Diagnosis of symptomatic gastroesophageal reflux disease

Towards a better diagnosis of gastro esophageal reflux disease

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.

High prevalence of functional dyspepsia in nonalcoholic fatty liver disease: a cross-sectional study

BACKGROUND

Gastrointestinal (GI) symptoms are frequent complaints from individuals with nonalcoholic fatty liver disease (NAFLD). Dyspepsia is a universal clinical symptom and is among the most common GI complaints observed in the general population, but its prevalence in the population with NAFLD has not been previously investigated.

OBJECTIVE

To compare the prevalence of functional dyspepsia (FD) between patients with NAFLD and controls without liver disease.

DESIGN AND SETTING

Cross-sectional study at the Outpatient Liver Clinic, University Hospital, Belo Horizonte, Brazil.

METHODS

We included 96 NAFLD patients and 105 controls without liver disease. All participants were assessed for GI symptoms in accordance with the Rome III criteria. Evaluation methods included a questionnaire for FD (validated in Brazil), laboratory tests and upper GI endoscopy.

RESULTS

Mean age and sex were similar between the groups. The NAFLD group presented higher frequency of proton-pump inhibitor usage (31.3% vs 4.8%; P < 0.001) and prevalence of FD (25.0% versus 12.4%; P = 0.021). The symptom frequencies were as follows: postprandial distress, 22.9% versus 11.4% (P = 0.030); postprandial fullness, 18.8% versus 10.5% (P = 0.095); early satiation, 8.3% versus 5.7% (P = 0.466); and epigastric pain or burning, 18.8% versus 5.7% (P = 0.004), in NAFLD patients and controls, respectively. Multivariate analysis demonstrated that female sex (odds ratio, OR 6.97; 95% confidence interval, CI: 1.51-32.12; P = 0.013) and NAFLD diagnosis (OR 2.45; 95% CI: 1.14-5.27; P = 0.021) were independently associated with FD occurrence.

CONCLUSION

FD occurs more frequently in individuals with NAFLD than in controls without hepatic disease.

Understanding the relationship between esophageal motor disorders and reflux disease

INTRODUCTION

The management of gastro-esophageal reflux disease (GERD) patients is often complex as the clinical presentation is heterogeneous and the mechanisms underlying symptoms are multifactorial. In the past decades, investigations conducted with conventional manometry and, above all, the more accurate high resolution manometry (HRM), helped us in exploring the field of esophageal motility and in understanding the link between motor features and GERD pathogenesis.

AREAS COVERED

Several studies carried out with conventional manometry and HRM have confirmed a relevant role of esophageal motor function in GERD pathogenesis. In particular, HRM studies have shown a direct correlation between impaired esophageal body motility, disruption of the esophagogastric junction and reflux burden. These findings impact the clinical and therapeutical management of GERD patients. Moreover, HRM findings might be helpful in evaluating patients with proton pump inhibitor (PPI) resistance and inconclusive evidences of GERD.

EXPERT OPINION

The relationship between esophageal motility and GERD pathogenesis needs to be further evaluated by multicenter outcome studies involving a large number of GERD patients and healthy controls. However, other more promising areas could be progressed.

Confocal Laser Endomicroscopic Findings of Refractory Erosive Reflux Disease versus Non-Erosive Reflux Disease with Anti-Reflux Mucosectomy: An in vivo and ex vivo Study

Background/Aims

To date, there is no standard tool to diagnose gastroesophageal reflux disease (GERD). Typically, GERD is a non-erosive reflux disease (NERD) that does not present endoscopic abnormalities. Confocal laser endomicroscopy (CLE) has been shown to be an effective tool to identify and diagnose GERD. We aimed to investigate the cellular and vascular changes in vivo and ex vivo through CLE in patients with GERD.

Methods

Patients with refractory GERD who underwent mucosectomy were recruited. The distal esophagus was observed in vivo using CLE. Mucosectomy tissue was stained with acriflavine and CLE image was obtained ex vivo. We compared cellular and vascular changes in CLE between erosive reflux disease (ERD), NERD, and a control group.

Results

Eleven patients who underwent anti-reflux mucosectomy and five control patients were enrolled in the study. Patients with ERD and NERD presented greater dilated intercellular space than patients in the control group on CLE image. The diameter, number, and cross-sectional area of the intra-papillary capillary loops (IPCLs) were significantly larger in the ERD group than in the NERD group. The irregular shape of the IPCLs were observed in both patients with ERD and NERD.

Conclusions

The irregular shape of the IPCLs were significantly correlated with a positive diagnosis of GERD. CLE may diagnose NERD with high sensitivity and accuracy.

New classifications of gastroesophageal reflux disease: an improvement for patient management?

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.

Prevalence and Correlates of Gastroesophageal Reflux Disease in Southern Iran: Pars Cohort Study

BACKGROUND

Prevalence of gastroesophageal reflux disease (GERD) is increasing worldwide. We aimed to estimate the prevalence of GERD in Pars Cohort Study (PCS) and to find its correlates.

METHODS

We used the baseline data from PCS. PCS was conducted in the district of Valashahr in Fars province in southern Iran from 2012 to 2014. 9264 inhabitants who were 40-75 years old, and agreed to participate were enrolled. Data were collected by a structured questionnaire and simple physical examination of all participants.

RESULTS

Generally, 58.50% (95% CI 57.49 - 59.51) of the participants had GERD and 25.10% (95% CI 24.22 - 25.99) experienced it at least weekly. Approximately, 32.0%, 52.0%, and 24.4% of the participants reported heart burn sensation, regurgitation, and both symptoms, respectively. Being female (OR: 1.45, 95% CI 1.27 - 1.65), being older (OR: 1.20, 95% CI 1.06 - 1.36), being divorced/ widowed/separated (OR: 1.38, 95% CI 1.01 - 1.91), and lower education (OR: 1.43, 95% CI 1.02 - 2.03) were associated with frequent GERD.

CONCLUSION

GERD is common in PCS and its prevalence is close to that in western countries. Being female, higher age, being divorced/widowed/separated, lower education, history of hypertension, anxiety, insomnia, and non-cigarette tobacco smoking were associated with frequent GERD. We are going to investigate the causal relationship between these risk factors and GERD in the next stages of PCS.

Use of direct, endoscopic-guided measurements of mucosal impedance in diagnosis of gastroesophageal reflux disease

BACKGROUND & AIMS

Diagnostic tests for gastroesophageal reflux disease (GERD) are constrained because measurements are made at a single time point, so the long-term effects on the mucosa cannot be determined. We developed a minimally invasive system to assess changes in esophageal mucosal impedance (MI), a marker of reflux. We measured the extent of changes in MI along the esophagus and show that the device to assess MI can be used to diagnose patients with GERD.

METHODS

A single-channel MI catheter composed of a unique sensor array was designed to easily traverse the working channel of an upper endoscope. We performed a prospective longitudinal study of patients with erosive esophagitis (n = 19), nonerosive but pH-positive GERD (n = 23), and those without GERD (n = 27). MI was measured at the site of esophagitis as well as 2, 5, and 10 cm above the squamocolumnar junction. The MI values were compared among groups, at different levels along the esophageal axis.

RESULTS

Median MI values were significantly lower at the site of erosive mucosa (811 Ω; range, 621-1272 Ω) than other nonerosive regions (3723 Ω; range, 2421-4671 Ω; P = .001), and were significantly lower at 2 cm above the squamocolumnar junction in patients with GERD (2096 Ω; range, 1415-2808 Ω), compared with those without GERD (3607 Ω; range, 1973-4238 Ω; P = .008). There was a significant and graded increase in MI along the axis of the distal to proximal esophagus in patients with GERD that was not observed in individuals without reflux (P = .004).

CONCLUSIONS

Measurements of MI along the esophagus can be used to identify patients with GERD. ClinicalTrials.gov, number NCT01194323.

Heterogeneity in oesophageal dysfunction among patients with different reflux symptoms

BACKGROUND AND AIM

Ineffective oesophageal motility (IOM) often occurs in patients with gastro-oesophageal reflux disease. We aimed to examine the hypothesis of whether the presence of IOM differs between patients with gastro-oesophageal reflux disease with different symptom profiles.

METHODS

Eligible patients were subclassified according to their predominant symptom of heartburn (HB) or acid regurgitation (AR). All patients underwent combined multichannel intraluminal impedance and oesophageal manometry. IOM was further graded according to the presence of oesophageal transit abnormalities.

RESULTS

Fourteen healthy individuals, 16 HB patients and 24 AR patients participated in this study. The percentage of swallows with complete bolus transit was lower in AR than in HB patients during liquid and viscous swallowing (P<0.05). Abnormal bolus transit occurred more frequently in AR patients than in HB patients with liquid swallows (P<0.001) and viscous swallows (P<0.05). IOM occurred more frequently in AR patients than in HB patients (42.7 vs. 12.5%, P=0.049). In patients with IOM, severe functional abnormality was more frequently found in AR patients than in HB patients (P<0.05).

CONCLUSION

This study suggests a potential link between oesophageal body dysfunction and individual reflux symptom. Patients with a predominant symptom of AR are characterized by greater IOM and defective bolus clearance.

Predicting the efficacy of proton pump inhibitors in patients with non-erosive reflux disease before therapy using dual-channel 24-h esophageal pH monitoring

BACKGROUND AND AIM

We aimed to determine whether reflux- and symptom-related parameters can predict the efficacy of proton pump inhibitors (PPI) in non-erosive reflux disease (NERD).

METHODS

Twenty-seven NERD patients who had experienced heartburn more than once a week within the previous month were enrolled. Intraesophageal pH before therapy was measured simultaneously at 5 and 15 cm above the esophagogastric junction (EGJ) for 24 h. The PPI rabeprazole was administered at a dose of 10 mg once daily for 4 weeks. In the event that heartburn was not relieved, the dose was increased to 10 mg twice daily for an additional 2 weeks, and again to 20 mg twice daily for another 2 weeks.

RESULTS

Univariate analysis demonstrated no significant associations between any reflux- or symptom-related parameters at either site and complete heartburn relief after 4 weeks, or cumulative complete heartburn relief after 8 weeks. However, post-hoc analysis demonstrated more satisfactory heartburn relief after 4 weeks in patients with a high symptom index compared with those with a low symptom index, at 5 cm above the EGJ (P = 0.009). Cumulative satisfactory heartburn relief after 8 weeks was also greater in patients with a high total number of acid reflux episodes compared with those with a low total number of episodes, at 15 cm above the EGJ (P = 0.037).

CONCLUSIONS

Pre-therapeutic pH monitoring in the lower and mid-esophagus is useful for predicting the efficacy of PPI in NERD patients.

Pathogenesis of proton-pump inhibitor-refractory non-erosive reflux disease according to multichannel intraluminal impedance-pH monitoring

BACKGROUND AND AIM

Proton-pump inhibitor (PPI) therapy is the first-line treatment for gastroesophageal reflux disease; however, there are some reports of PPI failure in cases of non-erosive reflux disease (NERD). Among the pathogenic factors associated with PPI-refractory NERD, reflux other than acid reflux can not be detected by conventional pH monitoring. The purpose of this study was to clarify the usefulness of multichannel intraluminal impedance-pH (MII-pH) monitoring for PPI-refractory NERD patients and examine the pathogenesis.

METHODS

We used MII-pH monitoring to examine 29 PPI-refractory NERD patients on PPI treatment. Reflux parameters, symptom index (SI: positive if ≥ 50%), and proximal migration were analyzed. The acidity of the reflux was divided into acid (nadir pH ≤ 4) and non-acid (nadir pH > 4). Subjects were classified into reflux-related disease (abnormal reflux parameters or positive SI) and non-reflux-related disease (normal reflux parameters and negative SI).

RESULTS

Of the 29 subjects, 21 were diagnosed with reflux-related disease, including 6 with acid reflux type and 15 with non-acid reflux type, and 8 were diagnosed with non-reflux-related disease. Of the total 1816 liquid reflux episodes, 834 showed proximal migration, which was more common in symptomatic reflux than in asymptomatic reflux.

CONCLUSIONS

MII-pH monitoring could distinguish reflux-related disease (especially non-acid type) from PPI-refractory NERD. Proximal migration was associated with symptomatic reflux in PPI-refractory NERD patients.

A new method in the diagnosis of reflux esophagitis: confocal laser endomicroscopy

BACKGROUND

The diagnosis of GERD is made by using a combination of clinical symptoms, pH study, endoscopy, and histology. Histologic changes include basal cell hyperplasia and papillary elongation. Confocal laser endomicroscopy (CLE) enables surface and subsurface imaging of living cells in vivo at ×1000 magnification and up to 250 μm below the tissue surface. In the esophagus, the distance between the surface to papillary (S-P) tip can be measured by using CLE.

OBJECTIVE

To measure the S-P distance in the esophagus in patients with reflux esophagitis and controls by using CLE and comparing with histologic measurements.

DESIGN

Retrospective analysis of a prospective database.

SETTING

Endoscopy unit of a tertiary-care children's hospital.

PATIENTS

This study involved 7 patients (5 female) with a median age of 7.6 years (range 1.8-15.5 years) and median weight of 23 kg (range 13.2-71 kg) and 16 controls with a median age of 12.0 years (range 2.2-15.3 years) and median weight of 38.2 kg (range 10.7-83 kg).

INTERVENTION

S-P distance was measured both by CLE and histology and was corrected for height for both patients and controls and the results compared.

MAIN OUTCOME MEASUREMENTS

To determine if there were significant differences in the S-P distance in patients with esophagitis and controls.

RESULTS

The median confocal and histologic measurements for S-P distance, corrected for patient height, were 0.19 μm/cm (range 0.10-0.49 μm/cm) and 0.58 μm/cm (range 0.29-0.76 μm/cm) and for controls were 0.44 μm/cm (range 0.20-0.93 μm/cm) and 1.07 μm/cm (range 0.76-0.1.57 μm/cm), respectively.

LIMITATIONS

Small numbers involved in the study, reliance on only papillary elongation in arriving at a diagnosis.

CONCLUSION

Measurement of the S-P distance by CLE will enable real-time diagnosis of GERD-related esophagitis during ongoing endoscopy.

Acid-suppressive effect of rabeprazole 5 mg and 10 mg once daily by 24-hour esophageal pH monitoring in patients with non-erosive reflux disease in Japan: a multicenter, randomized, parallel-group, double-blind pharmacodynamic study

BACKGROUND

Acid suppression induced by rabeprazole 5 mg in patients with NERD has not been reported in the literature.

AIMS

The objective of this study was to investigate gastroesophageal acid suppression in NERD patients by rabeprazole 5 mg and 10 mg/day.

METHODS

Subjects were grade M (minimal changes) NERD patients. Twenty-two patients not responding to open label antacid therapy entered a double-blind treatment phase in which rabeprazole 5 mg or 10 mg/day for four weeks were compared. Twenty-four-hour esophageal pH monitoring was performed before and on treatment (at week 4) to assess the pharmacodynamic effect of these doses of rabeprazole.

RESULTS

The frequency of heartburn episodes and the number of acid reflux episodes in the esophagus corresponded well in grade M NERD patients (r=0.44, P=0.042). Median percentage of time at pH<4 was 4.3% before treatment and 1.1% on treatment with rabeprazole 5 mg (change from baseline; -2.5%), whereas the median percentage of time at pH<4 in the rabeprazole 10 mg group was 7.4% before treatment and 0.5% on treatment (change from baseline; -6.6%). Likewise, treatment-related changes of median number of reflux episodes were -18.0 with rabeprazole 5 mg and -44.0 with rabeprazole 10 mg. For each esophageal pH data, no significant differences were observed between the two groups (P=0.377, P=0.077).

CONCLUSIONS

Administration of 5 mg and 10 mg rabeprazole sufficiently inhibited pathological gastroesophageal acid reflux and relieved heartburn episodes in NERD patients who did not respond to an antacid. Further investigation would be necessary to determine proper usage of the two doses.

Anti-heartburn effects of a fenugreek fiber product

Frequent heartburn occurs in many people, some of whom prefer alternative treatments over conventional drugs. In a pilot study of subjects with frequent heartburn, 2 week intake of a fenugreek fiber product, taken 30 min before two meals/day, diminished heartburn severity. This conclusion was based on symptom diary results and reduced the use of a mild antacid as a rescue medicine. Improvement for each of the 2 weeks was judged by comparison with results from a baseline week. Placebo also produced some statistically significant effects, but the fiber product's effects differed significantly from the placebo. Moreover, the fenugreek fiber effects were generally similar to the results produced by an OTC antacid medication (ranitidine at 75 mg, twice a day). This study suggests that people with certain degrees of heartburn can benefit from a fenugreek fiber product.

Randomised clinical trial: a multicentre, double-blind, placebo-controlled study on the efficacy and safety of rabeprazole 5 mg or 10 mg once daily in patients with non-erosive reflux disease

BACKGROUND

The efficacy of rabeprazole 5 mg/day for patients with non-erosive reflux disease (NERD) has not been reported in the literature.

AIM

To evaluate the efficacy of rabeprazole 5 mg and 10 mg/day in Japanese NERD patients. The influence of baseline characteristics as well as genetic background on efficacy was also analysed.

METHODS

Subjects were grade M (minimal changes) NERD patients. Two hundred and eighty-eight of these subjects, who were nonresponders to open label antacid therapy, entered in a 4-week, double-blind treatment (placebo, rabeprazole 5 mg or 10 mg/day).

RESULTS

Complete heartburn relief rates were 21% in placebo, 34% in rabeprazole 5 mg and 44% in rabeprazole 10 mg (5 mg vs. placebo P = 0.074, 10 mg vs. placebo P = 0.001). Rabeprazole 5 mg was significantly more effective than placebo in elderly patients and in patients with low heartburn frequency or without hiatal hernia. The efficacy of rabeprazole 10 mg was not influenced by age, BMI, hiatal hernia, Helicobacter pylori infection, frequency and severity of heartburn or CYP2C19 genotypes.

CONCLUSIONS

Rabeprazole 5 mg was effective in a subgroup of Japanese NERD patients. Rabeprazole 10 mg provided more potent heartburn relief than 5 mg and was less fragile to baseline characteristics.

Endoscopy of the esophagus in gastroesophageal reflux disease: are we losing sight of symptoms? Another perspective

Gastroesophageal reflux disease (GERD) is an extremely common chronic disorder associated with impaired quality of life and huge economic burden. Recently, an International Consensus Group developed a global definition of GERD (The Montreal Definition): a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The traditional endoscopy-based classification of GERD patients into one of three groups - non-erosive reflux disease, erosive esophagitis, and Barrett's esophagus - is fraught with several limitations. Due to the lack of a gold standard, GERD is a symptom-based diagnosis, and hence symptom evaluation will remain the primary means by which treatment decisions are made for patients with suspected GERD. We propose that patients reporting the predominant GERD-like symptoms (GERS) in the primary care setting be classified based upon their response to an empiric trial of acid suppressive therapy: complete response to acid suppressive therapy, partial response to acid suppressive therapy, and no response to acid suppressive therapy. Given the limitations of objective medical testing, implementation of our proposed new symptom-based classification of patients with GERS would guide primary care physicians on when to refer patients to a gastroenterologist, which in turn could help in better resource utilization. Validation of this proposed classification by well-designed prospective multicenter studies is awaited.

It is possible to classify non-erosive reflux disease (NERD) patients into endoscopically normal groups and minimal change groups by subjective symptoms and responsiveness to rabeprazole -- a report from a study with Japanese patients

The hypothesis that non-erosive reflux disease (NERD) patients comprise various subgroups is gaining popularity. This study was conducted to investigate the possibility of categorizing NERD patients according to symptom types and response to acid-suppressive drug rabeprazole (RPZ) 10 mg/day. NERD patients were classified as grade N (endoscopically normal), M (minimal change), or erosive GERD, and answered a 51-item, yes-or-no questionnaire pre and post-treatment. Compared to erosive GERD, clear differences existed in pretreatment prevalence of symptoms and responsiveness to RPZ in grades N and M; the results suggested stomachaches (especially at night) were significant symptoms in grade N and dysmotility-like symptoms like bloated stomach were significant in grade M while gastroesophageal reflux symptoms were significant in erosive GERD. Clinical significance of classifying NERD was indicated from different symptoms and responsiveness to PPI.

Changes in a gastric air bubble linked to gastroesophageal reflux symptoms

The distribution of gas in the digestive tract is easily detected by a plain abdominal radiograph and associated with abdominal symptoms in some dyspeptic patients. Therefore, we investigate whether a gastric bubble detected on the abdominal radiograph is associated with gastroesophageal reflux diseases (GERD) symptoms or not. All of the patients were asked to respond to the F-scale questionnaire regardless of their chief complaints. Plain abdominal films in the erect position were used to classify the form of gastric bubble into four groups: dome-type, irregular-type, stomach-type and undetected-type. The gastric bubble was found in 93.4% of patients on plain films in the erect position. Of them, 55 had a dome-type gastric bubble that indicates the distended fundus and fluid levels. GERD was most frequently detected in the stomach-type group, followed by undetected-type, irregular-type and dome-type. The mean score of the F-scale was significantly higher in stomach-type than in dome-type. It is concluded that a gastric bubble detected on plain abdominal films is an informative marker for evaluating the functional disorder of upper digestive tracts. Physicians have to recognize the importance of plain films of the abdomen in the diagnostic process of GERD.

Epidemiological study of gastro-oesophageal reflux disease: reflux in spouse as a risk factor

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is a growing health-care problem with variable distribution.

AIM

To assess GERD prevalence and risk factors and their possible correlation with pathophysiology in a population-based study.

METHODS

Individuals aged 18-65 years were enrolled through random cluster sampling in Tehran. Previously validated self-administered questionnaires were used.

RESULTS

Of the 2500 questionnaires, 2057 were analysed (mean age: 34.8 +/- 13.0 years, 55.1% female). Frequent GERD was seen in 18.2%. Minor symptoms increased prevalence. Female gender (OR: 1.55, 95% CI: 1.01-2.41), BMI >30 kg/m(2) (OR: 1.79, 95% CI: 1.03-3.12), less education (OR: 1.52, 95% CI: 1.02-2.27), smoking (OR: 1.83, 95% CI: 1.12-2.99), NSAID use (OR: 4.23, 95% CI: 1.66-10.74) and GERD in spouse (OR: 1.82, 95% CI: 1.18-2.82) were associated with frequent GERD on multivariable analysis. GERD in first-degree relatives (OR: 1.73, 95% CI: 1.23-2.43) and asthma (OR: 4.09, 95% CI: 1.27-13.15) correlated with infrequent GERD. Minor symptoms correlated with GERD history in first-degree relatives, coffee consumption and NSAID use. Prevalence in the past 3 months was similar to that in the past 12 months (P < 0.05).

CONCLUSIONS

Gastro-oesophageal reflux disease is common in Tehran. The association of 'infrequent symptoms' with GERD history in first-degree relatives and 'frequent symptoms' with GERD history in spouse may point to the presence of yet unknown precipitating environmental factors inducing GERD in a genetically susceptible host. Minor GERD symptoms seem to have independent contribution to GERD. Assessing GERD in the past 3 months predicts prevalence in the past year.

Sleep symptoms and gastroesophageal reflux

BACKGROUND

This study was to determine whether patients with significant nighttime heartburn had more disturbed sleep and more gastroesophageal acid reflux than those without significant nighttime heartburn.

METHODS

Thirty-three reflux patients were stratified into 2 groups (nighttime heartburn, without nighttime heartburn). All patients completed questionnaires assessing daytime and nighttime heartburn and subjective sleep by Pittsburgh Sleep Quality Index. All participants underwent 24-hour esophageal pH monitoring and an overnight polysomnographic study.

RESULTS

The number of reflux events longer than 5 minutes was significantly greater in patients with nighttime heartburn than in those without nighttime heartburn for the total (P=0.004) and upright (P=0.01) position periods. Acid contact time was significantly greater in patients with nighttime heartburn during the upright (P=0.003) period and during the total (P=0.001) period. Patients with nighttime heartburn reported significantly greater subjective sleep impairment (8.1+/-0.7) than those without nighttime heartburn (6.1+/-0.4; P=0.02), but no difference could be observed in any objective sleep parameter by an overnight polysomnographic study between the groups.

CONCLUSIONS

Patients with significant nighttime heartburn seem to have more acid reflux compared with those without nighttime heartburn. Nighttime heartburn together with sleep complaints is associated with excessive gastroesophageal reflux.

Gastro-esophageal reflux disease symptoms are more common in general practice in Japan

AIM: To accurately assess the prevalence of GERD symptoms in general practice.

METHODS: 4139 consecutive patients (2025 men and 2114 women with a mean age of 43 years), who first attended the Outpatient Department of General Medicine and Emergency Care at Toho University Omori Hospital, were asked to respond to the F-scale questionnaire regardless of their chief complaints. The questionnaire is a self-report instrument, written in a simple and easy-to-understand language, containing 12 questions.

RESULTS: Of 4139 subjects, 1554 patients (37.6%) were identified as GERD according to their F-scale score (> 7). However, there were only 45 consultations (1.1%) for typical GERD symptoms. Although GERD symptoms are common in adults of all ages, the prevalence of GERD was highest in the 20-29 years age group and the age group 70-79 years had the lowest prevalence for both males and females.

CONCLUSION: Although there was a high rate indicating GERD in our primary care population, only 1.1% of outpatients attended our hospital with a chief complaint of GERD symptoms. Since about one-third of GERD patients are affected by atypical symptoms, general physicians need to be cautious about extrapolating these results to patients with a chief complaint other than typical GERD symptoms.

A feasibility trial of narrow band imaging endoscopy in patients with gastroesophageal reflux disease

BACKGROUND AND AIMS

Narrow band imaging (NBI) endoscopy system enhances visualization of microvasculature and mucosal patterns. This study assessed the utility of NBI in patients with gastroesophageal reflux disease (GERD) symptoms.

METHODS

Patients with and without GERD symptoms completed 2 validated GERD questionnaires prior to enrollment. The distal esophagus was examined by standard white light endoscopy followed by NBI. The features seen only by NBI were compared between GERD patients and controls.

RESULTS

Overall, 80 patients (50 GERD, 30 controls) were eligible for final analysis (mean age, 58.4 years; males, 93.7%; white, 82.5%). A significantly higher proportion of patients with GERD had increased number (OR, 12.6; 95% CI: 3.7-42; P < .0001), dilatation (OR, 20; 95% CI: 6.1-65.3; P < .0001), tortuosity of intrapapillary capillary loops (IPCLs) (OR, 6.9; 95% CI: 2.5-19; P < .0001), presence of microerosions (P < .0001), and increased vascularity at the squamocolumnar junction (OR, 9.3; 95% CI: 1.9-43.6; P = .001) compared with controls. On multivariate analysis, increased number (OR, 5.5; 95% CI: 1.4-21.6) and dilatation (OR, 11.3; 95% CI: 3.2-39.9) of IPCLs were the best predictors for diagnosing GERD. The maximum, minimum, and average number of IPCLs/field were significantly greater in the GERD group compared with controls (P < .0001). Although the interobserver agreement for the various NBI findings was very good, the intraobserver agreement was modest.

CONCLUSIONS

NBI endoscopy may represent a significant improvement over standard endoscopy for the diagnosis of GERD. These preliminary findings including inter- and intraobserver agreement need to be evaluated in future prospective, controlled, and blinded GERD trials.

Role of duodenogastroesophageal reflux in the pathogenesis of esophageal mucosal injury and gastroesophageal reflux symptoms

BACKGROUND AND AIM

Patients with gastroesophageal reflux disease (GERD) usually suffer from acid reflux and duodenogastroesophageal reflux (DGER) simultaneously. The question of whether DGER has an important effect on the development of GERD remains controversial. The aim of the present study was to investigate the role of DGER in the pathogenesis of GERD and its value for the diagnosis of nonerosive reflux disease (NERD).

METHODS

GERD was initially diagnosed using the reflux disease questionnaire. For further diagnosis, results of the upper gastrointestinal endoscopy (excluding a diagnosis of Barrett's esophagus) were considered in conjunction with simultaneous 24 h esophageal pH and bilirubin monitoring.

RESULTS

According to endoscopic findings, 95 patients (43 men, 50+/-10 years of age) were divided into two groups: the reflux esophagitis (RE) group (n=51) and the NERD group (n=44). Three DGER parameters, the percentage of time with absorbance greater than 0.14, the total number of reflux episodes and the number of bile reflux episodes lasting longer than 5 min, were evaluated in the study. For the RE group, the values of the DGER parameters (19.05%+/-23.44%, 30.56+/-34.04 and 5.90+/-6.37, respectively) were significantly higher than those of the NERD group (7.26%+/-11.08%, 15.68+/-20.92 and 2.59+/-3.57, respectively, P<0.05 for all) but no significant difference was found in acid reflux. Of NERD patients, 18.5% were diagnosed with simple DGER. The positive diagnosis rate of NERD could be significantly elevated from 65.9% to 84.1% (P<0.05), if bilirubin monitoring was employed in diagnosis.

CONCLUSIONS

DGER may occur independently but plays an important role in the development of RE and GERD symptoms. Simultaneous 24 h esophageal pH and bilirubin monitoring is superior to simple pH monitoring in helping identify patients at risk for NERD.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease refers to reflux of gastric contents into the oesophagus leading to oesophagitis, reflux symptoms sufficient to impair quality of life, or long-term complications. Transient relaxation of the lower oesophageal sphincter is believed to be the primary mechanism of the disease although the underlying cause remains uncertain. Obesity and smoking are weakly associated with the disease and genetic factors might be important. A negative association with Helicobacter pylori exists, but eradication of H pylori does not seem to cause reflux disease. Diagnosis is imprecise as there is no gold standard. Reflux symptoms are helpful in diagnosis but they lack sensitivity. Ambulatory oesophageal pH monitoring also seems to be insensitive despite high specificity. Empirical acid suppression with a proton-pump inhibitor (PPI) has reasonable sensitivity but poor specificity. Some evidence suggests that once patients develop the disease, severity is determined early and patients seem to continue with that phenotype long term. Unfortunately, most patients do not respond to life-style advice and require further therapy. H2 receptor antagonists and PPIs are better than placebo in oesophagitis, with a number needed to treat of five and two, respectively. In non-erosive reflux disease, acid suppression is better than placebo but the response rate is lower. Most patients need long-term treatment because the disease usually relapses. The role of endoscopic therapy is uncertain. Anti-reflux surgery is probably as effective as PPI therapy although there is a low operative mortality and morbidity.

CagA-positive Helicobacter pylori infection is not associated with decreased risk of Barrett's esophagus in a population with high H. pylori infection rate

BACKGROUND & AIM

The role that H. pylori infection plays in the development of and Barrett's esophagus (BE) is uncertain. We tested the hypothesis that infection with cagA+ Helicobacter pylori strains protects against the development of BE.

METHODS

We studied 104 consecutive patients, residents in an area with a high prevalence of H. pylori infection, with BE and 213 sex- and age-matched controls. H. pylori infection and CagA antibody status were determined by western blot serology.

RESULTS

H. pylori prevalence was higher in patients with BE than in controls (87.5% vs. 74.6%; OR. 2.3; 95% CI: 1.23-4.59). Increasing age was associated with a higher prevalence of H. pylori (p < 0.05). The prevalence of CagA+ H. pylori serology was similar in patients with BE and controls (64.4% vs. 54.5%; NS). Type I H. pylori infection (CagA+ and VacA+) was similar in patients with BE and controls (44.2% vs. 41.3%; NS). Logistic regression analysis identified alcohol (O.R. 7.09; 95% CI 2.23-22.51), and H. pylori infection (OR: 2.41; 95%CI: 1.20-4.84) but not CagA+ serology as independent factors.

CONCLUSION

Neither H. pylori infection nor H. pylori infection by CagA+ strains reduce the risk of BE in a population with high prevalence of H. pylori infection.

Gastroesophageal reflux symptoms and well-being in a random sample of the general population of a Swedish community

OBJECTIVES

There is limited information on the relationship between gastroesophageal reflux symptoms and well-being in the general population. This study aimed to investigate this relationship and determine the severity threshold at which reflux symptoms meaningfully affect patients' well-being.

METHODS

A random sample of the population of Malmö, Sweden (n = 4,624), was sent the Gastrointestinal Symptom Rating Scale, the Subjective Symptom Assessment Profile, and the Psychological General Well-Being Index. The relationship between well-being and the severity of heartburn, acid regurgitation, stomach pain, and abdominal pain was investigated by analysis of covariance (ANCOVA).

RESULTS

Complete data were obtained from 1,476 subjects (43% male; mean age [standard deviation], 49.9 [14.2] yr). The mean Psychological General Well-Being Index score was 102 (95% CI: 101-103). Increasing symptom severity was associated with a decrease in well-being, and correlations between Psychological General Well-Being Index score and symptom severity ratings were statistically significant. At least mild symptoms of heartburn or abdominal pain (a mean Gastrointestinal Symptom Rating Scale score of > or =3) were associated with a clinically meaningful reduction in well-being (a Psychological General Well-Being Index score of less than 98).

CONCLUSIONS

Reflux symptoms are associated with impaired well-being in the general population. Individuals with symptoms that are mild or more severe report a meaningful reduction in well-being similar to that seen in other diseases. This may represent an appropriate threshold for patient selection in trials of GERD therapy and for more detailed evaluation of patients consulting with reflux symptoms in clinical practice.

Association between dinner-to-bed time and gastro-esophageal reflux disease

OBJECTIVE

It is generally recommended that patients with gastro-esophageal reflux disease (GERD) refrain from eating within 3 h of going to sleep. In addition to a remarkable lack of supporting clinical evidence, whether GERD patients have shorter dinner-to-bed time is unknown. This study was designed to determine a possible association between dinner-to-bed time and GERD, compared with healthy adults.

METHODS

In a matched case-control study, we enrolled 147 GERD patients, and age- and sex-matched 294 controls without GERD symptoms such as heartburn and acid regurgitation during the previous year. Dinner-to-bed time, defined as the time intervals until going to bed after finishing eating dinner, was examined by a self-report questionnaire. Logistic regression was used to calculate odds ratio (OR) and 95% confidence intervals (CI) for GERD.

RESULTS

After adjustment for smoking habits, drinking habits, and body mass index, shorter dinner-to-bed time was significantly associated with an increased OR of GERD (p < 0.0001) and the OR for patients whose dinner-to-bed time was less than 3 h was 7.45 (95% CI 3.38-16.4) compared with patients whose dinner-to-bed time was 4 h or more. These observations were consistent in both patients with non-erosive GERD and erosive esophagitis, and there was no significant difference in dinner-to-bed time intervals between non-erosive GERD and erosive esophagitis.

CONCLUSION

In this matched case-control study, shorter dinner-to-bed time was significantly associated with an increased OR for GERD.

Lugol chromoendoscopy as a diagnostic tool in so-called endoscopy-negative GERD

BACKGROUND

Esophageal mucosal breaks are found in less than half of patients with typical reflux symptom. Thus, endoscopy appears to be an insensitive test for GERD. Lugol chromoendoscopy has been used to detect early esophageal cancer, which is difficult to recognize by routine observation without dye staining. The aim of this study was to determine the efficacy of Lugol chromoendoscopy in the diagnosis of so-called endoscopy-negative GERD (ENRD).

METHODS

The study was conducted with 61 patients (21 women; mean age of 59.8 years) with reflux symptoms and 42 controls (15 women; mean age, 65.0 years). In the absence of any esophageal mucosal abnormalities at conventional endoscopy, Lugol's iodine solution was sprayed onto the esophageal surface, followed by evaluation of the staining pattern. When Lugol-unstained streaks were observed at chromoendoscopy, biopsy specimens were obtained from unstained streaks and from adjacent stained mucosa. Histologic evaluation included basal cell hyperplasia, papillary length, and cellular infiltration.

RESULTS

Twenty-two (36%) of 61 patients with reflux, and 4 (10%) of 42 controls had visible esophagitis by conventional endoscopy. Lugol chromoendoscopy was performed in the remaining 39 patients and 38 controls. The entire esophageal mucosa was uniformly stained dark brown in 20 patients with reflux and 37 controls. In the remaining 19 patients with reflux and in one control, several unstained streaks were observed in the distal esophagus (p < 0.0001). Histologically, Lugol-unstained mucosa showed a significantly thicker basal cell layer (30.9% +/- 7.6% vs. 12.3% +/- 4.5% of total epithelial thickness, mean +/- standard deviation [SD], p < 0.01) and longer papillae (57.9% +/- 12.6% vs. 38.1% +/- 12.6% of total epithelial thickness, mean [SD], p < 0.01) compared with stained mucosa. In addition, infiltration of lymphocytes in the epithelium was significantly increased in unstained mucosa than in stained mucosa (p < 0.01).

CONCLUSIONS

Visible unstained streaks by Lugol chromoendoscopy seem to be indicative of mucosal injury, which was not detectable by conventional endoscopy. Lugol chromoendoscopy is simple and could be useful for the diagnosis of ENRD. This method could be appealing for the endoscopist as it is easy, safe, and can be performed at the same endoscopic session.

Impact of referral for gastro-oesophageal reflux disease on the workload of an academic Gastroenterology Unit

BACKGROUND

Gastro-oesophageal reflux disease is known to be a frequent cause of patients' referral to hospital gastroenterologists.

AIM

To increase knowledge on referral for reflux disease, in an Italian academic setting.

PATIENTS AND METHODS

The impact of gastro-oesophageal reflux disease on 1 year's workload, comprising upper endoscopy, outpatients' consultations in the general clinic, oesophageal pH monitoring and oesophageal manometry was retrospectively assessed. Appropriateness of oesophageal pH monitoring and oesophageal manometry was also evaluated.

RESULTS

Endoscopy: Out of 2269 upper endoscopies reflux symptoms comprised 16.9% (n=386) of referrals; 19.1% only of these 386 patients had erosive oesophagitis at endoscopy and none had oesophagogastric malignancies (68% of the patients were >45 years). Consultations: Thirty-three percent out of 553 patients were referred for reflux symptoms. Upper endoscopy had already been performed before consultation in 64% of them. pH monitoring and oesophageal manometry: Two hundred and sixteen oesophageal pH monitorings and 160 oesophageal manometries were performed and 29% and 28%, respectively, were inappropriate, being performed in the diagnostic work-up of patients with typical reflux symptoms.

CONCLUSIONS

At an academic Gastroenterology Unit, (a) gastro-oesophageal reflux disease is a frequent referral for upper endoscopy and consultations, (b) prevalence of oesophagitis is low, (c) consultation is preceded by endoscopy in the majority of patients and (d) oesophageal pH monitoring and oesophageal manometry are often inappropriately used.

Characteristics of symptomatic GERD in Japanese patients based on 24-h pH monitoring

BACKGROUND

We assessed the characteristics of symptomatic gastroesophageal reflux disease (sGERD), defined as the presence of symptoms, but no endoscopic findings of reflux esophagitis, in Japanese.

METHODS

Sixty-three patients were diagnosed with sGERD, and underwent 24-h esophagogastric pH monitoring (32 men; mean age, 50.5 years). Patients were classified into the following three groups : reflux group (group R), minor reflux group (group MR), and a no-reflux group (group N) by the percentage of time at pH below 4 (group R, 4.0% or more; group MR, 2.0%-3.9%; group N, 0-1.9%). Hiatal hernia was assessed based on the Anatomy-Function-Pathology (AFP) classification, and the shape of the cardia was assessed based on valve factors (V0-V3).

RESULTS

There were 13 patients (21%) in group R, 17 (27%) in group MR, and 33 (52%) in group N. Hiatal hernia was present in 11 patients (85%) in group R, 14 (82%) in group MR, and 22 (67%) in group N. Patients grouped according to presence of V2/V3 (chalasia) accounted for 100% of those in group R, 71% of those in group MR and 70% of those in group N. Hiatal hernia was present in 10 (91%), 10 (83%), and 6 patients (86%) who had 50 or more episodes of esophageal acid reflux per day in group R, group MR, and group N, respectively.

CONCLUSIONS

Reflux (percentage of time below pH 4, 4%) was seen in only about 20% of the patients with sGERD, and this percentage of patients with reflux was lower compared to the data reported from the United States and Europe. The percentage of patients who had a hiatal hernia or chalasia was high in all these groups, and this seemed to be a characteristic cause of sGERD in Japanese.

The influence of gastroesophageal reflux disease and its treatment on asthmatic cough

Gastroesophageal reflux is known to cause chronic cough and is also implicated in worsening of asthma. We conducted a prospective study to examine the clinical significance of gastroesophageal reflux disease (GERD) in asthmatic patients with chronic cough to analyze the temporal relationship between reflux events and coughing and to assess the effect of esomeprazole treatment on respiratory symptoms and lung function in these patients. Asthmatic patients (126) with chronic dry cough were studied. Diagnosis of GERD was based on typical symptoms and the effectiveness of therapeutic test or on pH monitoring. Patients without GERD (negative pH results) consisted of the control group. The results of pH monitoring showed that 64% of cough episodes were related to acid reflux and in 91% of reflux events preceded coughing. Esomeprazole treatment (40 mg/day for 3 months) not only diminished GERD symptoms but also improved asthma outcome Baseline FEV(1) and PEF values increased significantly together with a decrease in symptom scores and the use of rescue medication. In most patients included in the extended part of the study for another 3 months, the dose of inhaled steroids could be reduced with sustained GERD therapy. Our data showing that reflux events preceded coughing in most cases and that treatment of GERD resulted in an improvement in different outcome measures of asthma suggest that GERD worsens asthma, and its treatment is of clinical importance to effectively manage these patients.

Famotidine vs. omeprazole: a prospective randomized multicentre trial to determine efficacy in non-erosive gastro-oesophageal reflux disease

BACKGROUND

Several studies in Western countries showed that proton-pump inhibitors are superior to histamine2-receptor antagonists or placebo in the treatment of non-erosive gastro-oesophageal reflux disease. The efficacy of acid-suppressive drugs for non-erosive gastro-oesophageal reflux disease in Japan, in which the prevalence of Helicobacter pylori infection is higher compared with Western countries, is unknown.

AIM

To compare the efficacy of famotidine and omeprazole in Japanese patients with non-erosive gastro-oesophageal reflux disease by a prospective randomized multicentre trial.

METHODS

A total of 98 patients received either famotidine 20 mg b.d. (n = 48) or omeprazole once daily (n = 50). Frequency of gastro-oesophageal reflux disease symptoms and health-related quality of life were evaluated at baseline and after 4 weeks of treatment. Complete relief was defined as no gastro-oesophageal reflux disease symptoms during the 7-day interval in week 4.

RESULTS

Complete relief was achieved in 23 (48%) of patients receiving famotidine and 28 (56%) of patients treated with omeprazole. In the famotidine group, complete relief rate in H. pylori-negative patients was significantly lower than H. pylori-positive patients (35% vs. 64%). Both famotidine and omeprazole improved most scales of health-related quality of life. Omeprazole significantly improved reflux score irrespective of H. pylori infection while famotidine significantly improved reflux score in H. pylori-positive patients but not in H. pylori-negative patients.

CONCLUSIONS

Omeprazole is more effective than famotidine for the control of gastro-oesophageal reflux disease symptoms in H. pylori-negative patients, while similar efficacy is observed in H. pylori-positive patients with non-erosive gastro-oesophageal reflux disease.

Differences in clinical characteristics between patients with endoscopy-negative reflux disease and erosive esophagitis in Japan

OBJECTIVE

Helicobacter pylori infection and atrophic gastritis are inversely related to erosive esophagitis. Whether these factors affect the pathogenesis of endoscopy-negative reflux disease is not clear. We aimed to elucidate the differences in clinical characteristics between endoscopy-negative erosive disease and erosive esophagitis.

METHODS

253 subjects (89 with endoscopy-negative reflux disease and 164 with erosive esophagitis) were studied. Gastric atrophy was assessed by measurement of serum pepsinogen. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (CI) of endoscopy-negative reflux disease compared with erosive esophagitis.

RESULTS

Among GERD patients, female gender (OR = 2.27, 95% CI, 1.25-4.10), smoking (OR = 0.45, 95% CI, 0.22-0.91), and the presence of hiatal hernia (OR = 0.30, 95% CI, 0.17-0.56) were significantly associated with endoscopy-negative reflux disease compared with male gender, not smoking, and absence of hiatal hernia, respectively. Body mass index (BMI) was also significantly associated with a decreased OR for endoscopy-negative reflux disease. Although H. pylori infection and gastric atrophy were significantly more common in patients with endoscopy-negative reflux disease, these associations did not persist in a multiple-adjustment model. After adjustment for gender, BMI, smoking, and hiatal hernia, a decrease in serum pepsinogen I/II ratio was significantly associated with an increased OR for endoscopy-negative reflux disease (p for trend = 0.018).

CONCLUSIONS

Female gender, low BMI, not smoking, absence of hiatal hernia, and severity of gastric atrophy were positively associated with endoscopy-negative reflux disease compared with erosive esophagitis among Japanese patients.

Dilated intercellular spaces: extending the reach of the endoscope

Two manuscripts in this issue utilize quantitative methods to analyze the association between gastroesophageal reflux disease (GERD) and dilated intercellular spaces (DIS) evident on transmission electron microscopy of the esophageal epithelium. One study of 20 patients found that, irrespective of whether or not a pH study was positive, all GERD patients who had responded to proton pump inhibitors therapy had intercellular space measurements that were at least twice normal. The other study demonstrated that DIS resolved with effective GERD therapy in essentially every instance. Both studies suggest that DIS are an objective structural marker of endoscopy-negative reflux disease.

Impact of hiatal hernia on histological pattern of non-erosive reflux disease

BACKGROUND

Hiatus hernia (HH) has major pathophysiological effects favoring gastroesophageal reflux and hence contributing to esophageal mucosa injury, especially in patients with severe gastroesophageal disease. However, prospective studies investigating the impact of HH on the esophageal mucosa in non-erosive reflux disease (NERD) are lacking. This study evaluated the association between the presence of (HH) and the histological findings in symptomatic patients with NERD.

METHODS

Fifty consecutive patients with gastroesophageal reflux disease (GERD) were enrolled. After conventional endoscopy, Lugol solution was applied and biopsy specimens were obtained. Histological parameters including basal zone hyperplasia, papillary length and cellular infiltration were evaluated. The chi-square test with Yates' correlation was used for comparing discrete parameters between groups. However, Fisher's exact probability test was used where the expected frequencies were lower than 5. Wilcoxon's test for unpaired samples was preferred in cases of semi-quantitative parameters.

RESULTS

The presence of HH along with more severe findings (0.01 <P < 0.05) was confirmed in 18 patients. NERD was observed in 29 (58%) patients. Basal zone hyperplasia and loss of glycogen accompanied HH in all cases, and the correlation was significant in NERD (P < 0.001). The remaining histological patterns were similar between erosive reflux disease and NERD in the presence of HH.

CONCLUSION

The presence of HH is correlated with more severe endoscopy findings, and predisposes for severe histological abnormality in cases of NERD.

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.

Review article: diagnosis and investigation of gastro-oesophageal reflux disease in Japanese patients

Gastro-oesophageal reflux disease (GERD) encompasses a wide range of disorders defined by either reflux-related symptoms or by complications of gastro-oesophageal reflux. The most characteristic GERD symptoms are heartburn and acid regurgitation. Patients with these symptoms are in most cases easily identifiable and diagnosis is made on the basis of symptoms alone. For patients with a decreased frequency of heartburn, diagnosis is more difficult, and endoscopy is the single best test for diagnosis of GERD. A major difference between the West and Asia is the frequency of endoscopic investigation. In Japan, the earlier high prevalence of stomach cancers resulted in the increased use of endoscopy as an investigational tool for dyspeptic symptoms and today endoscopy continues to be widely available as a diagnostic tool. However, the overall sensitivity of endoscopy for the diagnosis of GERD is less than 50% since not all patients will have oesophagitis at the time of endoscopy. Ambulatory pH monitoring is therefore a frequently used diagnostic tool as it allows correlation between reflux events and symptoms, and is especially useful in patients with atypical or extraoesophageal symptoms. Oesophageal manometry is also an excellent test to evaluate oesophageal function and to measure sphincter pressure and while it may not provide an unequivocal diagnosis of GERD it is a useful tool with which to evaluate oesophageal function.

Symptomatic gastro-oesophageal reflux, arousals and sleep quality in patients undergoing polysomnography for possible obstructive sleep apnoea

INTRODUCTION

Nocturnal acid reflux is common and could disturb sleep by causing arousals that fragment sleep.

AIM

To determine the prevalence of gastro-oesophageal reflux symptoms and their association with arousals, stages of sleep and quality of life in patients undergoing evaluation for excessive daytime sleepiness and obstructive sleep apnoea.

METHODS

Ninety-four consecutive patients with excessive daytime sleepiness were prospectively studied. Patients completed the gastrointestinal symptom rating scale, a validated symptom questionnaire for reflux disease and a disease-specific quality of life questionnaire, the sleep apnoea quality of life index and then underwent overnight polysomnography, which was read in a blinded manner.

RESULTS

There were 40 males and 54 females with a mean age of 47 +/- 13 years. Reflux symptoms were present in 63 of the 94 (67%) patients. Patients with reflux symptoms had significantly more arousals from sleep 43 +/- 70/h than those without (20 +/- 24/h; P = 0.03). The sleep duration during the second stage of sleep was shorter (44 +/- 21%) for those with reflux symptoms than those without (52 +/- 12%; P = 0.03). Patients with reflux spent significantly shorter periods in stage II sleep (44 +/- 21%) than those without (52 +/- 12%; P = 0.03). The sleep-related quality of life score in patients with gastro-oesophageal reflux (3.1 +/- 1.1) was significantly lower than in patients without reflux (3.7 +/- 1.0; P = 0.02). Regression analysis demonstrated a significant inverse correlation between quality of life and reflux symptom score (P =0.002) and total spontaneous arousals (P = 0.04).

CONCLUSIONS

Gastro-oesophageal reflux is common in patients with sleep disorders, is associated with increased arousal, decreased durations spent in the deeper stages of sleep and poorer sleep-related quality of life.

Effectiveness of proton pump inhibitors in nonerosive reflux disease

BACKGROUND & AIMS

Little information is available about the efficacy of proton pump inhibitors (PPIs) in patients with nonerosive reflux disease (NERD). We aimed to synthesize available data and determine the effectiveness of PPIs on symptom resolution in patients with NERD.

METHODS

A systematic review of the literature identified studies reporting the effects of PPIs in patients with NERD. Heartburn resolution data were pooled across studies. The effectiveness of PPI therapy in inducing complete heartburn resolution was compared in patients with NERD vs. erosive esophagitis (EE).

RESULTS

Seven trials evaluating heartburn resolution in NERD were identified. Higher proportions of patients reported achieving sufficient heartburn resolution compared with complete heartburn resolution. The effect of PPIs on sufficient heartburn resolution was observed sooner than was complete heartburn resolution. Therapeutic gain of PPI therapy over placebo ranged from 30% to 35% for sufficient heartburn control and from 25% to 30% for complete heartburn control. Pooled response rates at 4 weeks were significantly higher for patients with EE compared with NERD (56% vs. 37%, P < 0.0001).

CONCLUSIONS

PPIs provide a more modest therapeutic gain in patients with NERD as compared with those with EE. A trend in increased therapeutic gain for NERD patients was shown throughout the 4 weeks, suggesting that 4 weeks of follow-up evaluation may be insufficient to show full therapeutic gain in this patient population.

Relationship of Helicobacter pylori related gastritis, gut hormones and gastroesophageal reflux disease

AIM: To evaluate the relationship of H. pylori infection, H. pylori -related gastritis, serum gastrin and motilin levels and esophageal lesions in gastroesophageal reflux disease (GERD).

METHODS: All 53 GERD patients were divided into non-erosive reflux disease (NERD group, 32 cases) and reflux esophagitis (RE group, 21 cases ) by endoscopy. The degrees of gastritis in antrum and body as well as esophagitis were evaluated by pathological examinations. Fasting serum gastrin and motilin concentrations were determined by radioimmunoassay. H. pyloriwas examined by serum H. pylori-antibody, Warthin-Starry stain, urease-dependent test (rapid urease test or ¹⁴C-breath test).H. pylori infection was affirmed when at least two of three tests were positive. 20 normal persons were as controls. In NERD group, 18 were H. pylori positive and 14 were negative. In RE group 12 were H. pylori positive and 9 were negative. According to the classification of esophagitis, 11 were ClassⅠ, 7 ClassⅡ and 3 Class Ⅲ. There were 30 H. pylori (+) and 23 H. pylori (-) in 53 GERD patients.

RESULTS: As compared with healthy controls, fasting serum motilin levels in RE group were significantly lower (360±126 vs 440±110 mg/L, ^aP < 0.05) and those in NERD group were similar (P > 0.05). No differences in gastrin levels were found between NERD or RE group and controls (both P > 0.05). The serum gastrin levels in H. pylori (+) GERD were significantly higher than controls (35.8±11.6 vs 28.5±10.6 mg/L, ^bP < 0.05). In H. pylori (+) GERD patients, gastritis grades in the antrum and gastric body were significantly higher than that in H. pylori (-) patients (χ² = 32.97, χ² = 15.67, both P < 0.005). The esophagitis grades were similar in H. pylori (+) and H. pylori (-) GERD (χ² = 0.82, P > 0.05). The gastritis grades were not associated with the esophagitis degrees, but with H. pylori infection.

CONCLUSION: Motilin is involved in the pathogenesis of RE. H. pylori can lead to hypergastrinemia and gastritis in the antrum and gastric body.

Report of the Asia-Pacific consensus on the management of gastroesophageal reflux disease

This report summarizes the conclusions and recommendations of a panel of gastroenterologists practising in the Asia-Pacific region. The group recognized that although gastroesophageal reflux disease (GERD) is less common and milder in endoscopic severity in Asia than in the West, there is nevertheless data to suggest an increasing frequency of the disease. During a 2-day workshop, the evidence for key issues in the diagnosis and clinical strategies for the management of the disease was evaluated, following which the recommendations were made and debated. The consensus report was presented at the Asia-Pacific Digestive Week 2003 in Singapore for ratification. Upper gastrointestinal (GI) endoscopy is the gold standard for the diagnosis of erosive GERD. There is no gold standard for the diagnosis of non-erosive GERD (NERD). Diagnosis therefore relies on symptoms, a positive 24-h pH study or a response to a course of proton pump inhibitor (PPI) treatment. The goals of treatment for GERD are to heal esophagitis, relieve symptoms, maintain the patient free of symptoms, improve quality of life and prevent complications. The PPI are the most effective medical treatment. Following initial treatment, on-demand therapy may be effective in some patients with NERD or mild (GI) erosive esophagitis. Anti-reflux surgery by a competent surgeon could achieve a similar outcome, although there is an operative mortality of 0.1-0.8%. The decision is dependent on the patient's preference and the availability of surgical expertise. Currently, endoscopic treatment should be performed only in the context of a clinical trial. Treatment of patients with typical GERD symptoms without alarm features in primary care could begin with PPI for 2 weeks followed by a further 4 weeks before going to on-demand therapy.