Clinical presentation, diagnosis, and management of gastroesophageal reflux disease

Gastro‑oesophageal reflux disease in liver cirrhosis: Possible pathogenesis and clinical intervention (Review)

Oesophageal variceal bleeding is a common complication of decompensated liver cirrhosis (LC). Some studies have reported that reflux oesophagitis (RE) is a risk factor for upper gastrointestinal bleeding, and greatly impacts the quality of life. However, the frequency and mechanism of gastro-oesophageal reflux disease (GERD) in LC remain unclear. The present review explored the possible pathogenesis, and analysed the advantages and disadvantages of the interventional measures and the need for implementation of these measures. By combining the comprehensive terms associated with LC, GERD and RE, EMBASE, Medline/PubMed and the Cochrane Library were systematically searched. The underlying pathological mechanism of GERD in LC was summarized: Transient relaxation of the lower oesophageal sphincter, delayed gastric emptying, increased intra-abdominal pressure, increased intragastric pressure and excessive nitric oxide production destroyed the 'anti-reflux barrier', causing gastric content reflux. Proton pump inhibitors (PPIs) have been widely used empirically to lower the risk of oesophageal venous rupture and bleeding. However, long-term use of acid inhibitors in patients with LC may induce complications, such as spontaneous bacterial peritonitis. The metabolic half-life of PPIs is prolonged in patients with severe liver function impairment. Therefore, the indications for using acid inhibitors lack clarity. However, after endoscopic oesophageal variceal eradication, additional benefits may be gained from the long-term use of PPIs in small doses.

Prevalence and risk factors of endoscopically confirmed gastroesophageal reflux disease (GERD) in patients with liver cirrhosis

Background

Gastroesophageal reflux disease (GERD) is one of the most common diseases in modern civilization that originates basically from a disturbance in the structure and function of the lower esophageal sphincter (LES). Liver cirrhosis with or without esophageal varices (EV) may predispose to GERD, and GERD may precipitate rupture of esophageal varices. As variceal bleeding is a serious life-threatening complication of liver cirrhosis, GERD prevalence among cirrhotic patients is continuously subjected to research. We aimed to determine the prevalence of endoscopy-confirmed GERD in patients with liver cirrhosis and its possible risk factors. So, one hundred patients with HCV-related liver cirrhosis were consecutively enrolled in this study. They were subjected to history taking {including Reflux Disease Questionnaire}, thorough clinical examination, abdominal ultrasound, and lab investigations and then referred for upper endoscopy to screen for GERD and/or esophageal varices.

Results

GERD was endoscopically confirmed in 83 patients (83%) and the highest prevalence was in patients with Child B and C. Among 82 patients with esophageal varices, there were 68 patients who had endoscopic GERD (82.9%), and among 62 patients with ascites, there were 56 patients who had endoscopic GERD (90.3%).

Conclusion

We found a high prevalence of GERD (83%) among patients with liver cirrhosis. The severity of GERD was significantly related to the Child grade, the grade of varices, and the degree of ascites but ascites was the only significant risk factor for GERD development in cirrhotic patients.

Gastroesophageal reflux and asthma: when, how, and why

PURPOSE OF REVIEW

Gastro-esophageal reflux is a possible cause of uncontrolled symptoms of asthma and should be actively investigated and treated before severe asthma is diagnosed and biological therapy started.

RECENT FINDINGS

Recent investigations on esophageal function and tissue biomarkers in patients with asthma and associated GERD have established a relevant role for esophageal motility and neuronal sensory abnormalities in linking the two diseases. Characterization of the underpinning inflammatory substrate has showed mixed results as both neutrophilic and eosinophilic type 2 inflammatory changes have been described.

SUMMARY

New findings regarding inflammatory mechanisms in GERD-associated asthma as well as new diagnostic tools to investigate functional esophageal abnormalities and characterize asthma endotype have identified potential treatable traits that may improve the clinical management and outcome of asthmatic patients with GERD.

Physiological implications of biased signaling at histamine H2 receptors

Histamine mediates numerous functions acting through its four receptor subtypes all belonging to the large family of seven transmembrane G-protein coupled receptors. In particular, histamine H2 receptor (H2R) is mainly involved in gastric acid production, becoming a classic pharmacological target to treat Zollinger–Ellison disease and gastric and duodenal ulcers. H2 ligands rank among the most widely prescribed and over the counter-sold drugs in the world. Recent evidence indicate that some H2R ligands display biased agonism, selecting and triggering some, but not all, of the signaling pathways associated to the H2R. The aim of the present work is to study whether famotidine, clinically widespread used ligand acting at H2R, exerts biased signaling. Our findings indicate that while famotidine acts as inverse agonist diminishing cAMP basal levels, it mimics the effects of histamine and the agonist amthamine concerning receptor desensitization and internalization. Moreover, the treatment of HEK293T transfected cells with any of the three ligands lead to a concentration dependent pERK increment. Similarly in AGS gastric epithelial cells, famotidine treatment led to both, the reduction in cAMP levels as well as the increment in ERK phosphorylation, suggesting that this behavior could have pharmacological relevant implications. Based on that, histidine decarboxylase expression was studied by quantitative PCR in AGS cells and its levels were increased by famotidine as well as by histamine and amthamine. In all cases, the positive regulation was impeded by the MEK inhibitor PD98059, indicating that biased signaling toward ERK1/2 pathway is the responsible of such enzyme regulation. These results support that ligand bias is not only a pharmacological curiosity but has physiological and pharmacological implications on cell metabolism.

Acid peptic diseases: pharmacological approach to treatment

Acid peptic disorders are the result of distinctive, but overlapping pathogenic mechanisms leading to either excessive acid secretion or diminished mucosal defense. They are common entities present in daily clinical practice that, owing to their chronicity, represent a significant cost to healthcare. Key elements in the success of controlling these entities have been the development of potent and safe drugs based on physiological targets. The histamine-2 receptor antagonists revolutionized the treatment of acid peptic disorders owing to their safety and efficacy profile. The proton-pump inhibitors (PPIs) represent a further therapeutic advance due to more potent inhibition of acid secretion. Ample data from clinical trials and observational experience have confirmed the utility of these agents in the treatment of acid peptic diseases, with differential efficacy and safety characteristics between and within drug classes. Paradigms in their speed and duration of action have underscored the need for new chemical entities that, from a single dose, would provide reliable duration of acid control, particularly at night. Moreover, PPIs reduce, but do not eliminate, the risk of ulcers in patients taking NSAIDs, reflecting untargeted physiopathologic pathways and a breach in the ability to sustain an intragastric pH of more than 4. This review provides an assessment of the current understanding of the physiology of acid production, a discussion of medications targeting gastric acid production and a review of efficacy in specific acid peptic diseases, as well as current challenges and future directions in the treatment of acid-mediated diseases.

Anti-Oxidative and Anti-Inflammatory Effects of QGC in Cultured Feline Esophageal Epithelial Cells

Quercetin-3-O-β-D-glucuronopyranoside (QGC) is a flavonoid glucoside extracted from Rumex Aquaticus Herba. In the present study, anti-oxidative and anti-inflammatory effects of QGC were tested in vitro. Epithelial cells obtained from cat esophagus were cultured. When the cells were exposed to acid for 2 h, cell viability was decreased to 36%. Pretreatment with 50 µM QGC for 2 h prevented the reduction in cell viability. QGC also inhibited the productions of intracellular ROS by inflammatory inducers such as acid, lipopolysaccharide, indomethacin and ethanol. QGC significantly increased the activities of superoxide dismutase (SOD) and catalase, and also induced the expression of SOD2, while it restored the decrease of catalase expression in cells exposed to acid. QGC inhibited NF-κB translocation, cyclooxygenase-2 expression and PGE₂ secretion in cells exposed to acid, which plays an important role in the pathogenesis of esophagitis. The data suggest that QGC may well be one of the promising substances to attenuate oxidative epithelial cell injury and inflammatory signaling in esophagus inflammation.

Distal esophageal hypercontractility is related to abnormal acid exposure

BACKGROUND AND AIMS

Nutcracker esophagus (NE) is a frequent primary motility disorder of the distal esophagus, and the relationship with acid exposure remains controversial. We studied simultaneous distal esophageal hypercontractility (EH) using two sensors at 8 and 3 cm above the lower sphincter (LES) and abnormal exposure to acid (pH DeMeester score).

METHODS

From 400 screened patients with chest pain and heartburn, 54 (age 44.5 ± 8.8 years and 74% females) had abnormal manometry and underwent acid exposure measurement. Frequencies of the EH disorder were classic NE (EH(3 cm)) found in 29 (40.8%) patients, diffuse (EH(3,8 cm)) in 30 patients (42.3%), and upper segmental (EH(8 cm)) in 12 patients (16.9%).

RESULTS

We found a positive correlation among age with high amplitude in EH(3 cm) and EH(3,8 cm). DeMeester's score (DMS) had the lowest value for EH(3,8 cm) (2.58 ± 0.23) compared with EH(8 cm) (3.78 ± 0.3, p <0.003) and EH(3 cm) (3.12 ± 0.2, p <0.06). Surface response for joint effect of age and DMS on amplitude at EH(3 cm) confirmed the highest amplitude was for older age and lower DMS.

CONCLUSIONS

EH(3 cm) and EH(3,8 cm) were common for esophageal motility and were inversely associated with DMS. Meanwhile, acid exposure was higher in younger patients and hypercontractility was more frequent in older subjects. The former group may benefit more from proton pump inhibitors and the latter from visceral analgesics or possibly both.

Gastroesophageal reflux in cirrhotic patients without esophageal varices

AIM: To evaluate the esophageal motility and abnormal acid and bile reflux incidence in cirrhotic patients without esophageal varices (EV).

METHODS: Seventy-eight patients with liver cirrhosis without EV confirmed by upper gastroesophageal endoscopy and 30 healthy control volunteers were prospectively enrolled in this study. All the patients were evaluated using a modified protocol including Child-Pugh score, upper gastrointestinal endoscopy, esophageal manometry, simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring. All the patients and volunteers accepted the manometric study.

RESULTS: In the liver cirrhosis group, lower esophageal sphincter pressure (LESP, 15.32 ± 2.91 mmHg), peristaltic amplitude (PA, 61.41 ± 10.52 mmHg), peristaltic duration (PD, 5.32 ± 1.22 s), and peristaltic velocity (PV, 5.22 ± 1.11 cm/s) were all significantly abnormal in comparison with those in the control group (P < 0.05), and LESP was negatively correlated with Child-Pugh score. The incidence of reflux esophagitis (RE) and pathologic reflux was 37.18% and 55.13%, respectively (vs control, P < 0.05). And the incidence of isolated abnormal acid reflux, bile reflux and mixed reflux was 12.82%, 14.10% and 28.21% in patients with liver cirrhosis without EV.

CONCLUSION: Cirrhotic patients without EV presented esophageal motor disorders and mixed acid and bile reflux was the main pattern; the cirrhosis itself was an important causative factor.

Combined Dual Channel Impedance/pH-metry in Patients With Suspected Laryngopharyngeal Reflux

BACKGROUND/AIMS

Laryngopharyngeal symptoms of gastroesophageal reflux disease (GERD) such as globus sensation, hoarseness and chronic cough are becoming increasingly recognized. This study was aimed to investigate the diagnostic usefulness of combined dual channel multichannel intraluminal impedance (MII)/pH-metry in 'off-proton pump inhibitor (PPI)' patients with suspected laryngopharyngeal reflux.

METHODS

Ninety-eight patients with laryngopharyngeal symptoms of GERD were included. All patients were 'off-PPI' state for at least 2 weeks prior to the study, and underwent endoscopy and dual channel combined MII/pH-metry.

RESULTS

The mean age of the patients was 49.8 +/- 10.9 years and there were 44 males (44.9%). Fifty-three patients (54.1%) showed pathologic gastroesophageal reflux (GER). Combined dual channel MII/pH-metry achieved highest diagnostic yield of 49.0% and diagnostic yield of single channel combined MII/pH-metry was 37.8%. Addition of MII to standard pH-metry increased twofold of the diagnostic yield for detecting GER. Among 37 patients (37.8%) who had pathologic GER being detected by MII/pH-metry, 19 patients (19.4%) had nonacid GER (nonacid GER group) while 18 patients (18.4%) had acid GER (acid GER group). Pathologic GER group, as classified by MII/pH-metry showed more frequent globus sensation than nonpathologic GER group. Acid GER group had more proximal reflux than nonacid GER group, especially in the upright position.

CONCLUSIONS

In this study, combined dual channel MII/pH-metry showed the highest diagnostic yield for detecting GER. This technique can be performed primarily to accurately diagnose laryngopharyngeal reflux disease and exclude other causes of laryngopharyngeal symptoms.

Gastroesophageal reflux disease (GERD): risk factors, and impact on quality of life-a population-based study

BACKGROUND

We aimed to determine the prevalence of gastroesophageal reflux disease (GERD) and associated risk factors, and assess quality of life (QoL) in relation to the frequency and severity of reflux symptoms.

METHODS

A random sample of 1000 residents of Western Sydney were mailed a validated self-report questionnaire. GERD symptoms, risk factors, psychologic distress, QoL, and demographics were measured.

RESULTS

The response rate was 73% (n=672; mean age, 46 y; 52% female). A total of 78 [12%, 95% confidence interval (CI): 9-14] had GERD (at least weekly heartburn and/or acid regurgitation). Independent risk factors for GERD were high cholesterol [odds ratio (OR) =3.28, 95% CI: 1.42-7.57, P=0.005] and current smoker (OR=2.47, 95% CI: 1.07-5.70, P=0.03). Anxiety, depression, and neuroticism were not risk factors. Worse physical functioning was the only QoL domain associated with GERD (OR=0.98, 95% CI: 0.97-0.99, P=0.006). QoL was significantly impaired regardless of the severity of GERD for the QoL domains physical function, body pain, vitality, and social function. The frequency of heartburn and acid regurgitation were not associated with significantly reduced QoL domain scores.

CONCLUSIONS

Cardiac risk factors (high cholesterol and smoking) were independently associated with GERD. Increasing GERD symptom severity is associated with worse QoL scores, whereas GERD symptom frequency did not impact the QoL scores.

Esomeprazole induces upper gastrointestinal tract transmucosal permeability increase

BACKGROUND

Proton pump inhibitors (PPIs) are one of the most widely used drug classes in the US and are now frontline medications for gastro-oesophageal reflux disease (GERD) and dyspepsia. In a previous work, we observed that a transmucosal, upper gastrointestinal (GI) leak exists in Barrett's oesophagus (BO) patients. PPI medications are commonly used by Barrett's patients.

AIM

To examine if the PPI, esomeprazole, affects the barrier function of the upper GI tract.

METHODS

The sucrose permeability test (SPT) was used to assess the possible effect of the PPI, esomeprazole, on upper GI leak in 37 first-time-presenting GERD patients and 25 healthy controls.

RESULTS

Esomeprazole induced a significant transmucosal leak in the upper GI tract of patients taking the drug for the first time. The leak occurred quickly, within days of first taking the drug. The leak was also reversed within days of stopping the medication.

CONCLUSIONS

This is the first patient-based study showing that a PPI compromises upper GI barrier function. There are potential implications for transmucosal leak of other medications that a patient on a PPI may be taking, as well as possible leak of endogenous peptides/proteins. The clinical consequences of this phenomenon are currently unknown, but are potentially important.

Evaluation of surgical outcomes and gallbladder characteristics in patients with biliary dyskinesia

INTRODUCTION

This study was designed to compare symptomatic outcomes following cholecystectomy in patients with biliary dyskinesia.

MATERIALS AND METHODS

From 1999 to 2006 at New York University Medical Center, 197 adults underwent hepatobiliary scintigraphy with cholecystokinin administration to evaluate gallbladder ejection fraction (GBEF). Biliary dyskinesia was demonstrated in 120 patients based on decreased GBEF of </=35%. Forty-four patients underwent cholecystectomy, and data from chart review and telephone questionnaires were available for 42 patients. Patients reported symptomatic improvement whether gallstones were present (25/27, 92.6%) or absent (13/15, 86.7%) prior to cholecystectomy (p = 0.90). The most common pathologic findings were chronic cholecystitis and cholesterolosis, regardless of the presence of gallstones. Additional data from 101 of the 120 patients with decreased GBEF demonstrated 74/101 (73.2%) patients were diagnosed with gastroesophageal reflux disease (GERD), and 59/101 (58.4%) patients were diagnosed with gastritis.

RESULTS

The results of this study suggest that biliary dyskinesia should be considered as part of the spectrum of symptomatic gallbladder disease that can be successfully treated with cholecystectomy and that biliary dyskinesia is associated with GERD and gastritis.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Use of pH-impedance testing to evaluate patients with suspected extraesophageal manifestations of gastroesophageal reflux disease

GOALS

To report the use of pH-impedance testing in evaluating patients with suspected gastroesophageal reflux disease (GERD) with atypical symptoms.

BACKGROUND

Although the role of acid reflux in causing atypical GERD symptoms is generally accepted, the role, if any, of nonacid reflux is controversial, largely because until recently it has not been possible to detect nonacid reflux. The advent of intraluminal combined pH impedance testing (MII-pH), to detect nonacid reflux has heightened interest in its possible contribution to atypical symptoms.

STUDY

Fifty consecutive patients referred for MII-pH testing to evaluate the cause of atypical symptoms presumed due to GERD were evaluated. The symptoms were either refractory to acid inhibition therapy or so atypical that further work up was desired by the referring physician. Patients underwent MII-pH testing to determine whether reflux was present, and, if so, if it was due to acid, nonacid, or gas.

RESULTS

Only 16%, 22%, and 2% patients were found to have symptoms due to acid reflux, nonacid reflux, or both, respectively. Ten percent of these patients had gas reflux. MII-pH testing was useful in redirecting the management of patients who did not have reflux as the cause of their symptoms.

CONCLUSIONS

MII-pH testing is useful in determining whether gastroesophageal reflux is present in patients with atypical symptoms that have not responded to proton pump inhibitor therapy. It also distinguishes between reflux due to acid, nonacid, and gas, with consequences for management.

Impact of changing epidemiology of gastroesophageal reflux disease on its diagnosis and treatment

Gastroesophageal reflux disease (GERD) has emerged as one of the most common diseases in modern civilization. This article reviews selected changes in epidemiology of GERD during the past decade and provides information on treatment options with a focus on the impact of GERD and potential role of laparoscopic antireflux surgery in patients with diabetes mellitus, obesity, liver cirrhosis, at the extremes of life age and in immunocompromised individuals such as liver and lung transplant recipients.

Technical considerations in laparoscopic fundoplication. How I do it

Gastroesophageal reflux disease (GERD) is a common disease and can be successfully treated by laparoscopic fundoplication. This article describes the technique of laparoscopic surgery for GERD with a focus on operative pitfalls.

Laryngopharyngeal reflux and chronic sinusitis

In patients with chronic and recurrent sinusitis, laryngopharyngeal reflux disease may play a significant role. Laryngopharyngeal reflux disease differs from gastroesophageal reflux disease in the extent of reflux (into the hypopharynx and above) as well as timing (occurring more often when the patient is upright). Most patients are unaware of the extent of their symptoms, and diagnostic tools such as pH probe, multichannel intraluminal impedance, and manometry are required for adequate diagnosis. Although therapy with lifestyle modification and acid-suppressive agents may improve reflux in the majority of patients, for many with persistent symptoms, endoscopic or surgical intervention is required to reduce reflux successfully.