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Fangxu L, Wenbin L, Pan Z, Dan C, Xi W, Xue X, Jihua S, Qingfeng L, Le X, Songbai Z. Chinese expert consensus on diagnosis and management of gastroesophageal reflux disease in the elderly (2023). Aging Med (Milton) 2024; 7:143-157. [PMID: 38725699 PMCID: PMC11077342 DOI: 10.1002/agm2.12293] [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] [Received: 12/28/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 05/12/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) in the elderly is characterized by atypical symptoms, relatively severe esophageal injury, and more complications, and when GERD is treated, it is also necessary to fully consider the general health condition of the elderly patients. This consensus summarized the epidemiology, pathogenesis, clinical manifestations, and diagnosis and treatment characteristics of GERD in the elderly, and provided relevant recommendations, providing guidance for medical personnel to correctly understand and standardize the diagnosis and treatment of GERD in the elderly.
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Affiliation(s)
- Liu Fangxu
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Li Wenbin
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Zhang Pan
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Chen Dan
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Wu Xi
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Xu Xue
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Shi Jihua
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Luo Qingfeng
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Xu Le
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Zheng Songbai
- Department of GeriatricsHuadong Hospital Affiliated to Fudan UniversityShanghaiChina
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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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Mari A, Marabotto E, Ribolsi M, Zingone F, Barberio B, Savarino V, Savarino EV. Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future. Expert Rev Clin Pharmacol 2023; 16:913-923. [PMID: 37632213 DOI: 10.1080/17512433.2023.2252327] [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] [Received: 07/09/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 08/27/2023]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) have revolutionized the management of acid-related disorders, representing today the mainstay treatment of these conditions. However, despite their large range of indications and usefulness, the remarkable expansion of their use in the last two decades cannot be explained by the increasing prevalence of acid-related diseases only. An inappropriate prescription for clinical conditions in which the pathogenetic role of acid has not been documented has been described, with the natural consequence of increasing the costs and the potential risk of iatrogenic harm due to adverse events and complications recently emerged. AREAS COVERED In this review, we summarize current indications of PPIs administration, potential adverse events associated with their chronic utilization, and misuse of PPIs. Moreover, we describe existing and possible initiatives for improving the use of PPIs, and some proposals for the future. EXPERT OPINION PPI deprescribing is the preferred and most effective approach to reduce the use of PPIs, rather than adopting sharp discontinuation, probably due to fewer withdrawal symptoms. Nonetheless, large knowledge gaps still exist in clinical practice regarding the optimal approach of PPI deprescribing in various clinical scenarios. Further prospective well-designed international studies are eagerly warranted to improve our perspectives on controlling global PPI inappropriate use.
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Affiliation(s)
- Amir Mari
- Gastroenterology Unit, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar Ilan University, Nazareth, Israel
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Mentore Ribolsi
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Rome, Italy
| | - Fabiana Zingone
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Reiter AJ, Farina DA, Fronza JS, Komanduri S. Magnetic sphincter augmentation: considerations for use in Barrett's esophagus. Dis Esophagus 2023; 36:doac096. [PMID: 36575922 PMCID: PMC10267686 DOI: 10.1093/dote/doac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 12/29/2022]
Abstract
Barrett's esophagus (BE) occurs in 5-15% of patients with gastroesophageal reflux disease (GERD). While acid suppressive therapy is a critical component of BE management to minimize the risk of progression to esophageal adenocarcinoma, surgical control of mechanical reflux is sometimes necessary. Magnetic sphincter augmentation (MSA) is an increasingly utilized anti-reflux surgical therapy for GERD. While the use of MSA is listed as a precaution by the United States Food and Drug Administration, there are limited data showing effective BE regression with MSA. MSA offers several advantages in BE including effective reflux control, anti-reflux barrier restoration and reduced hiatal hernia recurrence. However, careful patient selection for MSA is necessary.
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Affiliation(s)
- Audra J Reiter
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Domenico A Farina
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeffrey S Fronza
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Srinadh Komanduri
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Gould MJ, Lin C, Walsh CM. A Systematic Assessment of the Quality of Smartphone Applications for Gastroesophageal Reflux Disease. GASTRO HEP ADVANCES 2023; 2:733-742. [PMID: 39129878 PMCID: PMC11308438 DOI: 10.1016/j.gastha.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/02/2023] [Indexed: 08/13/2024]
Abstract
Background and Aims Smartphone applications aimed at patients with gastroesophageal reflux disease (GERD) have been downloaded more than 100,000 times, yet no systematic assessment of their quality has been completed. This study aimed to objectively assess the quality of GERD smartphone applications for patient education and disease management. Methods The Apple App Store and Google Play Store were systematically searched for relevant applications. Two independent reviewers performed the application screening and eligibility assessment. Included applications were graded using the validated Mobile Application Rating Scale, which encompasses 4 domains (engagement, functionality, aesthetics, and information) as well as an overall application quality score. The associations between overall application quality, user ratings and download numbers were evaluated. Results Of the 4816 unique applications identified, 46 met inclusion criteria (patient education = 37, disease management = 9). Mean overall application quality score was 3.02 ± 0.40 out of 5 ("acceptable"), with 61% (28/46) rated as "poor" (score 2.0-2.9). Applications scored highest for aesthetics (3.24 ± 0.48) and functionality (3.88 ± 0.37) and lowest for information (2.58 ± 0.64) and engagement (2.39 ± 0.65). Disease management applications were of significantly higher quality than education-focused applications (3.59 ± 0.38 vs 2.88 ± 0.26, P < .001). There was no correlation between graded quality and either user ratings or the number of downloads. Conclusion While numerous smartphone applications exist to support patients with GERD, their quality is variable. Patient education applications are of particularly low quality. Our findings can help to inform the selection of applications by patients and guide clinicians' recommendations. This study also highlights the need for higher-quality, evidence-informed applications aimed at GERD patient education.
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Affiliation(s)
- Michelle J. Gould
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Chantelle Lin
- SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Catharine M. Walsh
- Division of Gastroenterology, Hepatology, and Nutrition and the SickKids Research and Learning Institutes, Department of Paediatrics and the Wilson Centre, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Qi M, Zhou Y, Zhou YX, Fang SQ. Progress in research of pathogenesis of refractory gastroesophageal reflux disease. Shijie Huaren Xiaohua Zazhi 2022; 30:769-774. [DOI: 10.11569/wcjd.v30.i17.769] [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: 02/07/2023] Open
Abstract
Refractory gastroesophageal reflux disease (rGERD) is a common clinical disease with many pathogenic factors, complex mechanisms, and increasing incidence. At present, scholars believe that the pathogenesis of rGERD is closely related to intra- and extra-esophageal factors. Elucidating the mechanism of rGERD can contribute to the diagnosis and treatment of the disease. This paper summarizes the current progress in the research of the pathogenesis of rGERD, and puts forward our own thoughts and prospects for the disease, in order to provide ideas for the in-depth study of the pathogenesis of rGERD.
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Affiliation(s)
- Mei Qi
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200080, China
| | - Yue Zhou
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200080, China
| | - Yu-Xuan Zhou
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200080, China
| | - Sheng-Quan Fang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200080, China
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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: 100] [Impact Index Per Article: 50.0] [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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Distinct Clinical Physiologic Phenotypes of Patients With Laryngeal Symptoms Referred for Reflux Evaluation. Clin Gastroenterol Hepatol 2022; 20:776-786.e1. [PMID: 34022451 PMCID: PMC8715518 DOI: 10.1016/j.cgh.2021.05.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Heterogeneous presentations and disease mechanisms among patients with laryngeal symptoms account for misdiagnosis of laryngopharyngeal reflux (LPR), variations in testing, and suboptimal outcomes. We aimed to derive phenotypes of patients with laryngeal symptoms based on clinical and physiologic data and to compare characteristics across phenotypes. METHODS A total of 302 adult patients with chronic laryngeal symptoms were prospectively enrolled at 3 centers between January 2018 to October 2020 (age 57.2 ± 15.2 years; 30% male; body mass index 27.2 ± 6.0 kg/m2). Discriminant analysis of principal components (DAPC) was applied to 12 clinical and 11 physiologic variables collected in stable condition to derive phenotypic groups. RESULTS DAPC identified 5 groups, with significant differences across symptoms, hiatal hernia size, and number of reflux events (P < .01). Group A had the greatest hiatal hernia size (3.1 ± 1.0 cm; P < .001) and reflux events (37.5 ± 51; P < .001), with frequent cough, laryngeal symptoms, heartburn, and regurgitation. Group B had the highest body mass index (28.2 ± 4.6 kg/m2; P < .001) and salivary pepsin (150 ± 157 ng/mL; P = .03), with frequent cough, laryngeal symptoms, globus, heartburn, and regurgitation. Group C frequently reported laryngeal symptoms (93%; P < .001), and had fewest esophageal symptoms (9.6%; P < .001) and reflux events (10.7 ± 11.0; P < .001). Group D commonly reported cough (88%; P < .001) and heartburn. Group E (18%) was oldest (62.9 ± 14.3 years; P < .001) and distinguished by highest integrated relaxation pressure. CONCLUSIONS DAPC identified distinct clinicophysiologic phenotypes of patients with laryngeal symptoms referred for reflux evaluation: group A, LPR and gastroesophageal reflux disease (GERD) with hiatal hernia; group B, mild LPR/GERD; group C, no LPR/No GERD; group D, reflex cough; and group E, mixed/possible obstructive esophagogastric junction. Phenotypic differences may inform targeted clinical trials design and improve outcomes.
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Yadlapati R, Pandolfino JE, Greytak M, Cahoon J, Clarke M, Clary M, Fink D, Menard-Katcher P, Vahabzadeh-Hagh AM, Weissbrod P, Gupta S, Kaizer A, Wani S. Upper Esophageal Sphincter Compression Device as an Adjunct to Proton Pump Inhibition for Laryngopharyngeal Reflux. Dig Dis Sci 2022; 67:3045-3054. [PMID: 34275061 PMCID: PMC8286644 DOI: 10.1007/s10620-021-07172-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/08/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Reflux Band, an external upper esophageal sphincter (UES) compression device, reduces esophago-pharyngeal reflux events. This study aimed to assess device efficacy as an adjunct to proton pump inhibitor (PPI) therapy in patients with laryngopharyngeal reflux (LPR). METHODS This two-phase prospective clinical trial enrolled adults with at least 8 weeks of laryngeal symptoms (sore throat, throat clearing, dysphonia) not using PPI therapy at two tertiary care centers over 26 months. Participants used double dose PPI for 4 weeks in Phase 1 and the external UES compression device nightly along with PPI for 4 weeks in Phase 2. Questionnaire scores and salivary pepsin concentration were measured throughout the study. The primary endpoint of symptom response was defined as reflux symptom index (RSI) score ≤ 13 and/or > 50% reduction in RSI. RESULTS Thirty-one participants completed the study: 52% male, mean age 47.9 years (SD 14.0), and mean body mass index (BMI) 26.2 kg/m2 (5.1). Primary endpoint was met in 11 (35%) participants after Phase 1 (PPI alone) and 17 (55%) after Phase 2 (Device + PPI). Compared to baseline, mean RSI score (24.1 (10.9)) decreased at end of Phase 1 (PPI alone) (21.9 (9.7); p = 0.06) and significantly decreased at end of Phase 2 (Device + PPI) (15.5 (10.3); p < 0.01). Compared to non-responders, responders to Device + PPI had a significantly lower BMI (p = 0.02) and higher salivary pepsin concentration (p = 0.01). CONCLUSION This clinical trial highlights the potential efficacy of the external UES compression device (Reflux Band) as an adjunct to PPI for patients with LPR (ClinicalTrials.Gov NCT03619811).
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego School of Medicine, ACTRI Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA 92093 USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University, Feinberg School of Medicine, Chicago, IL USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California, San Diego School of Medicine, ACTRI Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA 92093 USA
| | - Jonathon Cahoon
- Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Mary Clarke
- Division of Gastroenterology, University of California, San Diego School of Medicine, ACTRI Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA 92093 USA
| | - Matthew Clary
- Division of Otolaryngology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Daniel Fink
- Division of Otolaryngology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Andrew M. Vahabzadeh-Hagh
- Division of Otolaryngology, Department of Surgery, University of California San Diego, La Jolla, CA USA
| | - Philip Weissbrod
- Division of Otolaryngology, Department of Surgery, University of California San Diego, La Jolla, CA USA
| | - Samir Gupta
- Division of Gastroenterology, University of California, San Diego School of Medicine, ACTRI Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA 92093 USA
| | - Alexander Kaizer
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Sachin Wani
- Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
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Domingues G, Moraes-Filho JPPD. GASTROESOPHAGEAL REFLUX DISEASE: A PRACTICAL APPROACH. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:525-533. [PMID: 34909861 DOI: 10.1590/s0004-2803.202100000-94] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/26/2021] [Indexed: 01/10/2023]
Abstract
Gastroesophageal reflux disease (GERD) presents typical manifestations such as heartburn and/or regurgitation as well as atypical manifestations such as throat symptoms, laryngitis, hoarseness, chronic cough, asthma, and sleep alterations. There are two phenotypes of the disease: erosive GERD, when erosions are identified by upper digestive endoscopy, and non-erosive GERD, when the esophageal mucosa presents a normal endoscopic aspect. Relevant clinical findings are usually absent in the physical examination, but it should be highlighted that obesity is an important aggravating factor of reflux. The treatment is established based on clinical findings and, according to the clinical situation, on complementary exams such as upper digestive endoscopy. In dubious cases where a precise diagnosis is required, the indicated test is esophageal pHmetry or impedance-pHmetry. Clinical treatment is divided into behavioral/dietary measures and pharmacological measures. Most patients benefit from clinical treatment, but surgical treatment may be indicated in the presence of a larger hiatal hernia and complications of the disease.
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Affiliation(s)
- Gerson Domingues
- Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Alzahrani F, Al Turki Y. Knowledge and practice of family medicine and internal medicine residents toward the management of gastroesophageal reflux disease in Riyadh, Saudi Arabia. J Family Med Prim Care 2021; 10:3005-3012. [PMID: 34660439 PMCID: PMC8483100 DOI: 10.4103/jfmpc.jfmpc_236_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/17/2021] [Accepted: 03/23/2021] [Indexed: 11/04/2022] Open
Abstract
Background Accurate diagnosis and management of gastroesophageal reflux disease (GERD) remain a challenge in the primary care setting. The objective was to assess GERD management's knowledge and practice and its association with the family and internal medicine residents. Methods A cross-sectional study between January 2019 and September 2020 among the family and internal medicine residents in Riyadh, Saudi Arabia. Residents answered a self-administrated questionnaire about knowledge and practices of GERD management. Results A total of 596 residents were included in the current study. The average age was 26.8 ± 2.1 years, and 54.5% of the residents were males. The median knowledge score was 62.5%. The majority (89.8%) of the residents were using acid suppression drugs empirically, mainly proton-pump inhibitors (75.8%), for <8-week durations (69.7%) being taken before meals (84.7%). Frequent diagnostic testing for GERD included urea breath test (50.7%), 24-hour pH-metry/24-hour pH probe (47.3%), and upper endoscopy with biopsy (40.7%). Frequent causes for referral included gastrointestinal bleeding (82.6%), weight loss/appetite loss (82.2%), and failure of therapy (78.7%). Better knowledge was associated with older age, family medicine training, better referral practices, frequent reporting of atypical symptoms, and reading recent guidelines. Conclusions We are reporting a moderate knowledge level among a group of family and internal medicine residents trained in Riyadh hospitals. Practices were generally good with some areas that need improvement, especially diagnostic testing. There is an urgent need for educational programs that target family and internal medicine residents, such as education courses that include lectures and clinical discussions with the senior staff. Also, we suggest health care organizations in Saudi Arabia establish well-structured Saudi National GERD Guidelines.
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Affiliation(s)
- Fahad Alzahrani
- Department of Family and Community Medicine, King Saud University, King Saud University Medical Saud City Riyadh, Saudi Arabia
| | - Yousef Al Turki
- Department of Family and Community Medicine, King Saud University, Collage of Medicine, King University Medical City Riyadh, Saudi Arabia
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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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Krigel A, Lebwohl B, Yadlapati R, Jodorkovsky D. Association of patient gender and gastroenterologists' diagnosis and management choices in gastroesophageal reflux disease. Dis Esophagus 2021; 34:6231787. [PMID: 33870435 PMCID: PMC9989594 DOI: 10.1093/dote/doab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/26/2021] [Indexed: 12/11/2022]
Abstract
Symptom severity and prevalence of erosive disease in gastroesophageal reflux disease (GERD) differ between genders. It is not known how gastroenterologists incorporate patient gender in their decision-making process. We aimed to evaluate how gender influences the diagnosis and management recommendations for patients with GERD. We invited a nationwide sample of gastroenterologists via voluntary listservs to complete an online survey of fictional patient scenarios presenting with different GERD symptoms and endoscopic findings. Patient gender for each case was randomly generated. Study participants were asked for their likelihood of a diagnosis of GERD and subsequent management recommendations. Results were analyzed using chi-square tests, Fisher Exact tests, and multivariable logistic regression. Of 819 survey invitations sent, 135 gastroenterologists responded with 95.6% completion rate. There was no significant association between patient gender and prediction for the likelihood of GERD for any of the five clinical scenarios when analyzed separately or when all survey responses were pooled. There was also no significant association between gender and decision to refer for fundoplication, escalate PPI therapy, or start of neuromodulation/behavioral therapy. Despite documented symptomatic and physiologic differences of GERD between the genders, patient gender did not affect respondents' estimates of GERD diagnosis or subsequent management. Further outcomes studies should validate whether response to GERD treatment strategies differ between women and men.
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Affiliation(s)
- Anna Krigel
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, USA
| | - Benjamin Lebwohl
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Rena Yadlapati
- Department of Medicine, UC San Diego School of Medicine, San Diego, CA, USA
| | - Daniela Jodorkovsky
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, USA
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Advances in the diagnosis of GERD. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MÉDECINE INTERNE 2021; 59:3-9. [PMID: 33010143 DOI: 10.2478/rjim-2020-0027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Indexed: 12/22/2022]
Abstract
Gastroesophageal reflux disease (GERD) is considered one of the most frequent chronic gastrointestinal diseases globally with high costs due to treatment and investigations.First line therapy is with proton pump inhibitors, those who do not respond to initial treatment usually require further investigations such as upper gastrointestinal endoscopy or ambulatory 24-hours esophageal pH monitoring. The total time of exposure to acid and the DeMeester score represent the most useful parameters associated with conventional pH-metry, because they can identify gastroesophageal reflux disease.Although pH-metry is considered the gold standard for the evaluation of gastroesophageal reflux disease, new impedance-based parameters have been introduced in recent years with the role of increasing the accuracy of diagnosing gastroesophageal reflux disease and characterizing the type of reflux. The development of multichannel intraluminal pH-impedance has improved the ability to detect and quantify gastroesophageal reflux. New parameters such as post-reflux swallowing peristaltic wave (PSPW) index and the mean nocturnal basal impedance (MNBI) have recently been introduced to assess GERD phenotypes more accurately. This review evaluates current GERD diagnotic tools while also taking a brief look at newer diagnostic parameters like PSPW and MNBI.
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15
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Herszényi L. Reflux Symptoms - Functional and Structural Diseases: The Approach from the General Practitioner. Dig Dis 2021; 39:585-589. [PMID: 33561852 DOI: 10.1159/000515116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Abstract
A primary care management strategy of gastroesophageal reflux disease (GERD) should pay attention to the epidemiology, prevalence, and distribution of reflux-like symptoms in the community and to the special characteristics of patients presenting for the first time with reflux symptoms in primary care. General practitioners (GPs) encounter daily challenges to make cost-effective differential diagnostic and therapeutic decisions, avoiding needless and costly investigation or referral. They should provide long-term effective control of symptoms and esophageal healing in a personalized, symptom-based, patient-centered, and evidence-based manner. GPs should use a practical system of triage in order to distinguish the high majority of patients with self-limiting conditions from the minority with alarm symptoms with potentially severe disorder. They should also discriminate between troublesome and nontroublesome reflux symptoms. Most GERD is uncomplicated and can be treated using management algorithms that make the best use of resources. Some strategies such as "step-down," "intermittent," or "on-demand" therapy can cost-effectively improve the long-term management and quality of life of patients with recurrent GERD. The accurate interpretation of "step-down" therapeutic strategy and a careful interpretation of proton pump inhibitor refractoriness are also essential.
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Affiliation(s)
- László Herszényi
- Department of Gastroenterology, Hungarian Defence Forces, Budapest, Hungary
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16
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Talley NJ, Zand Irani M. Optimal management of severe symptomatic gastroesophageal reflux disease. J Intern Med 2021; 289:162-178. [PMID: 32691466 DOI: 10.1111/joim.13148] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder, and empirical proton pump inhibitor (PPI) treatment is often the first step of management; however, up to 40% of patients remain symptomatic despite PPI treatment. Refractory reflux refers to continued symptoms despite an adequate trial of PPI, and management remains challenging. The differential diagnosis is important; other oesophageal (e.g. eosinophilic oesophagitis) and gastroduodenal disorders (e.g. functional dyspepsia) should be ruled out, as this changes management. A combination of clinical assessment, endoscopic evaluation and in selected cases oesophageal function testing can help characterize patients with refractory reflux symptoms into oesophageal phenotypes so appropriate therapy can be more optimally targeted. Medical options then may include adding a H2 receptor antagonist, alginates, baclofen or antidepressant therapy, and there is emerging evidence for bile acid sequestrants and diaphragmatic breathing. The demonstration of a temporal association of symptoms with reflux events on pH-impedance testing (reflux hypersensitivity) serves to focus the management on modulating oesophageal perception and reducing the reflux burden, or identifies those with no obvious pathophysiologic abnormalities (functional heartburn). Anti-reflux surgery based on randomized controlled trial evidence has a role in reflux hypersensitivity or continued pathological acid reflux despite PPI in carefully considered, fully worked up cases that have failed medical therapy; approximately two of three cases will respond but there is a small risk of complications. In patients with persistent volume reflux despite medical therapy, given the lack of alternatives, anti-reflux surgery is a consideration. Promising newer approaches include endoscopic techniques. This review aims to summarize current diagnostic approaches and critically evaluates the evidence for the efficacy of available treatments.
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Affiliation(s)
- N J Talley
- From the, NHMRC Centre of Research Excellence of Digestive Health, Faculty of Health and Medicine, University of Newcastle, New Lambton Heights, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - M Zand Irani
- From the, NHMRC Centre of Research Excellence of Digestive Health, Faculty of Health and Medicine, University of Newcastle, New Lambton Heights, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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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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18
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Sharma P, Yadlapati R. Pathophysiology and treatment options for gastroesophageal reflux disease: looking beyond acid. Ann N Y Acad Sci 2020; 1486:3-14. [PMID: 33015827 DOI: 10.1111/nyas.14501] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 12/14/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a disorder due to the retrograde flow of refluxate into the esophagus. Although GERD is a common clinical diagnosis, its pathogenesis is quite complex. As a result of its multifactorial development, many patients continue to experience adverse symptoms due to GERD despite prolonged acid suppression with proton pump inhibitor therapy. The pathogenesis of GERD involves an interplay of chemical, mechanical, psychologic, and neurologic mechanisms, which contribute to symptom presentation, diagnosis, and treatment. As such, GERD should be approached as a disorder beyond acid. This review will investigate the major factors that contribute to the development of GERD, including factors related to the refluxate, esophageal defenses, and factors that promote pathologic reflux into the esophagus. In reviewing GERD pathogenesis, this paper will highlight therapeutic advances, with mention of future opportunities of study when approaching GERD.
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Affiliation(s)
- Priya Sharma
- Department of Medicine, University of California San Diego School of Medicine, La Jolla, California
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, Center for Esophageal Diseases, La Jolla, California
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