase I Clinical Trial Unit, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Chen Zhang
- Department of Nuclear Medicine, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Juan Chen
- Phase I Clinical Trial Unit, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Bei Zhu
- Phase I Clinical Trial Unit, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Sijia Ding
- Phase I Clinical Trial Unit, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Huan Li
- Department of DMPK Service, Lab Testing Division, WuXi AppTec Co. Ltd., Nanjing, China
| | - Lingling Zhang
- Department of DMPK Service, Lab Testing Division, WuXi AppTec Co. Ltd., Nanjing, China
| | - Li Wang
- Department of Medical Affairs, Xuanzhu Technology Co., Ltd, Shijiazhuang, China
| | - Lingmei Xu
- Department of Medical Affairs, Xuanzhu Technology Co., Ltd, Shijiazhuang, China
| | - Feng Shao
- Phase I Clinical Trial Unit, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Lu Wang
- Phase I Clinical Trial Unit, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
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5
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Rapolti DI, Monrabal Lezama M, Manueli Laos EG, Schlottmann F, Masrur MA. Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies. J Laparoendosc Adv Surg Tech A 2024; 34:581-602. [PMID: 38568115 DOI: 10.1089/lap.2024.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2024] Open
Abstract
Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.
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Affiliation(s)
- Diana I Rapolti
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | | | | | - Francisco Schlottmann
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Mario A Masrur
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
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Sreepad B, Chennupati K, Zeeshan MS, Ramzan Z. Endoscopic Management Options for Gastroesophageal Reflux Disease. Cureus 2024; 16:e62069. [PMID: 38989395 PMCID: PMC11235412 DOI: 10.7759/cureus.62069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 07/12/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) is a prevalent condition that affects a significant portion of the Western population. Despite its benign pathophysiology, it has the potential to cause serious complications over time, ranging from conditions that are benign, premalignant, and/or malignant. Traditional treatment options include lifestyle measures, anti-secretory medications (e.g., proton pump inhibitor (PPI)), and surgical options (e.g., Nissen and Toupet fundoplication). However, recent studies have revealed long-term side effects of anti-secretory medications. Moreover, surgical options, though effective, are considered invasive and associated with potential complications. In the current age of ongoing research in minimally invasive options, endoscopic treatment of GERD has become popular. As a result, procedures such as radiofrequency treatment and transoral incisionless fundoplication (TIF) have gained FDA approval and are currently being covered by most insurance. In this review article, we will discuss pre-procedural workup, appropriate patient selection, advantages, disadvantages, procedure techniques, and follow-up of patients who undergo various endoscopic treatments for GERD. In addition, we will review the short and long-term success of these techniques in improving quality of life, use of PPI, and improvement in symptoms considering published data in high-quality peer-reviewed journals.
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Affiliation(s)
- Bhavana Sreepad
- Medical School, TCU Burnett School of Medicine, Fort Worth, USA
| | - Karteek Chennupati
- Gastroenterology, Texas Health Harris Methodist Hospital, Fort Worth, USA
| | | | - Zeeshan Ramzan
- Gastroenterology, Texas Health Harris Methodist Hospital, Fort Worth, USA
- Gastroenterology, TCU Burnett School of Medicine, Fort Worth, USA
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7
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Huang KZ, Weber HC. Potassium-competitive acid blockers and acid-related disorders. Curr Opin Endocrinol Diabetes Obes 2024; 31:107-114. [PMID: 38483115 DOI: 10.1097/med.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Abstract
PURPOSE OF REVIEW Potassium-competitive acid blockers (PCABs) represent a new class of compounds for the treatment of acid-related disorders. Recent FDA approval of the PCAB vonoprazan for erosive esophagitis has started an important new approach to acid-related disorders. RECENT FINDINGS Compared to conventional proton pump inhibitors (PPIs), PCABs provide more rapid, potent, and sustained suppression of gastric acid with faster and more durable symptom relief. Studies have demonstrated the efficacy of PCABs for erosive esophagitis, nonerosive reflux disease, and peptic ulcer disease including H. pylori. However, the PCAB vonoprazan was only approved in the US as part of combination therapy for eradication of H. pylori. Clinical trials have now demonstrated noninferiority of vonoprazan to lansoprazole for treatment of erosive esophagitis, particularly noting superiority of vonoprazan in patients with severe esophagitis resulting in FDA approval of vonoprazan for treatment of erosive esophagitis. Emerging data suggests a possible utility of vonoprazan for PPI-resistant gastroesophageal reflux disease (GERD) and on-demand therapy for nonerosive reflux disease. Vonoprazan is generally well tolerated but long-term safety data is not well established. SUMMARY The PCAB vonoprazan is a newly FDA approved treatment option for erosive esophagitis. Its possible role in PPI-resistant GERD and nonerosive reflux disease warrants further investigation.
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Affiliation(s)
- Kevin Z Huang
- Boston University Chobanian & Avedisian School of Medicine
| | - H Christian Weber
- Boston University Chobanian & Avedisian School of Medicine
- VA Boston Healthcare System, Section of Gastroenterology and Hepatology, Boston, Massachusetts, USA
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8
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Alzahrani MA, Alqaraawi AM, Alzubide SR, Abufarhaneh E, Alkhowaiter SS, Alsulaimi M, Alkhiari R, AlMalki AS, Alfadda AA, Aljahdli ES, Alsohaibani FI, AlLehibi AH, Almadi MA. The Saudi Gastroenterology Association consensus on the clinical care pathway for the diagnosis and treatment of GERD. Saudi J Gastroenterol 2024:00936815-990000000-00086. [PMID: 38813746 DOI: 10.4103/sjg.sjg_82_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
ABSTRACT Gastroesophageal reflux disease (GERD) is one of the most common problems encountered in outpatient general medicine and gastroenterology clinics. GERD may present with classic esophageal symptoms, extraesophageal symptoms, or mixed symptoms. The diagnosis and treatment of GERD are challenging due to the variety of symptoms and multifactorial pathophysiology. Since there is no consensus on the diagnosis and treatment of GERD in Saudi Arabia, the Saudi Gastroenterology Association established an expert group to formulate a consensus on the clinical care pathway for the diagnosis and treatment of GERD to update health-care providers in Saudi Arabia. The expert group reviewed the literature including recently published international guidelines, clinical trials, and expert opinion and conducted virtual and in-person meetings. A total of 22 statements on the definition, diagnosis, and treatment of GERD were formulated, and three algorithms for the clinical care of GERD were developed with a detailed description for each step. The expert group endorsed the new definition of GERD, the practical principles of interpretation of the diagnostic GERD evaluation, and the practical guidance for GERD treatment including medical, surgical, and endoscopic therapy. The expert group recommends further studies to investigate local data on the diagnosis and treatment of GERD.
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Affiliation(s)
- Mohammed A Alzahrani
- Department of Medicine, College of Medicine, King Khalid University, Abha, Riyadh, Saudi Arabia
| | - Abdullah M Alqaraawi
- Department of Medicine, Gastroenterology Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saeed R Alzubide
- Department of Gastroenterology and Hepatology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ehab Abufarhaneh
- Liver and Small Bowel Health Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saad S Alkhowaiter
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Resheed Alkhiari
- Department of Medicine, College of Medicine, Qassim University, Qassim, Saudi Arabia
| | - Ahmed S AlMalki
- Gastroenterology Section, Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Abdulrahman A Alfadda
- Department of Medicine, Gastroenterology Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Emad S Aljahdli
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Gastrointestinal Oncology Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Fahad I Alsohaibani
- Department of Medicine, Gastroenterology Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abid H AlLehibi
- Department of Gastroenterology and Hepatology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Majid A Almadi
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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9
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Lee J, Lee I, Oh Y, Kim JW, Kwon Y, Alromi A, Eledreesi M, Khalid A, Aljarbou W, Park S. Current Status of Anti-Reflux Surgery as a Treatment for GERD. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:518. [PMID: 38541244 PMCID: PMC10972421 DOI: 10.3390/medicina60030518] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/01/2024] [Accepted: 03/20/2024] [Indexed: 06/29/2024]
Abstract
Anti-reflux surgery (ARS) is an efficient treatment option for gastroesophageal reflux disease (GERD). Despite growing evidence of the efficacy and safety of ARS, medications including proton pump inhibitors (PPIs) remain the most commonly administered treatments for GERD. Meanwhile, ARS can be an effective treatment option for patients who need medications continuously or for those who are refractory to PPI treatment, if proper candidates are selected. However, in practice, ARS is often regarded as a last resort for patients who are unresponsive to PPIs. Accumulating ARS-related studies indicate that surgery is equivalent to or better than medical treatment for controlling typical and atypical GERD symptoms. Furthermore, because of overall reduced medication expenses, ARS may be more cost-effective than PPI. Patients are selected for ARS based on endoscopic findings, esophageal acid exposure time, and PPI responsiveness. Although there is limited evidence, ARS may be expanded to include patients with normal acid exposure, such as those with reflux hypersensitivity. Additionally, other factors such as age, body mass index, and comorbidities are known to affect ARS outcomes; and such factors should be considered. Nissen fundoplication or partial fundoplication including Dor fundoplication and Toupet fundoplication can be chosen, depending on whether the patient prioritizes symptom improvement or minimizing postoperative symptoms such as dysphagia. Furthermore, efforts to reduce and manage postoperative complications and create awareness of the long-term efficacy and safety of the ARS are recommended, as well as adequate training programs for new surgeons.
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Affiliation(s)
- Jooyeon Lee
- Department of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Inhyeok Lee
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Youjin Oh
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Jeong Woo Kim
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Yeongkeun Kwon
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Ahmad Alromi
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- The Jordanian Ministry of Health, Department of General Surgery, Princes Hamzh Hospital, Amman 11947, Jordan
| | - Mohannad Eledreesi
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- Taif Armed Forces Hospital, Taif 26792, Saudi Arabia
| | - Alkadam Khalid
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Wafa Aljarbou
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- Dr. Sulaiman Al Habib Hospital, Riyadh 34423, Saudi Arabia
| | - Sungsoo Park
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
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10
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Pourhadi N, Janbek J, Jensen‐Dahm C, Gasse C, Laursen TM, Waldemar G. Response to "Comment on 'Proton pump inhibitors and dementia: A nationwide population-based study'". Alzheimers Dement 2024; 20:2287-2288. [PMID: 38183355 PMCID: PMC10984444 DOI: 10.1002/alz.13656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Nelsan Pourhadi
- Danish Dementia Research CentreDepartment of NeurologyCopenhagen University Hospital ‐ RigshospitaletCopenhagenDenmark
| | - Janet Janbek
- Danish Dementia Research CentreDepartment of NeurologyCopenhagen University Hospital ‐ RigshospitaletCopenhagenDenmark
| | - Christina Jensen‐Dahm
- Danish Dementia Research CentreDepartment of NeurologyCopenhagen University Hospital ‐ RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Christiane Gasse
- Department of Affective DisordersAarhus University Hospital PsychiatryAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Thomas Munk Laursen
- National Centre for Register‐Based ResearchAarhus UniversityAarhusDenmark
- Centre for Integrated Register‐Based ResearchAarhus UniversityAarhusDenmark
| | - Gunhild Waldemar
- Danish Dementia Research CentreDepartment of NeurologyCopenhagen University Hospital ‐ RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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11
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Weh KM, Howard CL, Zhang Y, Tripp BA, Clarke JL, Howell AB, Rubenstein JH, Abrams JA, Westerhoff M, Kresty LA. Prebiotic proanthocyanidins inhibit bile reflux-induced esophageal adenocarcinoma through reshaping the gut microbiome and esophageal metabolome. JCI Insight 2024; 9:e168112. [PMID: 38329812 PMCID: PMC11063939 DOI: 10.1172/jci.insight.168112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/02/2024] [Indexed: 02/10/2024] Open
Abstract
The gut and local esophageal microbiome progressively shift from healthy commensal bacteria to inflammation-linked pathogenic bacteria in patients with gastroesophageal reflux disease, Barrett's esophagus, and esophageal adenocarcinoma (EAC). However, mechanisms by which microbial communities and metabolites contribute to reflux-driven EAC remain incompletely understood and challenging to target. Herein, we utilized a rat reflux-induced EAC model to investigate targeting the gut microbiome-esophageal metabolome axis with cranberry proanthocyanidins (C-PAC) to inhibit EAC progression. Sprague-Dawley rats, with or without reflux induction, received water or C-PAC ad libitum (700 μg/rat/day) for 25 or 40 weeks. C-PAC exerted prebiotic activity abrogating reflux-induced dysbiosis and mitigating bile acid metabolism and transport, culminating in significant inhibition of EAC through TLR/NF-κB/TP53 signaling cascades. At the species level, C-PAC mitigated reflux-induced pathogenic bacteria (Streptococcus parasanguinis, Escherichia coli, and Proteus mirabilis). C-PAC specifically reversed reflux-induced bacterial, inflammatory, and immune-implicated proteins and genes, including Ccl4, Cd14, Crp, Cxcl1, Il6, Il1b, Lbp, Lcn2, Myd88, Nfkb1, Tlr2, and Tlr4, aligning with changes in human EAC progression, as confirmed through public databases. C-PAC is a safe, promising dietary constituent that may be utilized alone or potentially as an adjuvant to current therapies to prevent EAC progression through ameliorating reflux-induced dysbiosis, inflammation, and cellular damage.
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Affiliation(s)
- Katherine M. Weh
- Department of Surgery, Section of Thoracic Surgery, and
- Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Connor L. Howard
- Department of Surgery, Section of Thoracic Surgery, and
- Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Yun Zhang
- Department of Surgery, Section of Thoracic Surgery, and
- Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jennifer L. Clarke
- Department of Statistics, Department of Food Science Technology, Quantitative Life Sciences Initiative, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Amy B. Howell
- Marucci Center for Blueberry and Cranberry Research, Rutgers University, Chatsworth, New Jersey, USA
| | - Joel H. Rubenstein
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Julian A. Abrams
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Maria Westerhoff
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura A. Kresty
- Department of Surgery, Section of Thoracic Surgery, and
- Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
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12
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Teke E, Esen Bulut N, Onur E, Güneş Y, Fersahoglu MM, Ergin A, Taşdelen İ, Köroğlu M, Çavuş B, Akyüz Ü, Akyüz F. Investigation of the Relationship Between Laparoscopic Sleeve Gastrectomy and Gastroesophageal Reflux Disease Using 24-hour Multichannel Intraluminal Impedance With pH Testing According to Current Consensus. Surg Laparosc Endosc Percutan Tech 2024; 34:9-13. [PMID: 38078925 DOI: 10.1097/sle.0000000000001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/04/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss procedure with potential effects on gastroesophageal reflux disease (GERD). However, research on the association between LSG and GERD using objective evaluation criteria, such as multichannel intraluminal impedance combined with pH testing (MII-pH), is limited. This study aimed to investigate the impact of LSG on GERD using MII-pH and current consensus guidelines. MATERIALS AND METHODS It was conducted as a prospective clinical study on 33 patients who underwent LSG between January 2022 and August 2022. MII-pH and high-resolution manometry were performed preoperatively and 3 to 6 months postoperatively. GERD diagnosis was based on MII-pH results using the Lyon and Update Porto consensus guidelines. RESULTS Postoperative MII-pH analysis revealed a significant increase in acid reflux time, acid exposure time, reflux index, esophageal clearance, total reflux time, and longest reflux period. Weak acid reflux episodes decreased, while Demeester score and alkaline reflux showed nonsignificant increases. Pathologic reflux significantly increased postoperatively based on MII-pH diagnosis. High-resolution manometry showed a significant increase in unsuccessful motility. CONCLUSION Although the Demeester score calculation consists of 6 metrics, including acid exposure time, the acid exposure time is more specific in detecting pathologic reflux. Pathologic GERD increases significantly with LSG in the early period. Therefore, preoperative and postoperative endoscopy and MII-pH can provide valuable information regarding the need for closer follow-up after LSG.
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Affiliation(s)
| | | | | | | | | | | | | | - Mehmet Köroğlu
- Gastroenterology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Bilger Çavuş
- Istanbul University Istanbul Medical Faculty/Gastroenterohepatology Department, İstanbul University, İstanbul Medical School, Turgut Özal Millet Street, Fatih/İstanbul
| | - Ümit Akyüz
- Gastroenterology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Filiz Akyüz
- Istanbul University Istanbul Medical Faculty/Gastroenterohepatology Department, İstanbul University, İstanbul Medical School, Turgut Özal Millet Street, Fatih/İstanbul
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13
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Davis TA, Gyawali CP. Refractory Gastroesophageal Reflux Disease: Diagnosis and Management. J Neurogastroenterol Motil 2024; 30:17-28. [PMID: 38173155 PMCID: PMC10774805 DOI: 10.5056/jnm23145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/16/2023] [Indexed: 01/05/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.
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Affiliation(s)
- Trevor A Davis
- Division of Pediatric Gastroenterology, Washington University School of Medicine, Saint Louis Children’s Hospital, St. Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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14
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Khan Z, Mehan S, Saifi MA, Das Gupta G, Narula AS, Kalfin R. Proton Pump Inhibitors and Cognitive Health: Review on Unraveling the Dementia Connection and Co-morbid Risks. Curr Alzheimer Res 2024; 20:739-757. [PMID: 38424433 PMCID: PMC11107432 DOI: 10.2174/0115672050289946240223050737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/28/2024] [Accepted: 01/31/2024] [Indexed: 03/02/2024]
Abstract
Dementia, an international health issue distinguished by the impairment of daily functioning due to cognitive decline, currently affects more than 55 million people worldwide, with the majority residing in low-income and middle-income countries. Globally, dementia entails significant economic burdens in 2019, amounting to a cost of 1.3 trillion US dollars. Informal caregivers devote considerable hours to providing care for those affected. Dementia imposes a greater caregiving and disability-adjusted life-year burden on women. A recent study has established a correlation between prolonged Proton Pump Inhibitor (PPI) usage and dementia, in addition to other neurodegenerative conditions. PPIs are frequently prescribed to treat peptic ulcers and GERD (gastroesophageal reflux disease) by decreasing stomach acid secretion. They alleviate acid-related symptoms through the inhibition of acid-secreting H+-K+ ATPase. In a number of observational studies, cognitive decline and dementia in the elderly have been linked to the use of PPIs. The precise mechanism underlying this relationship is unknown. These drugs might also alter the pH of brain cells, resulting in the accumulation of amyloid-beta (Aβ) peptides and the development of Alzheimer's disease (AD). Despite the compelling evidence supporting the association of PPIs with dementia, the results of studies remain inconsistent. The absence of a correlation between PPI use and cognitive decline in some studies emphasizes the need for additional research. Chronic PPI use can conceal underlying conditions, including cancer, celiac disease, vitamin B12 deficiency, and renal injury, highlighting dementia risk and the need for further investigations on cognitive health.
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Affiliation(s)
- Zuber Khan
- Division of Neuroscience, Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab, India (Affiliated to IK Gujral Punjab Technical University), Jalandhar, Punjab, 144603, India;
| | - Sidharth Mehan
- Division of Neuroscience, Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab, India (Affiliated to IK Gujral Punjab Technical University), Jalandhar, Punjab, 144603, India;
| | - Mohd. Anas Saifi
- Department of Medical Elementology and Toxicology, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi-110062, India;
| | - Ghanshyam Das Gupta
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, India (Affiliated to IK Gujral Punjab Technical University), Jalandhar, Punjab, 144603, India;
| | - Acharan S. Narula
- Narula Research, LLC, 107 Boulder Bluff, Chapel Hill, NC 27516, USA;
| | - Reni Kalfin
- Institute of Neurobiology, Bulgarian Academy of Sciences, Acad. G. Bonchev St., Block 23, Sofia 1113, Bulgaria;
- Department of Healthcare, South-West University “NeofitRilski”, Ivan Mihailov St. 66, Blagoevgrad 2700, Bulgaria
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15
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Biermann M, Hersh M, Kline M, Fowler H, Calderon L, Godiers M, Kundu S, Jain AS. Functional lumen imaging probe topography identifies patients with normal acid exposure and esophageal hypervigilance amongst proton-pump inhibitor non-responders. Surg Endosc 2024; 38:291-299. [PMID: 37991572 PMCID: PMC11270151 DOI: 10.1007/s00464-023-10556-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/20/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Multiple factors contribute to symptom generation and treatment response in proton-pump inhibitor non-responders (PPI-NRs). We aimed to test whether PPI-NRs with normal acid exposure have a higher degree of esophageal hypersensitivity and hypervigilance and can be identified using functional lumen imaging probe (FLIP) topography at the time of endoscopy. METHODS Data from PPI-NRs whom underwent endoscopy, FLIP and wireless 96-h pH-metry were retrospectively analyzed. Patients were grouped according to acid exposure time (AET) as (a) 0 days abnormal (AET > 6%), (b) 1-2 days abnormal, or (c) 3-4 days abnormal. The esophageal hypervigilance and anxiety scale (EHAS) score and other symptom scores were compared between groups. The discriminatory ability of the esophagogastric junction (EGJ) distensibility index (DI) and max EGJ diameter in identifying patients with 0 days abnormal AET was tested via receiver-operating-characteristic (ROC) curve analysis. RESULTS EHAS score was 38.6 in the 0 days abnormal AET group, 30.4 in the 1-2 days abnormal AET group (p = 0.073 when compared to 0 days abnormal) and 28.2 in the 3-4 days abnormal AET group (p = 0.031 when compared to 0 days abnormal). Area-under-the-curve (AUC) for the DI in association with 0 days AET > 6% was 0.629. A DI of < 2.8 mm2/mmHg had a sensitivity of 83.3%, and negative predictive value of 88% in classifying patients with 0 days abnormal acid exposure (p = 0.004). CONCLUSIONS FLIP complements prolonged wireless pH-metry in distinguishing the subset of PPI-NRs with completely normal acid exposure and a higher burden of esophageal hypervigilance. Proper identification of patients along the functional heartburn spectrum can improve overall surgical outcomes.
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Affiliation(s)
- Maya Biermann
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Marc Hersh
- Department of Medicine, Division of Digestive Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Meredith Kline
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Halley Fowler
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Lucie Calderon
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Marie Godiers
- Physician Assistant Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Suprateek Kundu
- Data Analytics and Biostatistics Core, Emory University Department of Medicine, Atlanta, GA, USA
| | - Anand S Jain
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA.
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16
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Zhang Y, Weh KM, Tripp BA, Clarke JL, Howard CL, Sunilkumar S, Howell AB, Kresty LA. Cranberry Proanthocyanidins Mitigate Reflux-Induced Transporter Dysregulation in an Esophageal Adenocarcinoma Model. Pharmaceuticals (Basel) 2023; 16:1697. [PMID: 38139823 PMCID: PMC10747310 DOI: 10.3390/ph16121697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
We recently reported that cranberry proanthocyanidins (C-PACs) inhibit esophageal adenocarcinoma (EAC) by 83% through reversing reflux-induced bacterial, inflammatory and immune-implicated proteins and genes as well as reducing esophageal bile acids, which drive EAC progression. This study investigated whether C-PACs' mitigation of bile reflux-induced transporter dysregulation mechanistically contributes to EAC prevention. RNA was isolated from water-, C-PAC- and reflux-exposed rat esophagi with and without C-PAC treatment. Differential gene expression was determined by means of RNA sequencing and RT-PCR, followed by protein assessments. The literature, coupled with the publicly available Gene Expression Omnibus dataset GSE26886, was used to assess transporter expression levels in normal and EAC patient biopsies for translational relevance. Significant changes in ATP-binding cassette (ABC) transporters implicated in therapeutic resistance in humans (i.e., Abcb1, Abcb4, Abcc1, Abcc3, Abcc4, Abcc6 and Abcc10) and the transport of drugs, xenobiotics, lipids, and bile were altered in the reflux model with C-PACs' mitigating changes. Additionally, C-PACs restored reflux-induced changes in solute carrier (SLC), aquaporin, proton and cation transporters (i.e., Slc2a1, Slc7a11, Slc9a1, Slco2a1 and Atp6v0c). This research supports the suggestion that transporters merit investigation not only for their roles in metabolism and therapeutic resistance, but as targets for cancer prevention and targeting preventive agents in combination with chemotherapeutics.
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Affiliation(s)
- Yun Zhang
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; (Y.Z.); (K.M.W.); (C.L.H.); (S.S.)
| | - Katherine M. Weh
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; (Y.Z.); (K.M.W.); (C.L.H.); (S.S.)
| | - Bridget A. Tripp
- Bioinformatics Core Research Facility, Center for Biotechnology, University of Nebraska—Lincoln, N300 Beadle Center, Lincoln, NE 68588, USA;
| | - Jennifer L. Clarke
- Department of Statistics and Department of Food Science Technology, Quantitative Life Sciences Initiative, University of Nebraska—Lincoln, 253 Food Innovation Center, Lincoln, NE 68583, USA;
| | - Connor L. Howard
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; (Y.Z.); (K.M.W.); (C.L.H.); (S.S.)
| | - Shruthi Sunilkumar
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; (Y.Z.); (K.M.W.); (C.L.H.); (S.S.)
| | - Amy B. Howell
- Marucci Center for Blueberry and Cranberry Research, Rutgers University, 125A Lake Oswego Road, Chatsworth, NJ 08019, USA;
| | - Laura A. Kresty
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; (Y.Z.); (K.M.W.); (C.L.H.); (S.S.)
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17
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Ustaoglu A, Daudali FA, D’afflitto M, Murtough S, Lee C, Moreno E, Blaydon DC, Kelsell DP, Sifrim D, Woodland P, Peiris M. Identification of novel immune cell signature in gastroesophageal reflux disease: altered mucosal mast cells and dendritic cell profile. Front Immunol 2023; 14:1282577. [PMID: 38098488 PMCID: PMC10720318 DOI: 10.3389/fimmu.2023.1282577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Heartburn pathogenesis in GERD remains incompletely understood. We aimed to identify differences in the immune cell signature and sensory mucosal markers between reflux phenotypes and healthy asymptomatic subjects. Methods Thirty-seven patients with heartburn symptoms were phenotyped endoscopically and with objective reflux studies into erosive reflux disease (ERD) (N=10), nonerosive reflux disease (NERD) (N=9), functional heartburn (FH) (N=9), and Barrett's esophagus (BO) (N=9). Bulk mRNA-sequencing(RNA-seq) was conducted on RNA extracted from endoscopic biopsies, and immune cell deconvolution analysis was performed using CIBERSORT. RNA-seq findings were validated by immunofluorescent staining for CD1a, nerve growth factor (NGF), and mast cell tryptase in corresponding patient biopsies. Results Transcriptomic analysis detected higher mast cell abundance in BO, ERD, and NERD compared to healthy controls (p<0.05), with decreased dendritic cell infiltration in BO, ERD, and NERD patients compared to healthy controls and FH patients. CD1a-positive dendritic cell infiltration was significantly higher in the healthy esophageal mucosa at protein level compared to BO (p=0.0005), ERD (p=0.0004), and FH patients (p=0.0096). Moreover, NGF co-expression on mast cells in GERD patients was significantly higher than in healthy controls (p=0.0094). Discussion The mucosa in patients with GERD had a significant increase in NGF expression on mast cells, suggesting an upregulation of signalling for neuronal sprouting in GERD. Moreover, decreased dendritic cell abundance in GERD esophageal mucosa may play a role in reduced oral tolerance and development of subsequent immune responses which may participate in esophageal sensitivity.
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Affiliation(s)
- Ahsen Ustaoglu
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Fatema Arif Daudali
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Manfredi D’afflitto
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Stephen Murtough
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Chung Lee
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Estefania Moreno
- Royal London Hospital, Barts National Health Service (NHS) Health, London, United Kingdom
| | - Diana C. Blaydon
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - David P. Kelsell
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Daniel Sifrim
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Philip Woodland
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Madusha Peiris
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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18
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Tsukanov VV, Vasyutin AV, Tonkikh JL. Modern aspects of managing patients with non-erosive reflux disease. MEDITSINSKIY SOVET = MEDICAL COUNCIL 2023:28-33. [DOI: 10.21518/ms2023-218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
A review of current data on the management of patients with non-erosive reflux disease (NERD) was made. Diagnosis of gastroesophageal reflux disease (GERD) is based on symptom analysis, endoscopic evaluation of the esophageal mucosa, objective evidence of gastric contents reflux into the esophagus during pH-impedancemetry, and response to therapeutic intervention. Treatment for GERD should include weight loss if overweight, lifestyle modification, and dietary modification. Current consensus recommends starting NERD treatment with once-daily proton pump inhibitors (PPIs), but only 50% of patients with this pathology respond to such therapy. Incomplete response to PPIs is a reason to increase the dose of PPI and add Gaviscon to treatment to neutralize the post-prandial “acid pocket”. Gaviscon is especially effective in patients with postprandial or nocturnal symptoms and in those with hiatal hernia. The mechanism of action of Gaviscon is based on the formation of an alginate “raft” on the surface of the gastric contents, which neutralizes the acid and blocks its pathological effect to esophageal mucosa. A modern meta-analysis on the NERD treatment, which included 23 studies and 10,735 patients, showed the efficacy of Gaviscon monotherapy comparable to PPIs in treatment for 4 weeks. The combination of a PPI with Gaviscon offers the opportunity to optimize response to treatment in NERD patients with an incomplete response to PPIs monotherapy. The Russian Gastroenterological Association thinks that alginates can be used both as monotherapy for mild clinical variants of NERD and in complex treatment regimens for various GERD variants.
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Affiliation(s)
- V. V. Tsukanov
- Scientific Research Institute of Medical Problems of the North
| | - A. V. Vasyutin
- Scientific Research Institute of Medical Problems of the North
| | - Ju. L. Tonkikh
- Scientific Research Institute of Medical Problems of the North
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19
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Weh KM, Howard CL, Zhang Y, Tripp BA, Clarke JL, Howell AB, Rubenstein JH, Abrams JA, Westerhoff M, Kresty LA. Prebiotic proanthocyanidins inhibit bile reflux-induced esophageal adenocarcinoma through reshaping the gut microbiome and esophageal metabolome. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.08.22.554315. [PMID: 37662411 PMCID: PMC10473615 DOI: 10.1101/2023.08.22.554315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
The gut and local esophageal microbiome progressively shift from healthy commensal bacteria to inflammatory-linked pathogenic bacteria in patients with gastroesophageal reflux disease, Barrett's esophagus and esophageal adenocarcinoma (EAC). However, mechanisms by which microbial communities and metabolites contribute to reflux-driven EAC remain incompletely understood and challenging to target. Herein, we utilized a rat reflux-induced EAC model to investigate targeting the gut microbiome-esophageal metabolome axis with cranberry proanthocyanidins (C-PAC) to inhibit EAC progression. Sprague Dawley rats, with or without reflux-induction received water or C-PAC ad libitum (700 µg/rat/day) for 25 or 40 weeks. C-PAC exerted prebiotic activity abrogating reflux-induced dysbiosis, and mitigating bile acid metabolism and transport, culminating in significant inhibition of EAC through TLR/NF-κB/P53 signaling cascades. At the species level, C-PAC mitigated reflux-induced pathogenic bacteria (Clostridium perfringens, Escherichia coli, and Proteus mirabilis). C-PAC specifically reversed reflux-induced bacterial, inflammatory and immune-implicated proteins and genes including Ccl4, Cd14, Crp, Cxcl1, Il6, Il1β, Lbp, Lcn2, Myd88, Nfkb1, Tlr2 and Tlr4 aligning with changes in human EAC progression, as confirmed through public databases. C-PAC is a safe promising dietary constituent that may be utilized alone or potentially as an adjuvant to current therapies to prevent EAC progression through ameliorating reflux-induced dysbiosis, inflammation and cellular damage.
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20
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Sultan W, Naik S, Kondapally K, Johnston L. A Rare Case of Chylothorax Following a Redo Laparoscopic Nissen Fundoplication. Cureus 2023; 15:e41419. [PMID: 37546033 PMCID: PMC10403242 DOI: 10.7759/cureus.41419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/08/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a highly prevalent disease. Mechanical etiology, including hiatal hernia, can be resistant to empiric proton pump inhibitor (PPI) trials; Nissen fundoplication is commonly used to treat mechanical GERD. Chylothorax is a rare complication of abdominal surgeries, including anti-reflux procedures. In this case report, a 75-year-old female presented with shortness of breath following a redo laparoscopic Nissen fundoplication. Chest CT pulmonary angiography (CTPA) showed bilateral large pleural effusions that were managed by fluid restriction, repeated thoracocentesis, and chest tube insertion; the pleural fluid analysis was significant for fluid triglycerides high at 232 mg/dL which was diagnostic for chylothorax. The patient was treated conservatively. Appropriate management of chylothorax is crucial to avoid subsequent respiratory failure, immunodeficiency, and malnutrition. Chylomicrons and triglycerides in the pleural fluid can be diagnostic for chylothorax. Treatment of chylothorax includes three main approaches: controlling the cause, conservative treatment, and surgical interventions.
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Affiliation(s)
- Waleed Sultan
- Family Medicine, Conemaugh Memorial Medical Center, Johnstown, USA
| | - Sarvesh Naik
- Family Medicine, Conemaugh Memorial Medical Center, Johnstown, USA
| | | | - Lynn Johnston
- Family Medicine, Conemaugh Memorial Medical Center, Johnstown, USA
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21
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Ribolsi M, Savarino E. Towards a better diagnosis of gastro esophageal reflux disease. Expert Rev Gastroenterol Hepatol 2023; 17:999-1010. [PMID: 37800858 DOI: 10.1080/17474124.2023.2267435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/03/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION GERD is a common disorder and is characterized by the presence of typical or atypical symptoms. In GERD patients, the presence of mucosal alterations in endoscopy is detected in up to 30% of individuals. The clinical presentation of GERD patients may be complex and their management is challenging, due to the heterogeneous clinical presentation. The present review has been performed searching all relevant articles in this field, over the past years, using PubMed database. AREAS COVERED The diagnosis and management of GERD have been significantly improved in the last years due to the increasing availability of reflux monitoring techniques and the implementation of new procedures in the therapeutic armamentarium. Beside traditional impedance-pH variables, new metrics have been developed, increasing the diagnostic yield of reflux monitoring and better predicting the treatment response. Traditional pharmacological treatments include acid-suppressive-therapy and/or anti-acid. On the other hand, surgical treatment and, more recently, endoscopic procedures represent a promising field in the therapeutic approach. EXPERT OPINION Diagnosis and treatment of GERD still represent a challenging area. However, we believe that an accurate upfront evaluation is, nowadays, necessary in addressing patients with GERD to a more accurate diagnosis as well as to the best treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
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22
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Salman MA, Salman A, Shaaban HED, Alasmar M, Tourky M, Elhaj MGF, Khalid S, Gebril M, Alrahawy M, Elsherbiney M, Assal MM, Osman MHA, Mohammed AA, Elewa A. Nissen Versus Toupet Fundoplication For Gastro-oesophageal Reflux Disease, Short And Long-term Outcomes. A Systematic Review And Meta-analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:171-183. [PMID: 36971517 DOI: 10.1097/sle.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/22/2022] [Indexed: 03/29/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) remains one of the most commonly encountered gastrointestinal disorders. Proton pump inhibitors still show an inadequate effect on about 10% to 40% of the patients. Laparoscopic antireflux surgery is the surgical alternative for managing GERD in patients who are not responding to proton pump inhibitors. AIM OF THE STUDY This study objected at comparing laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication (LTF) concerning the short-term and long-term outcomes. PATIENTS AND METHODS This is a systematic review and meta-analysis that evaluated the studies comparing between Nissen fundoplication and LTF for the treatment of GERD. Studies were obtained by searching on the EMBASE, the Cochrane Central Register of Controlled Trials, and PubMed central database. RESULTS The LTF group showed significantly longer operation time, less postoperative dysphagia and gas bloating, less pressure on the lower esophageal sphincter, and higher Demeester scores. No statistically significant differences were found between the 2 groups in the perioperative complications, the recurrence of GERD, the reoperation rate, the quality of life, or the reoperation rate. CONCLUSION LTF is favored for the surgical treatment of GERD being of lower postoperative dysphagia and gas bloating rates. These benefits were not at the expense of significantly additional perioperative complications or surgery failure.
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Affiliation(s)
| | - Ahmed Salman
- Internal Medicine, Kasralainy School of Medicine, Cairo University, Giza
| | - Hossam El-Din Shaaban
- National Hepatology and Tropical Medicine Research Institute, Gastroenterology and Hepatology, Cairo, Egypt
| | - Mohamed Alasmar
- General/OesophagoGastric Surgery, Salford Royal Hospital, Manchester
- Division of Cancer Sciences, University of Manchester
| | | | | | | | | | | | | | | | | | | | - Ahmed Elewa
- Laparoscopic and HBP Surgery at National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
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23
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Mayhew PD, Marks SL, Pollard R, Balsa IM, Culp WTN, Giuffrida MA. Effect of conventional multilevel brachycephalic obstructive airway syndrome surgery on clinical and videofluoroscopic evidence of hiatal herniation and gastroesophageal reflux in dogs. Vet Surg 2023; 52:238-248. [PMID: 36273378 DOI: 10.1111/vsu.13906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 08/25/2022] [Accepted: 09/15/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate the effect of conventional multilevel surgery (CMS) for brachycephalic obstructive airway syndrome (BOAS) on associated sliding hiatal hernia (SHH) and/or gastroesophageal reflux (GER). STUDY DESIGN Prospective clinical trial. ANIMALS Sixteen client-owned dogs with clinical signs consistent with BOAS and associated SHH and GER. METHODS All dogs were treated with 1 or more components of CMS including soft palate resection, laryngeal ventriculectomy, and alaplasty. A standardized Dog Swallowing Assessment Tool (Dog SAT) questionnaire was completed by owners preoperatively and postoperatively. Videofluoroscopic swallow studies (VFSS) were used to evaluate esophageal motility, gastroesophageal reflux, and hiatal herniation preoperatively, and in a subset of dogs postoperatively. Upper gastrointestinal endoscopic studies were performed to document esophagitis and lower esophageal sphincter pathology. RESULTS All dogs were discharged from the hospital. One dog experienced aspiration pneumonia immediately postoperatively. Owner-assigned clinical scores improved in scores related to regurgitation after eating and regurgitation (P = .012) during increased activity/exercise (P = .002) between preoperative and postoperative time points. However, no improvement was detected in masked assessment of preoperative and postoperative VFSS studies in terms of GER frequency (P = .46) or severity (P = .79), SHH frequency (P = .082) or severity (P = .34) scores. CONCLUSION Owners of dogs treated with CMS perceived an improvement in clinical signs of SHH and GER that was not confirmed by VFSS studies. CLINICAL SIGNIFICANCE Conventional multilevel surgery in dogs with BOAS does not appear to consistently resolve SHH and GER, although clinical signs may improve.
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Affiliation(s)
- Philipp D Mayhew
- The Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California, USA
| | - Stanley L Marks
- The Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California-Davis, Davis, California, USA
| | - Rachel Pollard
- The Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California, USA
| | - Ingrid M Balsa
- The Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California, USA
| | - William T N Culp
- The Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California, USA
| | - Michelle A Giuffrida
- The Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California, USA
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24
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Sarici IS, Dunn CP, Eriksson SE, Jobe BA, Ayazi S. Long-term clinical and functional results of magnetic sphincter augmentation. Dis Esophagus 2022:6965898. [PMID: 36585776 DOI: 10.1093/dote/doac109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Indexed: 01/01/2023]
Abstract
Magnetic sphincter augmentation (MSA) was introduced in 2007 as an alternative surgical procedure for patients with gastroesophageal reflux disease (GERD). The majority of data since MSA's introduction has focused on short and intermediate-term results, demonstrating safety and high efficacy in terms of reflux symptom control, freedom from proton pump inhibitor use and normalization of distal esophageal acid exposure. However, GERD is a chronic condition that demands a long-term solution. Limited available data from studies reporting outcomes at 5 years or later following MSA demonstrate that the promising short- and mid-term efficacy and safety profile of MSA remains relatively constant in the long term. Compared with Nissen fundoplication, MSA has a much lower rate of gas-bloat and inability to belch at a short-term follow-up, a difference that persists in the long-term. The most common complaint after MSA at a short-term follow-up is dysphagia. However, limited data suggest dysphagia rates largely decrease by 5 years. Dysphagia is the most common indication for dilation and device removal in both early- and long-term studies. However, the overall rates of dilation and removal are similar in short- and long-term reports, suggesting the majority of these procedures are performed in the short-term period after device implantation. The indications and standard practices of MSA have evolved over time. Long-term outcome data currently available are all from patient cohorts who were selected for MSA under early restricted indications and outdated regimens. Therefore, further long-term studies are needed to corroborate the preliminary, yet encouraging long-term results.
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Affiliation(s)
- Inanc S Sarici
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Colin P Dunn
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Sven E Eriksson
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Blair A Jobe
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA.,Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA.,Department of Surgery, Drexel University, Philadelphia, PA, USA
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25
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Bakulina NV, Tikhonov SV, Topalova YG, Ilchishina TA, Vasiliev RO. Esophagoprotective therapy in patients with erosive esophagitis. TERAPEVT ARKH 2022; 94:985-991. [DOI: 10.26442/00403660.2022.08.201828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 01/17/2023]
Abstract
Aim. To evaluate the advantages of using combined therapy of proton-pump inhibitors (PPIs) and esophagoprotector in comparison with basic therapy of PPIs for 4 weeks based on the results of changes in the endoscopic picture.To compare the effectiveness of 4-week PPI therapy and 4-week combination therapy with PPI and esophagoprotector Alfasoxx (sodium hyaluronate, chondroitin sulfate, poloxomer 407) in patients with erosive esophagitis (EE) of any degree according to the Los Angeles Endoscopic Classification.
Materials and methods. 81 patients with EE AC according to the Los Angeles endoscopic classification (1994) was enrolled in the study on the basis of the clinic of Peter the Great, Mechnikov North-Western State Medical University. By computer randomization, patients were divided into the control group 40 patients (pantoprazole 40 mg 1 time per day) and the intervention group 41 patients (pantoprazole 40 mg 1 time per day + Alfasoxx 1 sachet qid). The therapy was carried out for 4 weeks. In all patients before and after therapy, the frequency and severity of the main symptoms of gastroesophageal reflux disease (GERD) were assessed, esophagogastroduodenoscopy was performed.
Results. The advantage of combination therapy over standard PPI monotherapy in patients with EE was revealed. According to the results of the control endoscopy, healing of erosions of the esophageal mucosa was observed in 39 out of 41 (95.1%) patients in the intervention group and 32 out of 39 (82.1%) in the control group. The proportion of patients who showed an improvement in the endoscopic picture before and after treatment for 4 weeks by at least 1 level according to the Los Angeles classification was significantly higher in the comparison group 41 patients (100%), while in the control group 33 patients (85%); p0.009. After treatment, the combination therapy group had a lower incidence (p0.01) and severity of heartburn (p0.01). The same results are demonstrated by combination therapy regarding the symptom belching of air: in the study group after treatment, this symptom occurred less frequently (p=0.014), its severity was significantly less than in the control group (p0.01). There was a statistically significant decrease in the need for on-demand antacid therapy in the study group.
Conclusion. In this study involving 81 patients with erosive GERD, the benefits of combination therapy were demonstrated. The addition of Alfasoxx medical device to PPI therapy increases the clinical and endoscopic efficacy of therapy. This positive effect is associated with the esophagoprotective properties of the drug, based on unique pharmacodynamic characteristics. Combination therapy for GERD is preferred in patients with EE. Studies have shown the expediency of using Alfasoxx in case of insufficient effectiveness of classical acid-suppressive therapy for GERD.
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Mathew AS, Shilpa H. Is Adjunctive Alginate Therapy Beneficial in the Treatment of Laryngopharyngeal Reflux Disease in a Rural Indian Population? A Prospective Randomized Study. Indian J Otolaryngol Head Neck Surg 2022; 74:2104-2110. [PMID: 36452699 PMCID: PMC9702034 DOI: 10.1007/s12070-020-02005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022] Open
Abstract
To assess the benefit of adjunctive alginate therapy in the treatment of laryngopharyngeal reflux disease (LPRD) in a rural population in south India, by comparing the outcome of alginate plus proton pump inhibitor (PPI) therapy versus PPI monotherapy. 100 consenting adults of both sexes, with LPRD symptoms for ≥ 1 month, with both Reflux Symptom Index (RSI) > 13 and Reflux Finding Score (RFS) > 7, were included in a randomised prospective analytical clinical study. Patients were randomised into two treatment groups for 8 weeks. Group A received oral pantoprazole (40 mg, twice a day),and Group B received oral pantoprazole (40 mg) and oral alginate (500 mg/10 ml) twice a day each. Treatment outcome was assessed with RSI and RFS at 4 and 8 weeks. On follow-ups, both groups showed significant improvement in RSI. At 4 weeks, significant improvement in RFS was seen in Group B, but not in Group A; both groups showed improvement at 8 weeks. The improvement was significantly better in Group B RSI and RFS on both follow ups. On analysis of each RSI item at 8 weeks, choking sensation showed no significant improvement in Group A. All other items showed significant improvement in both groups, with all items except difficulty swallowing and choking sensation showing significantly better improvement in Group B. Analysis of each RFS item at 8 weeks, showed significant improvement in Group B but not in Group A. The addition of alginate to PPI shows greater definitive improvement in both symptoms and signs of LPRD within a short period of 8 weeks, compared to PPI monotherapy, making it a feasible treatment option with good results in routine practice in a rural set-up. Adjunctive alginate therapy enhances the resolution of clinical features of LPRD and is thus beneficial in its routine treatment in all populations.
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Affiliation(s)
- Amrita Suzanne Mathew
- Department of Otorhinolaryngology & Head and Neck Surgery, MVJ Medical College and Research Hospital, Hoskote, Bangalore, India
| | - H. Shilpa
- Department of Otorhinolaryngology & Head and Neck Surgery, MVJ Medical College and Research Hospital, Hoskote, Bangalore, India
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27
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Yadlapati R, Gyawali CP, Pandolfino JE. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. Clin Gastroenterol Hepatol 2022; 20:984-994.e1. [PMID: 35123084 PMCID: PMC9838103 DOI: 10.1016/j.cgh.2022.01.025] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/12/2022] [Accepted: 01/20/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS As many as one-half of all patients with suspected gastroesophageal reflux disease (GERD) do not derive benefit from acid suppression. This review outlines a personalized diagnostic and therapeutic approach to GERD symptoms. METHODS The Best Practice Advice statements presented here were developed from expert review of existing literature combined with extensive discussion and expert opinion to provide practical advice. Formal rating of the quality of evidence or strength of recommendations was not the intent of this clinical practice update. BEST PRACTICE ADVICE 1: Clinicians should develop a care plan for investigation of symptoms suggestive of GERD, selection of therapy (with explanation of potential risks and benefits), and long-term management, including possible de-escalation, in a shared-decision making model with the patient. BEST PRACTICE ADVICE 2: Clinicians should provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors, relaxation strategies, and awareness about the brain-gut axis relationship to patients with reflux symptoms. BEST PRACTICE ADVICE 3: Clinicians should emphasize safety of proton pump inhibitors (PPIs) for the treatment of GERD. BEST PRACTICE ADVICE 4: Clinicians should provide patients presenting with troublesome heartburn, regurgitation, and/or non-cardiac chest pain without alarm symptoms a 4- to 8-week trial of single-dose PPI therapy. With inadequate response, dosing can be increased to twice a day or switched to a more effective acid suppressive agent once a day. When there is adequate response, PPI should be tapered to the lowest effective dose. BEST PRACTICE ADVICE 5: If PPI therapy is continued in a patient with unproven GERD, clinicians should evaluate the appropriateness and dosing within 12 months after initiation, and offer endoscopy with prolonged wireless reflux monitoring off PPI therapy to establish appropriateness of long-term PPI therapy. BEST PRACTICE ADVICE 6: If troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy and, in the absence of erosive reflux disease (Los Angeles B or greater) or long-segment (≥3 cm) Barrett's esophagus, perform prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or to rule out GERD. BEST PRACTICE ADVICE 7: Complete endoscopic evaluation of GERD symptoms includes inspection for erosive esophagitis (graded according to the Los Angeles classification when present), diaphragmatic hiatus (Hill grade of flap valve), axial hiatus hernia length, and inspection for Barrett's esophagus (graded according to the Prague classification and biopsied when present). BEST PRACTICE ADVICE 8: Clinicians should perform upfront objective reflux testing off medication (rather than an empiric PPI trial) in patients with isolated extra-esophageal symptoms and suspicion for reflux etiology. BEST PRACTICE ADVICE 9: In symptomatic patients with proven GERD, clinicians should consider ambulatory 24-hour pH-impedance monitoring on PPI as an option to determine the mechanism of persisting esophageal symptoms despite therapy (if adequate expertise exists for interpretation). BEST PRACTICE ADVICE 10: Clinicians should personalize adjunctive pharmacotherapy to the GERD phenotype, in contrast to empiric use of these agents. Adjunctive agents include alginate antacids for breakthrough symptoms, nighttime H2 receptor antagonists for nocturnal symptoms, baclofen for regurgitation or belch predominant symptoms, and prokinetics for coexistent gastroparesis. BEST PRACTICE ADVICE 11: Clinicians should provide pharmacologic neuromodulation, and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies in patients with functional heartburn or reflux disease associated with esophageal hypervigilance reflux hypersensitivity and/or behavioral disorders. BEST PRACTICE ADVICE 12: In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients. BEST PRACTICE ADVICE 13: In patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients, and a salvage option in non-obese patients, whereas sleeve gastrectomy has potential to worsen GERD. BEST PRACTICE ADVICE 14: Candidacy for invasive anti-reflux procedures includes confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla, California
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Al-Marhabi A, Hashem A, Zuberi BF, Onyekwere C, Lodhi I, Mounir M, Alkhowaiter S, Al Awadhi S, Naidoo VG, Hamada Y. The views of African and Middle Eastern Gastroenterologists on the management of mild-to-moderate, non-erosive gastro-esophageal reflux disease (GERD). Expert Rev Gastroenterol Hepatol 2022; 16:217-233. [PMID: 35184616 DOI: 10.1080/17474124.2022.2043744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Gastro-esophageal reflux disease (GERD) is a common gastrointestinal disorder that occurs when backflow of the gastric contents into the esophagus results in troublesome symptoms. Though GERD has been extensively studied in Western populations, literature on the management of GERD in patients in Africa and Middle East (AME) is scarce. AREAS COVERED In this review, we provide an overview of the management of mild-to-moderate GERD in AME. Here we focus on the efficacy and safety of currently available treatments for GERD to help physicians and community pharmacists appropriately manage patients with mild-to-moderate GERD in the primary healthcare setting, detailing specific situations and patient scenarios that are relevant to the region, including management of GERD during Ramadan and post-bariatric surgery. EXPERT OPINION Under-appreciation of the burden of GERD in the region has resulted in a lack of consensus on management. Barriers that currently prevent the adoption of treatment guidelines in the primary healthcare setting may include lack of availability of local guidelines and referral systems, a paucity of region-specific research, and dogmatic adherence to traditional practice. By increasing awareness, strengthening knowledge, and by more effective utilization of resources, physicians and pharmacists could optimize GERD management strategies to better support patients.
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Affiliation(s)
- Ahmed Al-Marhabi
- Department of Internal Medicine, College of Medicine, Imam AbdulRahman Bin Faisal University, Khobar, Kingdom of Saudi Arabia
| | - Ahmed Hashem
- Endemic Medicine Department, Cairo University, Egypt.,Department of Medicine & Gastroenterology, Saudi German Hospital Jeddah, Jeddah, Kingdom of Saudi Arabia
| | - Bader Faiyaz Zuberi
- Department of Medicine & Gastroenterology, Dow University of Health Sciences, Karachi, Pakistan
| | - Charles Onyekwere
- Department of Medicine, Lagos State University College of Medicine, Lagos, Nigeria
| | - Imran Lodhi
- Global Medical Sciences, Reckitt Healthcare, London, UK
| | - Mohamed Mounir
- Regional Medical Affairs, Reckitt Benckiser (Arabia) FZE, Dubai, United Arab Emirates
| | - Saad Alkhowaiter
- Gastroenterology, King Saud University, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Sameer Al Awadhi
- Digestive Diseases Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Vasudevan G Naidoo
- Department of Gastroenterology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.,Department of Gastroenterology, University of KwaZulu-Natal, Durban, South Africa
| | - Yasser Hamada
- Endemic Medicine Department, Cairo University, Egypt
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29
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ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117:27-56. [PMID: 34807007 PMCID: PMC8754510 DOI: 10.14309/ajg.0000000000001538] [Citation(s) in RCA: 299] [Impact Index Per Article: 149.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/30/2021] [Indexed: 01/30/2023]
Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
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30
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Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
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31
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Mittal RK. Montreal, Rome, and Lyon Consensus: Will They Resolve the Conundrum of Gastroesophageal Reflux Disease. Gastroenterology 2021; 161:1776-1779. [PMID: 34461054 DOI: 10.1053/j.gastro.2021.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
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32
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Rettura F, Bronzini F, Campigotto M, Lambiase C, Pancetti A, Berti G, Marchi S, de Bortoli N, Zerbib F, Savarino E, Bellini M. Refractory Gastroesophageal Reflux Disease: A Management Update. Front Med (Lausanne) 2021; 8:765061. [PMID: 34790683 PMCID: PMC8591082 DOI: 10.3389/fmed.2021.765061] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.
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Affiliation(s)
- Francesco Rettura
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesco Bronzini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michele Campigotto
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Christian Lambiase
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Andrea Pancetti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Ginevra Berti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Santino Marchi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Massimo Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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DeLay K, Pandolfino JE, Roman S, Gyawali CP, Savarino E, Tye M, Kaizer A, Yadlapati R. Diagnostic yield and reliability of post-prandial high-resolution manometry and impedance-ph for detecting rumination and supragastric belching in PPI non-responders. Neurogastroenterol Motil 2021; 33:e14106. [PMID: 33687131 PMCID: PMC8426416 DOI: 10.1111/nmo.14106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Supragastric belching (SGB) and rumination are behavioral disorders associated with proton pump inhibitor (PPI) non-response and can be diagnosed using multichannel intraluminal impedance-pH (MII-pH) and post-prandial high-resolution impedance manometry (PPHRIM). This pilot study compared diagnostic yield and inter-rater agreement for SGB and rumination using MII-pH and PPHRIM. METHODS Three esophageal physiologists performed blinded interpretations of MII-pH and PPHRIM in 22 PPI non-responders. Raters selected from 4 diagnostic impressions (normal, GERD, behavioral disorders, GERD+behavioral disorders) without clinical context. Primary outcomes were diagnostic impressions compared against clinical gold standard impression, between raters, and between test modalities. Following a 28-month wash-out period, raters re-interpreted MII-pH with clinical context and under consensus definition of diagnostic criteria. KEY RESULTS Compared to gold standard, rater accuracy for presence of behavioral disorders ranged from 45 to 77% on MII-pH and 45-59% on PPHRIM. On MII-pH, inter-rater agreement was fair for diagnosis (ĸ0.32, p < 0.01) and suboptimal for presence of behavioral disorders (ĸ0.13, p = 0.14). On PPHRIM, inter-rater agreement was suboptimal for both diagnosis (ĸ0.03, p = 0.34) and presence of a behavioral disorder (ĸ-0.22, p = 0.96). Inter-rater agreement improved in post hoc MII-pH interpretations. Rumination was more frequently identified on PPHRIM (23, 35%) compared to MII-pH (7, 11%). CONCLUSIONS AND INFERENCES Diagnostic accuracy and inter-rater agreement are higher for MII-pH than PPHRIM, and behavioral disorders are more frequently identified on PPHRIM. Identifying behavioral disorders on MII-pH and PPHRIM has implications for clinical evaluation of PPI non-response; clinical context is essential for accurate study interpretation. Further work is needed to standardize definitions and interpretations.
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Affiliation(s)
- Kelli DeLay
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sabine Roman
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, Lyon, France; Université de Lyon, Lyon I University, Digestive Physiology, Lyon, France; Université de Lyon, Inserm U1032, LabTAU, Lyon, France
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Division of Gastroenterology, University of Padua, Padova, Italy
| | - Michael Tye
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alexander Kaizer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA;,UCSD Center for Esophageal Diseases, Division of Gastroenterology, University of California San Diego, San Diego, California; USA
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Kim JY, Shin IS, Min YW, Kim K, Lee H, Min BH, Lee JH, Kim JJ, Rhee PL. Endoscopic Prediction for Acid Reflux in Patients without Hiatus Hernia. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 76:134-141. [PMID: 32969361 DOI: 10.4166/kjg.2020.76.3.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 11/03/2022]
Abstract
Background/Aims A diagnosis of gastroesophageal reflux disease is challenging in patients who have reflux symptoms but do not respond to proton pump inhibitors nor have reflux esophagitis and hiatal hernia (HH) on endoscopy. This study examined the predictive role of the endoscopic findings, including the flap valve grade for pathologic acid exposure (PAE) to establish an endoscopic prediction model in patients with neither reflux esophagitis nor HH. Methods Five hundred seventy-eight patients who underwent upper endoscopy and 24 hours pH monitoring for reflux esophageal symptoms without evidence of reflux esophagitis and HH were analyzed. The gastroesophageal flap valve (GEFV), esophageal metaplasia, and chronic atrophic gastritis were assessed. The association between the endoscopic parameters and PAE was evaluated. Results Four hundred ninety-four patients were enrolled. The most common complaint was chest discomfort (42.3%) followed by globus (31.8%), dysphagia (7.9%), and heartburn (7.7%). PAE was present in 43 patients (8.7%). Multivariable analysis revealed PAE to be associated with the GEFV grade (p<0.001) and inversely associated with the chronic atrophic gastritis grade (p=0.005). Using these features, a predictive model was established and showed an area under the receiver operating characteristic curve of 0.705 (95% CI 0.619-0.790). The cutoff value of 12.0 had a sensitivity and specificity of 44.0% and 84.0%, respectively. Conclusions A loosened GEFV is associated with a risk of PAE in patients with neither reflux esophagitis nor HH, while atrophic gastritis is preventive. On the other hand, the endoscopic predictive model revealed a low sensitivity for detecting PAE. Thus, reflux testing needs to be performed further when gastroesophageal reflux disease is suspected, even without endoscopic evidence.
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Affiliation(s)
- Jun Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Seub Shin
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Biostatistics and Clinical Epidemiology Center, Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Han S, Choi HY, Kim YH, Nam JY, Kim B, Song GS, Lim HS, Bae KS. Effect of Food on the Pharmacokinetics and Pharmacodynamics of a Single Oral Dose of Tegoprazan. Clin Ther 2021; 43:1371-1380. [PMID: 34246485 DOI: 10.1016/j.clinthera.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/03/2021] [Accepted: 06/11/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Tegoprazan is a potassium-competitive acid blocker (P-CAB) that is designed to treat acid-related diseases through a fundamentally different mechanism than that of proton pump inhibitors (PPIs). Because PPIs inhibit only activated parietal cell H+/K+ adenosine triphosphatase, stimulation of parietal cells by a meal is necessary for optimal results. In contrast, P-CABs can inactivate proton pumps without acid activation and bind to both activated and inactivated adenosine triphosphatase. This study evaluates the effect of food consumption on the pharmacokinetic and pharmacodynamic properties of tegoprazan after a single oral dose in healthy men. METHODS In this open-label, 2-period crossover study, 24 healthy men were randomized to 1 of 2 treatment sequence groups: administration of tegoprazan under the fasting condition and administration of tegoprazan under the fed condition. The dosing periods of both sequence groups were separated by a washout period of 7 days. At each dosing period, the participants received a single dose of 200 mg of tegoprazan followed by pharmacokinetic and pharmacodynamic analysis. FINDINGS After the oral administration of 200 mg tegoprazan, the Cmax was decreased and delayed under the fed condition compared with that of the fasting condition. However, no significant differences were observed in the AUC and the time of gastric acid suppression (inhibition of integrated acidity) during 24 hours. IMPLICATIONS The pharmacokinetic and pharmacodynamic properties of tegoprazan are independent of food effect; thus, tegoprazan could be administered regardless of the timing of food consumption in patients. ClinicalTrials.gov identifier: NCT01830309.
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Affiliation(s)
- Sungpil Han
- Department of Clinical Pharmacology and Therapeutics, Seoul St. Mary's Hospital, Seoul, Korea; Pharmacometrics Institute for Practical Education and Training, Department of Pharmacology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Youn Choi
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Yo Han Kim
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Ji Yeon Nam
- Clinical Development Division, HK inno.N Corp, Seoul, Korea
| | - Bongtae Kim
- Clinical Development Division, HK inno.N Corp, Seoul, Korea
| | - Geun Seog Song
- Clinical Development Division, HK inno.N Corp, Seoul, Korea
| | - Hyeong-Seok Lim
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Kyun-Seop Bae
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan, Seoul, Korea.
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Ustaoglu A, Sawada A, Lee C, Lei WY, Chen CL, Hackett R, Sifrim D, Peiris M, Woodland P. Heartburn sensation in nonerosive reflux disease: pattern of superficial sensory nerves expressing TRPV1 and epithelial cells expressing ASIC3 receptors. Am J Physiol Gastrointest Liver Physiol 2021; 320:G804-G815. [PMID: 33655767 DOI: 10.1152/ajpgi.00013.2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The underlying causes of heartburn, characteristic symptom of gastroesophageal reflux disease (GERD), remain incompletely understood. Superficial afferent innervation of the esophageal mucosa in nonerosive reflux disease (NERD) may drive nociceptive reflux perception, but its acid-sensing role has not yet been established. Transient receptor potential vanilloid subfamily member-1 (TRPV1), transient receptor potential melastatin 8 (TRPM8), and acid-sensing ion channel 3 (ASIC3) are regulators of sensory nerve activity and could be important reflux-sensing receptors within the esophageal mucosa. We characterized TRPV1, TRPM8, and ASIC3 expression in esophageal mucosa of patients with GERD. We studied 10 patients with NERD, 10 with erosive reflux disease (ERD), 7 with functional heartburn (FH), and 8 with Barrett's esophagus (BE). Biopsies obtained from the distal esophageal mucosa were costained with TRPV1, TRPM8, or ASIC3, and CGRP, CD45, or E-cadherin. RNA expression of TRPV1, TRPM8, and ASIC3 was assessed using qPCR. Patients with NERD had significantly increased expression of TRPV1 on superficial sensory nerves compared with ERD (P = 0.028) or BE (P = 0.017). Deep intrapapillary nerve endings did not express TRPV1 in all phenotypes studied. ASIC3 was exclusively expressed on epithelial cells most significantly in patients with NERD and ERD (P ≤0.0001). TRPM8 was expressed on submucosal CD45+ leukocytes. Superficial localization of TRPV1-immunoreactive nerves in NERD, and increased ASIC3 coexpression on epithelial cells in NERD and ERD, suggests a mechanism for heartburn sensation. Esophageal epithelial cells may play a sensory role in acid reflux perception and act interdependently with TRPV1-expressing mucosal nerves to augment hypersensitivity in patients with NERD, raising the enticing possibility of topical antagonists for these ion channels as a therapeutic option.NEW & NOTEWORTHY We demonstrate for the first time that increased pain perception in patients with nonerosive reflux disease likely results from expression of acid-sensitive channels on superficial mucosal afferents and esophageal epithelial cells, raising the potential for topical therapy.
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Affiliation(s)
- Ahsen Ustaoglu
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Akinari Sawada
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Chung Lee
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Richard Hackett
- Centre for Tumour Biology, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Madusha Peiris
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Bell RCW, Freeman K, Heidrick R, Ayazi S. Transoral incisionless fundoplication demonstrates durability at up to 9 years. Therap Adv Gastroenterol 2021; 14:17562848211004827. [PMID: 33948113 PMCID: PMC8053838 DOI: 10.1177/17562848211004827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 02/04/2023] Open
Abstract
GOALS To assess the long-term results of transoral incisionless fundoplication (TIF 2). BACKGROUND TIF with the EsophyX2 is an accepted procedure to treat gastroesophageal reflux disease (GERD). Long-term data have been limited. We report clinical outcomes of 151 patients followed up to 9 years. STUDY A single institution prospective registry of patients undergoing TIF 2 between 11/2008 and 7/2015. Outcomes were assessed by complications, re-interventions, and a mixed effect model of clinical response over time. RESULTS A total of 151 patients (87 women), mean age 62 years (30-91), mean body mass index (BMI) 26.6 (20-36.1), 93% on daily proton pump inhibitor (PPI), underwent TIF 2 without hiatal hernia repair; 131 of the 151 patients (86%) were available for follow-up at a median of 4.92 years (0.7-9.7 years). Of 120 patients ⩾5 years post-TIF, 62 (51%) were followed for a median 6.8 years. Median GERD-health-related quality of life (HRQL) scores decreased from 21 (interquartile range (IQR) 9.5-30) off PPI and 14 (4-24) on PPI at baseline to 4 (2-8) at 4.92 years and remained at 5 (2-9) in the 62 patients 5-9 years post-TIF. Sixty-four per cent had successful (>50%) reductions in GERD-HRQL scores at 4.92 years and 68% of patients followed ⩾5 years. Median regurgitation decreased from 15 (8-20) off PPI and 11 (5-20) on PPI at baseline to 0 (0-4) at 4.92 years, remaining at 1 (0-3) in 62 patients 5-9 years post-TIF. Mixed model analyses confirmed significant and stable improvements in GERD-HRQL and regurgitation scores at all annual follow-up time points after TIF. Daily PPI use decreased from 93% to 32% at 4.92, and 22% at ⩾5 years post-TIF. Revision to laparoscopic fundoplication in 33(22%) showed comparable outcomes. Two patients recovered uneventfully after laparoscopic surgery for localized perforation. CONCLUSIONS TIF 2 provides durable relief of GERD symptoms at up to 9 years with 69-80% of patients having a successful outcome by symptom response and PPI use.
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Affiliation(s)
| | | | - Rachel Heidrick
- Institute of Esophageal and Reflux Surgery, Englewood, CO, USA
| | - Shahin Ayazi
- Allegheny Health Network Ringgold Standard Institution – Surgery, Pittsburgh, PA, USA
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Yadlapati R, Masihi M, Gyawali CP, Carlson DA, Kahrilas PJ, Nix BD, Jain A, Triggs JR, Vaezi MF, Kia L, Kaizer A, Pandolfino JE. Ambulatory Reflux Monitoring Guides Proton Pump Inhibitor Discontinuation in Patients With Gastroesophageal Reflux Symptoms: A Clinical Trial. Gastroenterology 2021; 160:174-182.e1. [PMID: 32949568 PMCID: PMC7755671 DOI: 10.1053/j.gastro.2020.09.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/29/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Proton pump inhibitor (PPI) therapy fails to provide adequate symptom control in up to 50% of patients with gastroesophageal reflux symptoms. Although a proportion do not require ongoing PPI therapy, a diagnostic approach to identify candidates appropriate for PPI cessation is not available. This study aimed to examine the clinical utility of prolonged wireless reflux monitoring to predict the ability to discontinue PPIs. METHODS This double-blinded clinical trial performed over 3 years at 2 centers enrolled adults with troublesome esophageal symptoms of heartburn, regurgitation, and/or chest pain and inadequate PPI response. Participants underwent prolonged wireless reflux monitoring (off PPIs for ≥7 days) and a 3-week PPI cessation intervention. Primary outcome was tolerance of PPI cessation (discontinued or resumed PPIs). Symptom burden was quantified using the Reflux Symptom Questionnaire electronic Diary (RESQ-eD). RESULTS Of 128 enrolled, 100 participants met inclusion criteria (mean age, 48.6 years; 41 men). Thirty-four participants (34%) discontinued PPIs. The strongest predictor of PPI discontinuation was number of days with acid exposure time (AET) > 4.0% (odds ratio, 1.82; P < .001). Participants with 0 days of AET > 4.0% had a 10 times increased odds of discontinuing PPI than participants with 4 days of AET > 4.0%. Reduction in symptom burden was greater among the discontinued versus resumed PPI group (RESQ-eD, -43.7% vs -5.3%; P = .04). CONCLUSIONS Among patients with typical reflux symptoms, inadequate PPI response, and absence of severe esophagitis, acid exposure on reflux monitoring predicted the ability to discontinue PPIs without symptom escalation. Upfront reflux monitoring off acid suppression can limit unnecessary PPI use and guide personalized management. (ClinicalTrials.gov, Number: NCT03202537).
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego School of Medicine, La Jolla, California
| | - Melina Masihi
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Dustin A Carlson
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Peter J Kahrilas
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Billy Darren Nix
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Anand Jain
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Joseph R Triggs
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leila Kia
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alexander Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado
| | - John E Pandolfino
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Rybak A, Sethuraman A, Nikaki K, Koeglmeier J, Lindley K, Borrelli O. Gastroesophageal Reflux Disease and Foregut Dysmotility in Children with Intestinal Failure. Nutrients 2020; 12:nu12113536. [PMID: 33217928 PMCID: PMC7698758 DOI: 10.3390/nu12113536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/09/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022] Open
Abstract
Gastrointestinal dysmotility is a common problem in a subgroup of children with intestinal failure (IF), including short bowel syndrome (SBS) and pediatric intestinal pseudo-obstruction (PIPO). It contributes significantly to the increased morbidity and decreased quality of life in this patient population. Impaired gastrointestinal (GI) motility in IF arises from either loss of GI function due to the primary disorder (e.g., neuropathic or myopathic disorder in the PIPO syndrome) and/or a critical reduction in gut mass. Abnormalities of the anatomy, enteric hormone secretion and neural supply in IF can result in rapid transit, ineffective antegrade peristalsis, delayed gastric emptying or gastroesophageal reflux. Understanding the underlying pathophysiologic mechanism(s) of the enteric dysmotility in IF helps us to plan an appropriate diagnostic workup and apply individually tailored nutritional and pharmacological management, which might ultimately lead to an overall improvement in the quality of life and increase in enteral tolerance. In this review, we have focused on the pathogenesis of GI dysmotility in children with IF, as well as the management and treatment options.
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Affiliation(s)
- Anna Rybak
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
- Correspondence:
| | - Aruna Sethuraman
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London E1 2AJ, UK;
| | - Jutta Koeglmeier
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Keith Lindley
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Osvaldo Borrelli
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
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Cho JH, Shin CM, Yoon H, Park YS, Kim N, Lee DH. Efficacy of a high-dose proton pump inhibitor in patients with gastroesophageal reflux disease: a single center, randomized, open-label trial. BMC Gastroenterol 2020; 20:275. [PMID: 32811427 PMCID: PMC7433117 DOI: 10.1186/s12876-020-01410-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/07/2020] [Indexed: 11/22/2022] Open
Abstract
Background The extraesophageal manifestations of gastroesophageal reflux disease (GERD) are more difficult to manage than the typical symptoms. The efficacy of high-dose and standard-dose proton pump inhibitors against these atypical symptoms is not yet established. Methods In this single center, randomized, open-label study, patients with GERD received rabeprazole for 8 weeks, either 20 mg once daily (standard-dose group) or 20 mg twice daily (high-dose group). Patients were assessed before treatment and at weeks 4 and 8 with a 5-graded scale questionnaire consisting of 2 typical symptoms (heartburn and acid regurgitation) and 8 atypical symptoms (chest pain, cough, globus, wheezing, laryngopharyngitis, hoarseness, belching, and dysphagia). Sufficient improvement of reflux symptoms was defined as ≥50% reduction from the initial questionnaire score. Results Final analyses included 35 patients in the standard-dose group and 38 patients in the high-dose group. The rate of sufficient improvement for typical symptoms was significantly higher in the high-dose group than in the standard-dose group (100.0% vs. 84.0%, P = 0.040). For atypical symptoms, the rate of sufficient improvement tended to be higher in the high-dose group than in the standard-dose group (82.4% vs. 63.0%, P = 0.087). Scores of typical and some atypical symptoms (cough and globus) improved after treatment, with significant inter-group differences in time-course changes. Conclusions High-dose rabeprazole is more effective for relieving typical GERD symptoms and some atypical symptoms such as cough and globus than a standard-dose regimen. Trial registration This research was enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT04001400). This study was registered on June 26, 2019 - Retrospectively registered.
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Affiliation(s)
- Jae Ho Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Young Soo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea.
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Vaezi MF, Fass R, Vakil N, Reasner DS, Mittleman RS, Hall M, Shao JZ, Chen Y, Lane L, Gates AM, Currie MG. IW-3718 Reduces Heartburn Severity in Patients With Refractory Gastroesophageal Reflux Disease in a Randomized Trial. Gastroenterology 2020; 158:2093-2103. [PMID: 32092310 DOI: 10.1053/j.gastro.2020.02.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Refractory gastroesophageal reflux disease (GERD) reduces quality of life and creates significant financial burden on the health care system. Approximately 30% of patients with GERD who receive label-dose proton pump inhibitors (PPIs) still have symptoms. We performed a trial to evaluate the efficacy and safety of IW-3718, a bile acid sequestrant, as an adjunct to PPI therapy. METHODS We performed a multicenter, double-blind, placebo-controlled trial, from March 2016 through April 2017, of 280 patients with confirmed GERD. The patients, stratified by esophagitis status, were randomly assigned (1:1:1:1) to groups given placebo or IW-3718 (500, 1000, or 1500 mg) twice daily, with ongoing label-dose PPI. The primary endpoint was percent change from baseline to week 8 in weekly heartburn severity score. We also analyzed percent change from baseline to week 8 in weekly regurgitation frequency score. RESULTS Mean changes from baseline to week 8 in weekly heartburn severity scores were reductions of 46.0% in the placebo group, 49.0% in the 500 mg group, 55.1% in the 1000 mg group, and 58.0% in the 1500 mg IW-3718 group (dose-response P = .02). The treatment difference was 11.9% between the 1500 mg IW-3718 and placebo groups (P = .04, analysis of covariance). The mean change in weekly regurgitation frequency score from baseline to week 8 in the 1500 mg IW-3718 vs placebo groups was a reduction of 17.5% (95% confidence interval, reductions of 31.4% to 3.6%). The most common adverse event was constipation (in 8.1% of patients receiving IW-3718 and 7.1% of patients receiving placebo). There were no drug-related serious adverse events. CONCLUSIONS In a randomized trial of patients with refractory GERD, adding 1500 mg IW-3718 to label-dose PPIs significantly reduced heartburn symptoms compared with adding placebo. Regurgitation symptoms also decreased. IW-3718 was well tolerated. (ClinicalTrials.gov, Number: NCT02637557).
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Affiliation(s)
| | - Ronnie Fass
- MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - Michael Hall
- Ironwood Pharmaceuticals, Inc, Boston, Massachusetts
| | - James Z Shao
- Ironwood Pharmaceuticals, Inc, Boston, Massachusetts
| | - Yan Chen
- Ironwood Pharmaceuticals, Inc, Boston, Massachusetts
| | - Lara Lane
- Ironwood Pharmaceuticals, Inc, Boston, Massachusetts
| | - Amy M Gates
- Ironwood Pharmaceuticals, Inc, Boston, Massachusetts
| | - Mark G Currie
- Ironwood Pharmaceuticals, Inc, Boston, Massachusetts
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Schwameis K, Oh D, Green KM, Lin B, Zehetner J, Lipham JC, Hagen JA, DeMeester SR. Clinical outcome after laparoscopic Nissen fundoplication in patients with GERD and PPI refractory heartburn. Dis Esophagus 2020; 33:5706866. [PMID: 31942976 DOI: 10.1093/dote/doz099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/19/2019] [Accepted: 10/07/2019] [Indexed: 12/11/2022]
Abstract
Typical reflux symptoms that respond well to proton pump inhibitor (PPI) therapy are key factors predictive of an excellent outcome with antireflux surgery for gastroesophageal reflux disease (GERD). Our aim was to evaluate whether poor preoperative heartburn (HB) relief with PPIs was associated with a worse outcome after Nissen fundoplication. Patients with a main symptom of HB and a positive pH-test who had a laparoscopic Nissen fundoplication between January 2008 and December 2014 were included. Prior to surgery, patients graded how effectively their HB symptoms were relieved by PPIs. Three groups were defined: good response (76-100% relief), partial response (26-75% relief) and poor response (0-25% relief). Outcomes and satisfaction were assessed at a minimum of 1 year after fundoplication. There were 129 patients who met inclusion criteria and 75 agreed to participate. The median follow-up was 48 months. Prior to Nissen fundoplication 13 patients had a good HB response to PPI-therapy, 36 had a partial response and 26 had a poor response. All patients were satisfied with their HB relief after fundoplication (mean satisfaction score: 9.5/10) and there was no difference in satisfaction score or heartburn relief between groups. Heartburn symptoms that respond poorly to PPI therapy are reliably relieved with a Nissen fundoplication in patients with objectively confirmed GERD. Patient satisfaction after Nissen fundoplication was excellent and was similar in patients with poor versus excellent HB relief with preoperative PPI therapy. Therefore, antireflux surgery is an option for patients with HB and confirmed GERD regardless of the degree of relief of HB symptoms provided by PPI medications.
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Affiliation(s)
- Katrin Schwameis
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Daniel Oh
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kyle M Green
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Brenda Lin
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jörg Zehetner
- Department of Surgery, Klinik Beau-Site Hirslanden Bern, Bern, Switzerland
| | - John C Lipham
- Division of General Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jeffrey A Hagen
- Division of Thoracic Surgery, Sanger Heart and Vascular Institute, Charlotte, NC, USA.,Thoracic, Surgical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Steven R DeMeester
- Division of Foregut and Minimally Invasive Surgery, The Oregon Clinic, Portland, OR, USA
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Spechler SJ. Refractory Gastroesophageal Reflux Disease and Functional Heartburn. Gastrointest Endosc Clin N Am 2020; 30:343-359. [PMID: 32146950 DOI: 10.1016/j.giec.2019.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This report discusses the potential mechanisms that might underlie refractory GERD and functional heartburn, and how to distinguish among those mechanisms using a systematic evaluation that includes careful medical history, endoscopy with esophageal biopsy, esophageal manometry, and esophageal multichannel intraluminal impedance-pH monitoring. The report provides an approach to patient management that depends on the underlying mechanism identified by this systematic evaluation.
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Affiliation(s)
- Stuart Jon Spechler
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center at Dallas, The Center for Esophageal Research, Baylor Scott & White Research Institute, 3500 Gaston Avenue, 2 Hoblitzelle, Suite 250, Dallas, TX 75246, USA.
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44
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Role of esophageal manometry and 24-h pH testing in patients with refractory reflux symptoms. Indian J Gastroenterol 2020; 39:165-170. [PMID: 32388711 DOI: 10.1007/s12664-020-01032-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/24/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND A proportion of patients with gastroesophageal reflux disease (GERD) do not respond to proton pump inhibitor (PPI) therapy. AIM OF THE STUDY To determine the findings on high-resolution esophageal manometry (HREM) and 24-h pH recording in patients with typical GERD symptoms, refractory to PPI treatment. METHODS Retrospective analysis of prospectively maintained database of patients referred for HREM and 24-h pH recording was done. We selected patients who were referred for evaluation of refractory GERD symptoms despite > 8 weeks of at least once-daily PPI treatment. Details noted were demographic profile, upper gastrointestinal endoscopy report, HREM findings and 24-h pH findings. RESULTS Ninety-six patients had symptoms of GERD that were refractory to PPI therapy. Seven patients (7.1%) were diagnosed having diseases mimicking GERD: eosinophilic esophagitis (n=2), supragastric belching (n=4) and rumination (n=1). After excluding these patients and those with insufficient data, the final study cohort included 82 cases. Fifty patients (61%) had normal motility. Major motility disorders were detected in 8 (9.75%) patients: achalasia cardia (6) and distal esophageal spasm (2). Ineffective esophageal motility was noted in 24 patients. A total of 74 patients underwent 24-h pH testing. Significant acid reflux with good symptom correlation was noted in 56 patients. Eighteen patients did not have significant acid reflux (Johnson-DeMeester score < 14.7): hypersensitive esophagus (12) and functional heartburn (6). CONCLUSION Fifty-six patients (68.3%) had definite diagnosis of GERD and 31.7% (26) had non-GERD conditions like motility disorders, functional heartburn and hypersensitive esophagus.
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Schizas D, Mastoraki A, Papoutsi E, Giannakoulis VG, Kanavidis P, Tsilimigras D, Ntourakis D, Lyros O, Liakakos T, Moris D. LINX ® reflux management system to bridge the “treatment gap” in gastroesophageal reflux disease: A systematic review of 35 studies. World J Clin Cases 2020; 8:294-305. [PMID: 32047777 PMCID: PMC7000944 DOI: 10.12998/wjcc.v8.i2.294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/06/2019] [Accepted: 12/14/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. When medical therapy is insufficient, surgical therapy is indicated and, until now, Laparoscopic fundoplication (LF) constitutes the gold-standard method. However, magnetic sphincter augmentation (MSA) using the LINX® Reflux Management System has recently emerged and disputes the standard therapeutic approach.
AIM To investigate the device’s safety and efficacy in resolving GERD symptoms.
METHODS This is a systematic review conducted in accordance to the PRISMA guidelines. We searched MEDLINE, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL databases from inception until September 2019.
RESULTS Overall, 35 studies with a total number of 2511 MSA patients were included and analyzed. Post-operative proton-pump inhibitor (PPI) cessation rates reached 100%, with less bloating symptoms and a better ability to belch or vomit in comparison to LF. Special patient groups (e.g., bariatric or large hiatal-hernias) had promising results too. The most common postoperative complication was dysphagia ranging between 6% and 83%. Dilation due to dysphagia occurred in 8% of patients with typical inclusion criteria. Esophageal erosion may occur in up to 0.03% of patients. Furthermore, a recent trial indicated MSA as an efficient alternative to double-dose PPIs in moderate-to-severe GERD.
CONCLUSION The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results.
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Affiliation(s)
- Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Aikaterini Mastoraki
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Chaidari, Athens 11527, Greece
| | - Eleni Papoutsi
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Vassilis G Giannakoulis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Prodromos Kanavidis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Diamantis Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH 45830, United States
| | - Dimitrios Ntourakis
- Department of Surgery, School of Medicine, European University Cyprus, Nicosia 2404, Cyprus
| | - Orestis Lyros
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig 04103, Germany
| | - Theodore Liakakos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Duke University, Durham, NC 27705, United States
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Kirkham EN, Main BG, Jones KJB, Blazeby JM, Blencowe NS. Systematic review of the introduction and evaluation of magnetic augmentation of the lower oesophageal sphincter for gastro-oesophageal reflux disease. Br J Surg 2019; 107:44-55. [PMID: 31800095 PMCID: PMC6972716 DOI: 10.1002/bjs.11391] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/13/2019] [Accepted: 09/11/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is reported to be an innovative alternative to antireflux surgery for patients with gastro-oesophageal reflux disease. Although used in practice, little is known about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of MSA and its introduction into clinical practice, in the context of guidelines (such as IDEAL) for evaluating innovative surgical devices. METHODS Systematic searches were used to identify all published studies reporting MSA insertion. Data collected included patient selection, governance arrangements, surgeon expertise, technique description and outcome reporting. RESULTS Searches identified 587 abstracts; 39 full-text papers were included (1 RCT 5 cohort, 3 case-control, 25 case series, 5 case reports). Twenty-one followed US Food and Drug Administration eligibility criteria for MSA insertion. Twenty-six documented that ethical approval was obtained. Two reported that participating surgeons received training in MSA; 18 provided information about how MSA insertion was performed, although techniques varied between studies. Follow-up ranged from 4 weeks to 5 years; in 14 studies, it was less than 1 year. CONCLUSION Most studies on MSA lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness.
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Affiliation(s)
- E N Kirkham
- Conformité Européenne Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK.,Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - B G Main
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK.,Conformité Européenne University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - K J B Jones
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - J M Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK.,Conformité Européenne University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - N S Blencowe
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK.,Conformité Européenne University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Bhatia SJ, Makharia GK, Abraham P, Bhat N, Kumar A, Reddy DN, Ghoshal UC, Ahuja V, Rao GV, Devadas K, Dutta AK, Jain A, Kedia S, Dama R, Kalapala R, Alvares JF, Dadhich S, Dixit VK, Goenka MK, Goswami BD, Issar SK, Leelakrishnan V, Mallath MK, Mathew P, Mathew P, Nandwani S, Pai CG, Peter L, Prasad AVS, Singh D, Sodhi JS, Sud R, Venkataraman J, Midha V, Bapaye A, Dutta U, Jain AK, Kochhar R, Puri AS, Singh SP, Shimpi L, Sood A, Wadhwa RT. Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology. Indian J Gastroenterol 2019; 38:411-440. [PMID: 31802441 DOI: 10.1007/s12664-019-00979-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.
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Affiliation(s)
- Shobna J Bhatia
- Seth GS Medical College and KEM Hospital, Mumbai, 400 012, India.
| | | | - Philip Abraham
- P D Hinduja Hospital and MRC, and Hinduja Heathcare Surgical, Mumbai, 400 016, India
| | - Naresh Bhat
- Aster CMI Hospital, Bengaluru, 560 092, India
| | - Ajay Kumar
- Fortis Escorts Liver and Digestive Diseases Institute, Delhi, 110 025, India
| | | | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Vineet Ahuja
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - G Venkat Rao
- Asian Institute of Gastroenterology, Hyderabad, 500 082, India
| | | | - Amit K Dutta
- Christian Medical College, Vellore, 632 004, India
| | - Abhinav Jain
- Seth GS Medical College and KEM Hospital, Mumbai, 400 012, India
| | - Saurabh Kedia
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Rohit Dama
- Asian Institute of Gastroenterology, Hyderabad, 500 082, India
| | - Rakesh Kalapala
- Asian Institute of Gastroenterology, Hyderabad, 500 082, India
| | | | | | - Vinod Kumar Dixit
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221 005, India
| | | | - B D Goswami
- Gauhati Medical College, Dispur Hospitals, Guwahati, 781 032, India
| | - Sanjeev K Issar
- JLN Hospital and Research Center, Bhilai Steel Plant, Bhilai, 490 009, India
| | | | | | | | - Praveen Mathew
- Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, 560 066, India
| | | | - Cannanore Ganesh Pai
- Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576 104, India
| | | | - A V Siva Prasad
- Institute of Gastroenterology, Visakhapatnam, 530 002, India
| | | | | | - Randhir Sud
- Medanta - The Medicity, Gurugram, 122 001, India
| | | | - Vandana Midha
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Amol Bapaye
- Deenanath Mangeshkar Hospital and Research Center, Pune, 411 004, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ajay K Jain
- Choithram Hospital and Research Centre, Indore, 452 014, India
| | - Rakesh Kochhar
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | | | | | | | - Ajit Sood
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
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Buckley FP, Havemann B, Chawla A. Magnetic sphincter augmentation: Optimal patient selection and referral care pathways. World J Gastrointest Endosc 2019; 11:472-476. [PMID: 31523378 PMCID: PMC6715569 DOI: 10.4253/wjge.v11.i8.472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/13/2019] [Accepted: 07/20/2019] [Indexed: 02/06/2023] Open
Abstract
Outcomes associated with magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD) have been reported, however the optimal population for MSA and the related patient care pathways have not been summarized. This Minireview presents evidence that describes the optimal patient population for MSA, delineates diagnostics to identify these patients, and outlines opportunities for improving GERD patient care pathways. Relevant publications from MEDLINE/EMBASE and guidelines were identified from 2000-2018. Clinical experts contextualized the evidence based on clinical experience. The optimal MSA population may be the 2.2-2.4% of GERD patients who, despite optimal medical management, continue experiencing symptoms of heartburn and/or uncontrolled regurgitation, have abnormal pH, and have intact esophageal function as determined by high resolution manometry. Diagnostic work-ups include ambulatory pH monitoring, high-resolution manometry, barium swallow, and esophagogastroduodenoscopy. GERD patients may present with a range of typical or atypical symptoms. In addition to primary care providers (PCPs) and gastroenterologists (GIs), other specialties involved may include otolaryngologists, allergists, pulmonologists, among others. Objective diagnostic testing is required to ascertain surgical necessity for GERD. Current referral pathways for GERD management are suboptimal. Opportunities exist for enabling patients, PCPs, GIs, and surgeons to act as a team in developing evidence-based optimal care plans.
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Affiliation(s)
- F Paul Buckley
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, United States
| | | | - Amarpreet Chawla
- Department of Health Economics and Market Access, Ethicon Inc. (Johnson and Johnson), Cincinnati, OH 45242, United States
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Ribolsi M, Giordano A, Guarino MPL, Tullio A, Cicala M. New classifications of gastroesophageal reflux disease: an improvement for patient management? Expert Rev Gastroenterol Hepatol 2019; 13:761-769. [PMID: 31327288 DOI: 10.1080/17474124.2019.1645596] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Gastroesophageal reflux disease (GERD) is a very common and often debilitating disease. In the broad spectrum of GERD phenotypes, three main groups may be traditionally distinguished: 1) patients only affected by esophageal and/or extra-esophageal symptoms; 2) patients with erosive esophagitis and 3) patients with further complications. Areas covered: This review provides an overview on the current classifications of GERD patients, and their impact on their management. Expert opinion: In 2017, the GERD Consensus Working Group focused the attention on patients unresponsive to PPIs. In this scenario, a diagnosis of GERD might be confirmed by evident signs of erosive esophagitis and the finding of pH or multichannel intraluminal impedance-pH tests, such as more than 6%. The 'Lyon Consensus' panel of experts confirmed that positive indices of reflux-symptom association, without other altered parameters, represent reflux hypersensitivity. GERD requires a customized management; it is crucial to assess frequency and severity of symptoms and their response to an optimal course of therapy as well as to explore the endoscopic alterations and consider other diagnoses responsible for persistent symptoms.
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Affiliation(s)
- Mentore Ribolsi
- a Unit of Gastroenterology and Digestive Endoscopy, University Campus Bio Medico , Rome , Italy
| | - Antonio Giordano
- a Unit of Gastroenterology and Digestive Endoscopy, University Campus Bio Medico , Rome , Italy
| | | | - Alessandro Tullio
- a Unit of Gastroenterology and Digestive Endoscopy, University Campus Bio Medico , Rome , Italy
| | - Michele Cicala
- a Unit of Gastroenterology and Digestive Endoscopy, University Campus Bio Medico , Rome , Italy
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50
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Hu Y, Yu X, Yu S. QX-314 inhibits acid-induced activation of esophageal nociceptive C fiber neurons. Neurogastroenterol Motil 2019; 31:e13543. [PMID: 30663188 PMCID: PMC6452878 DOI: 10.1111/nmo.13543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 12/10/2018] [Accepted: 12/14/2018] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Acid reflux in the esophagus can induce painful sensations such as heartburn and non-cardiac chest pain. These nociceptive symptoms are initiated by activation of TRPV1-positive afferent C fibers in the esophagus. The present study aimed to explore a novel C fiber inhibition approach. We hypothesized that activation of TRPV1 by acid enabled QX-314, a membrane impermeable sodium channel blocker, to inhibit acid-induced activation of esophageal nociceptive C fiber neurons. METHOD We determined the inhibitory effect of QX-314 in the presence of acid in guinea pig esophageal nociceptive vagal jugular C fiber neurons by both patch clamp recording in neuron soma and by extra-cellular recording at nerve terminals. KEY RESULTS Our data demonstrated QX-314 alone did not inhibit sodium currents. However, when applied along with capsaicin to activate TRPV1, QX-314 was able to block sodium currents in esophageal-specific jugular C fiber neurons. We then showed that in the presence of acid, QX-314 significantly blocked acid-evoked activation of jugular C fiber neurons. This effect was attenuated by TRPV1 antagonist AMG9810, suggesting acid-mediated inhibitory effect of QX-314 was TRPV1-dependent. Finally, we provided evidence at nerve endings that acid-evoked action potential discharges in esophageal jugular C fibers were inhibited by QX-314 when applied in the presence of acid. CONCLUSION AND INFERENCES Our data demonstrated that activation of TRPV1 by acid enabled membrane impermeable sodium channel blocker QX-314 to inhibit acid-induced activation in esophageal nociceptive C fibers. This supports a localized application of QX-314 in the esophagus to block esophageal nociception in acid reflux disorders.
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Affiliation(s)
| | | | - Shaoyong Yu
- Corresponding: Shaoyong Yu, MD, MPH., Johns Hopkins University School of Medicine, Ross Research Building, Room 945, 720 Rutland Ave, Baltimore 21205, Phone: (410) 502-2455,
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