Diagnostic evaluation in gastroesophageal reflux disease

Hormone replacement therapy is associated with gastro-oesophageal reflux disease: a retrospective cohort study

Background

Oestrogen and progestogen have the potential to influence gastro-intestinal motility; both are key components of hormone replacement therapy (HRT). Results of observational studies in women taking HRT rely on self-reporting of gastro-oesophageal symptoms and the aetiology of gastro-oesophageal reflux disease (GORD) remains unclear. This study investigated the association between HRT and GORD in menopausal women using validated general practice records.

Methods

51,182 menopausal women were identified using the UK General Practice Research Database between 1995–2004. Of these, 8,831 were matched with and without hormone use. Odds ratios (ORs) were calculated for GORD and proton-pump inhibitor (PPI) use in hormone and non-hormone users, adjusting for age, co-morbidities, and co-pharmacy.

Results

In unadjusted analysis, all forms of hormone use (oestrogen-only, tibolone, combined HRT and progestogen) were statistically significantly associated with GORD. In adjusted models, this association remained statistically significant for oestrogen-only treatment (OR 1.49; 1.18–1.89). Unadjusted analysis showed a statistically significant association between PPI use and oestrogen-only and combined HRT treatment. When adjusted for covariates, oestrogen-only treatment was significant (OR 1.34; 95% CI 1.03–1.74). Findings from the adjusted model demonstrated the greater use of PPI by progestogen users (OR 1.50; 1.01–2.22).

Conclusions

This first large cohort study of the association between GORD and HRT found a statistically significant association between oestrogen-only hormone and GORD and PPI use. This should be further investigated using prospective follow-up to validate the strength of association and describe its clinical significance.

Value of preoperative esophageal function studies before laparoscopic antireflux surgery

BACKGROUND

The value of esophageal manometry and ambulatory pH monitoring before laparoscopic antireflux surgery (LARS) has been questioned because tailoring the operation to the degree of hypomotility often is not required. This study evaluated a consecutive cohort of patients referred for esophageal function studies in preparation for LARS to determine the rates of findings that would alter surgical decisions.

METHODS

High-resolution manometry (HRM) was performed for each subject using a 21-lumen water-perfused system, and motor function was characterized. Gastroesophageal reflux disease (GERD) was evident from ambulatory pH monitoring if thresholds for acid exposure time and/or positive symptom association probability were passed.

RESULTS

Of 1,081 subjects (age, 48.4 ± 0.4 years; 56.7% female) undergoing preoperative HRM, 723 (66.9%) also had ambulatory pH testing performed. Lower esophageal sphincter (LES) hypotension (38.9%) and nonspecific spastic disorder (NSSD) of the esophageal body (36.1%) were common. Obstructive LES pathophysiology was noted in 2.5% (achalasia in 1%; incomplete LES relaxation in 1.5%), and significant esophageal body hypomotility in 4.5% (aperistalsis in 3.2%; severe hypomotility in 1.3%) of the subjects. Evidence of GERD was absent in 23.9% of the subjects. Spastic disorders were more frequent in the absence of GERD (43.9% vs. 23.1% with GERD; p < 0.0001), whereas hypomotility and normal patterns were more common with GERD.

CONCLUSIONS

Findings considered absolute or relative contraindications for standard 360º fundoplication are detected in 1 of 14 patients receiving preoperative HRM. Additionally, spastic findings associated with persistent postoperative symptoms are detected at esophageal function testing that could be used in preoperative counseling and candidate selection. Physiologic testing remains important in the preoperative evaluation of patients being considered for LARS.

[Study of the clinical profile and management of patients with gastroesophageal reflux disease in primary care in Spain]

OBJECTIVE

To assess the clinical profile and management of patients with gastroesophageal reflux disease (GERD) in primary care.

METHODS

A multinational, multicenter study was performed comprising a 4-month retrospective phase for the screening, selection and assessment of patients who had consulted for any GERD-related cause (index visit), and a cross-sectional phase in which clinical data were recorded and the following questionnaires were administered: the Reflux Disease Questionnaire and the Gastroesophageal Reflux Disease Impact Scale (GIS).

RESULTS

Among the 24 participating Spanish centers, 2.7% of the patients (95% CI: 2.6-2.9) had consulted at least once because of GERD. Approximately 50% of the patients showed frequent (2 or more days a week) or moderate to severe symptoms of heartburn, acid regurgitation or chest pain. Although the patients received effective pharmacological treatment at the index visit, clinically relevant GERD symptoms persisted in 16% after a median follow-up of 5 months. These symptoms were associated with a strong disease impact as evaluated with the GIS.

CONCLUSION

GERD represents a substantial burden for primary care physicians. Although effective drugs are used for the treatment of this condition, clinically relevant symptoms persist in a substantial proportion of patients.

Gastroesophageal Reflux Disease: A Population Based Study

Background

The prevalence of gastroesophageal reflux disease varies in different parts of the world. There are no population based studies in Nigeria. The main objectives of this study were to determine the prevalence and risk factors for gastroesophageal reflux disease in a population of Nigerian medical students.

Methods

The Carlsson-Dent questionnaire was administered to medical students in the clinical phase of their training at the University of Nigeria, Enugu Campus. Some putative risk factors for gastroesophageal reflux disease were also included in the questionnaire.

Results

The prevalence of gastroesophageal reflux disease was 26.34%. There was an association between the use of caffeine-containing substances (coffee and kolanuts) and the prevalence of gastroesophageal reflux disease (odds ratio = 2.2 and 2.015, respectively).

Conclusions

Gastroesophageal reflux disease is common among Nigerian medical students. The use of caffeine-containing substances (coffee and kolanuts) by students may have a role in the high prevalence.

Laryngopharyngeal reflux mimicking limited wegener granulomatosis

We present a case of subglottic stenosis (SGS) in a young patient with positive ANCA but a wrong diagnosis of Wegener granulomatosis (WG). Instead, she was diagnosed as having laryngopharyngeal reflux (LPR). Pitfalls of ANCA testing in this scenario, the route to diagnosis of LPR and the contribution of this entity to subglottic stenosis (SGS) in WG are discussed. Caution when interpreting ANCA results is mandatory to avoid improper management.

[Reflux esophagitis]

Gastroesophageal reflux disease (GERD) is one of the most prevalent diseases in the industrialized countries. Approximately 15-25% of adults suffer from reflux symptoms, characterized mainly by heartburn and/or regurgitation. Currently, antisecretory medication with proton pump inhibitors (PPI) or antireflux surgery are the established options for GERD-treatment. PPI are the therapeutic gold standard in acute, long-term or on-demand therapy of GERD. Since PPI do not restore the antireflux barrier but merely suppress acid secretion a life-long tablet adherence is required in most cases. In view of limitations of PPI and the potential risks of laparoscopic surgery, several endoscopic antireflux techniques were developed and may evolve as a valuable third option. However, so far objective long-term data are lacking for choosing the appropriate patient who will benefit most from endoluminal antireflux therapy.

Is esophageal pH monitoring used appropriately in an open-access system? A prospective multicenter study

OBJECTIVES

To evaluate the referral patterns and indications for esophageal pH monitoring in an open-access system and to determine whether these indications conform to practice guidelines of the American Gastroenterological Association (AGA).

METHODS

A total of 851 consecutive patients referred for ambulatory pH monitoring to nine open-access gastrointestinal units over a 12-month period received a structured interview. The indication for the examination was decided by the physician performing the procedure, on the basis of the patient's clinical history and main complaint.

RESULTS

Three hundred and twenty-three (38%) examinations were for indications in accordance with the guidelines. The proportion of appropriate requests in each center ranged from 34% to 47%. This figure was not significantly different in larger gastrointestinal units (more than 150 examinations per year) and smaller ones (35% and 40%; p= 0.14). The proportion of appropriate requests was 45% for gastroenterologists, 38% for surgeons, 32% for other specialists, and 24% for primary care physicians (PCPs) (p < 0.001). The percentage of appropriateness was significantly different between gastrointestinal specialists and PCPs (p < 0.001 vs gastroenterologists, p= 0.015 vs GI surgeons), and between gastroenterologists and other specialists (p= 0.006). The underuse of an empirical trial of acid-suppression therapy in patients with suspected reflux disease and the overuse of this test to confirm a diagnosis in patients with erosive esophagitis and in endoscopy-negative cases with typical symptoms responding completely to antisecretory therapy accounted for most of the referrals, which was not in accordance with the guidelines.

CONCLUSIONS

In an open-access system, a high proportion of esophageal pH studies are done for indications not consistent with published guidelines, particularly among the examinations not requested by gastrointestinal specialists. Further education is still needed on the appropriate use of esophageal pH monitoring and management of gastroesophageal reflux disease (GERD).

Discerning differences: gastroesophageal reflux and gastroesophageal reflux disease in infants

Gastroesophageal reflux (GER) is a frequently encountered problem in infancy; it commonly resolves spontaneously by 12 months of age. Caregivers are challenged to discriminate between physiologic GER and the much less common and more serious condition of pathologic gastroesophageal reflux disease (GERD). Pathologic GERD may require more extensive clinical evaluation and necessitate treatment. GERD may be primary or secondary; secondary GERD is associated with a number of genetic syndromes, chromosomal abnormalities, birth defects, or a host of neurologic conditions frequently seen in the newborn intensive care unit. This article reviews the unique anatomic, physiologic, developmental, and nutritional vulnerabilities of infants that make them susceptible to GER and GERD. The North American Society of Pediatric Gastroenterology and Nutrition have recently developed a comprehensive evidence-based clinical practice guideline that structures the diagnostic approach and treatment option in infants with suspected and confirmed GERD. These guidelines provide clear definitions of GER and GERD to aid the clinician in distinguishing between the 2 conditions. They emphasize the use of history and physical examination and discuss the indications for the use of other diagnostic procedures, such as upper gastrointestinal studies, nuclear medicine scintiscan, esophagogastroduodenoscopy with biopsy, and esophageal pH probe monitoring. Management of GERD begins with a nonpharmacologic approach; the emphasis is on positioning, a trial of a hypoallergenic formula, and thickening of feedings. When these measures fail to control symptoms, a trial of either histamine(2) antagonists or a proton pump inhibitor may be indicated. Finally, surgical treatment may be needed if all other management measures fail. New sleep recommendations for infants with GERD are now consistent with the American Academy of Pediatrics' standard recommendations. Prone sleep positioning is only considered in unusual cases, where the risk of death and complications from GERD outweighs the potential increased risk of sudden infant death syndrome (SIDS). The nursing care of infants with GER and GERD, as well as relevant issues for parent education and support, are reviewed and are essential elements in managing this common condition.

Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results

OBJECTIVE

Preoperative 24-hour pH testing is controversial in surgical patients who have symptomatic gastroesophageal reflux disease (GERD) and endoscopic evidence of esophagitis. The objective of this study was to compare the clinical outcomes of Nissen fundoplication for symptomatic reflux between patients with normal and abnormal preoperative pH testing.

METHODS

Patients were selected from a prospective database of patients who underwent laparoscopic esophageal procedures between January 1997 and December 2001 at our institution. Only patients having typical symptoms of GERD (heartburn and/or reflux), preoperative pH testing, manometry, and endoscopy and who had at least 6 months of post-operative follow-up were included in the study. Fifteen patients had normal preoperative DeMeester scores (DMS) (median 11.4, range 3.3 to 14.7). These were compared with 208 consecutive patients having abnormal preoperative DMS (median 49.6, range 15.2 to 250). Logistic regression modeling was performed to identify variables significant for poor outcome. Differences between means were tested using appropriate parametric or nonparametric tests.

RESULTS

There were no statistically significant differences in demographics, preoperative symptom score (mean 2.9 +/- 1.1 vs. 3.1 +/- 0.68, P = 0.30), or preoperative grade of esophagitis (P = 0.37) between the 2 groups. After a median follow-up of 8.8 months (range 6 to 36), 6 (40%) of the patients having normal preoperative DMS and 17 (8.1%) of the patients having abnormal preoperative DMS continued to have typical GERD symptoms (P <0.01, B error = 0.02). The most significant factor for poor outcome in the regression model was normal preoperative pH (odds ratio 9.02, P <0.01).

CONCLUSIONS

Symptomatic GERD patients with normal preoperative 24-hour pH test results have significantly worse subjective outcomes after Nissen fundoplication compared with patients having abnormal preoperative pH test results. To minimize poor symptomatic outcomes after antireflux surgery, a policy of routine preoperative pH testing is advised.

The classification of oesophageal 24 h pH measurements using a Kohonen self-organizing feature map

Analysis of 24 h oesophageal pH studies can be problematic with many patients asymptomatic during the investigation, despite observations of reflux. The aim of this study was to carry out a cluster analysis of ambulatory pH studies to determine any underlying patterns and classes within the data. The results of 900 24 h pH studies were investigated using the Kohonen self-organizing feature map (SOFM), a neural network that can be used to identify clusters within multidimensional data. The clinical features were presented to the network and the main classes identified. The SOFM-based analysis showed that patients clinically assessed as having symptomatic reflux during the study could be described by four major classifications. The results also showed that the probability of identifying a correlation between symptoms and reflux during an investigation varies from 0.49 to 0.78 for the classes identified. The developed network may be a useful tool in the classification of pH data. The cluster-based technique may offer an alternative to standard statistical techniques for high-dimensional gastrointestinal data and form the basis of an expert system for the automated analysis of pH data.

Improving health-related quality of life in gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) is a common, chronic disorder that can progress to erosive or ulcerative oesophagitis and other complications. Uncomplicated GORD can be defined using criteria that combine symptom assessment and the impact of symptoms on well being or quality of life. The extent of impairment of health-related quality of life (HRQL) in GORD patients has been evaluated using generic HRQL questionnaires, GORD-specific quality of life questionnaires or a combination of the two types of instruments. The impact of GORD on HRQL in affected individuals is proportional to the frequency and severity of heartburn, and is greater than that associated with many other chronic diseases. In the treatment of GORD, the goal should be complete symptom resolution as this has been shown to be associated with a clinically significant improvement in HRQL. Both drug treatment and surgical intervention have been successful in improving HRQL of patients with GORD when complete symptom resolution can be attained.

A pH-mucosa area unit of measure to consider morphology of the oesophagus when evaluating oesophagitis

Gastro-oesophageal pH measurements are routinely carried out to quantify and determine if levels of acid reflux are responsible for symptoms. Although considered the 'gold standard', evidence suggests that pH measurements do not correlate well with the degree of oesophagitis seen during endoscopy. In this study the current measure of pH was critically examined taking into account both the effects of changes in luminal diameter and endoscopy observations. The oesophageal lumen diameter was investigated using a barium swallow for 25 patients presenting with oesophageal disorders. For each subject the widest luminal diameter was measured for a series of five controlled swallows. The results showed that the lumen diameter varied widely from 0.9 to 3.8 cm. An alternative approach to the current measurement of pH was explored. In this approach the exposure not only included the luminal pH and time exposed but also the area of mucosa exposed as a result of differing luminal diameters. Although it is currently not possible to assess the diameter or morphology of the oesophageal lumen during a pH study, the analysis highlighted that the current measure of pH exposure time does not include the area of mucosa exposed. These results may explain, to some extent, the poor correlation between pH measurements and degree of oesophagitis seen during endoscopy.

Gastroesophageal reflux: comparison of barium studies with 24-h pH monitoring

OBJECTIVE

To determine the correlation between massive gastroesophageal reflux (GER) on barium studies and pathologic acid reflux on 24-h pH monitoring.

METHODS

A search of hospital records from January 1997 to January 2001 revealed 28 patients who underwent both barium studies and 24-h pH monitoring. The radiologic reports were reviewed to determine the presence and degree of GER. Patients with reflux to or above the thoracic inlet either spontaneously or with provocative maneuvers in the recumbent position were classified as having massive reflux, whereas the remaining patients with reflux below the thoracic inlet or no reflux comprised the control group. The pH monitoring reports were also reviewed to determine if pathologic acid reflux was present in the recumbent position. The findings on these studies were then compared to determine the frequency of pathologic acid reflux in the recumbent position on pH monitoring in patients with massive reflux on barium studies compared with the control group.

RESULTS

Massive GER was observed on barium studies in 11 (39%) of the 28 patients and reflux below the thoracic inlet or no reflux in the remaining 17 patients (61%) who comprised the control group. All 11 patients (100%) with massive reflux on barium studies had pathologic acid reflux on pH monitoring in the recumbent position compared with six (35%) of 17 patients in the control group (P = 0.0009). The pH in the distal esophagus on pH monitoring was less than 4.0 for 13.1% of the recumbent period for patients with massive GER on barium studies compared with 6.2% of the recumbent period for the control group (P = 0.0076).

CONCLUSION

Although 24-h pH monitoring remains the gold standard for the detection of GER, our experience suggests that patients with massive reflux on barium studies are so likely to have pathologic acid reflux in the recumbent position that these individuals can be further evaluated and treated for their gastroesophageal reflux disease (GERD) without need for pH monitoring.

A case-control study of endoscopy and mortality from adenocarcinoma of the esophagus or gastric cardia in persons with GERD

BACKGROUND

This study assessed whether EGD reduces mortality from adenocarcinoma of the esophagus or gastric cardia for patients with gastroesophageal reflux.

METHODS

A case-control study was performed. A total of 245 incident cases of death caused by adenocarcinoma of the esophagus or gastric cardia (1995-1999) in which reflux was present were identified using Veterans Health Administration databases. A total of 980 controls with reflux but no death from adenocarcinoma were frequency matched for age, gender, and race. The occurrences of EGD from 1990 onward were compared for cases and controls. Logistic regression analysis with adjustment for potential confounding factors was performed.

RESULTS

All the subjects were men. Cases were significantly less likely to have had an EGD in the time period of interest as compared with controls (adjusted odds ratio 0.66: 95% CI [0.45, 0.96], p = 0.03). This negative association was as strong for any EGD performed within 1 to 8 years before diagnosis as for a more recent EGD. However, there were no controls that included esophagectomy and no controls with a nonfatal diagnosis of adenocarcinoma, raising the question of whether EGD and reduced mortality are causally linked. The risk of dying from adenocarcinoma was significantly lower for men with a diagnosis of GERD as an inpatient relative to men in whom the diagnosis was made as an outpatient (adjusted odds ratio 0.21: 95% CI [0.15, 0.31], p < 0.01).

CONCLUSIONS

For patients with GERD, performing an EGD is associated with reduced mortality from adenocarcinoma of the esophagus or gastric cardia, but whether this is a causative association remains unclear.

Managing gastroesophageal reflux disease

A common condition, gastroesophageal reflux disease (GERD) involves the reflux of gastric contents into the esophagus. GERD may contribute to asthma, noncardiac chest pain, and other problems. This article presents trends in GERD management, including pathophysiology, diagnosis, and treatment. The authors also explore lifestyle modifications, pharmacologic therapy, and gastroenterology referral.

Esophageal pH monitoring, indications, and methods

Symptomatic gastroesophageal reflux disease (GERD) is a common problem that affects a substantial proportion of the American population. It is estimated that the symptoms of GERD may afflict 40% to 45% of Americans each month. The diagnosis of GERD can be difficult, as its symptoms vary from typical symptoms like heartburn to atypical symptoms such as hoarseness, coughing, and chest pain. Most patients present with typical symptoms and are diagnosed with GERD if they respond to empiric trials of acid suppression. Many tests are available to help with diagnosing GERD in patients who either present with atypical symptoms or who do not respond to acid suppression; however, each test has its own shortcomings. The only test that directly measures whether acid is refluxing into the esophagus is the pH probe, but this test is uncomfortable for the patient, can be difficult to interpret, and may not be necessary in all cases. This article reviews the indications for pH monitoring, its technique, its advantages and limitations, and its role the diagnosis of GERD.

Dysphagia after antireflux surgery

BACKGROUND

Dysphagia is experienced by many patients after antireflux surgery. This literature review examines factors associated with the development, prediction and management of postoperative dysphagia.

METHODS

Published studies examining issues related to dysphagia, gastro-oesophageal reflux and fundoplication were reviewed.

RESULTS

Postoperative dysphagia is usually temporary but proves troublesome for 5--10 per cent of patients. Technical modifications, such as a partial wrap, division of short gastric vessels and method of hiatal closure, have not conclusively reduced its incidence. There is no reliable preoperative test to predict dysphagia.

CONCLUSION

It is uncertain whether postoperative dysphagia arises from patient predilection or is largely a consequence of mechanical changes created by fundoplication. Anatomical errors account for a significant proportion of patients referred for correction of dysphagia but these are uncommon in large single-institution studies. Abnormal manometry cannot predict dysphagia and, on current evidence, 'tailoring' the operation does not prevent its occurrence.