Gastroesophageal reflux disease in patients with columnar-lined esophagus

Risk factors for Barrett's oesophagus: a population-based approach

OBJECTIVE

Given its often subclinical course, Barrett's oesophagus (BO) hardly lends itself to epidemiologically stringent evaluations. The objective of this study was to investigate risk factors for incident BO diagnosed in a defined population in southeast Sweden while paying particular attention to epidemiological aspects of the study design.

MATERIAL AND METHODS

Consecutive patients (aged 18-79 years) who were endoscoped with new indications at units exclusively responsible for all gastroscopies in defined catchment area populations were invited to take part in the study. Biopsies were taken above and immediately below the gastro-oesophageal junction, and exposure information was collected through self-administered questionnaires. Endoscopy-room-based cross-sectional data from 604 patients were supplemented with exposure data from 160 population controls. Associations, expressed as odds ratios (ORs), were modelled by means of multivariable logistic regression.

RESULTS

In the comparison with population controls, reflux symptoms and smoking indicated a 10.7- and 3.3-fold risk, respectively, for BO (95% confidence interval (CI) 3.5-33.4 and 1.1-9.9, respectively). Body mass was unrelated to risk. In the cross-sectional analysis among endoscopy-room patients, reflux symptoms were associated with an OR of 2.0 (95% CI 0.8-5.0). This association was, however, modified by the subjunctional presence of Helicobacter pylori; although the infection was not in itself significantly connected with risk, a combination of reflux symptoms and H. pylori infection was linked to an almost 5-fold risk (95% CI 1.4-16.5) as compared with the absence of both factors. The BO prevalence increased by 5% per year of age (95% CI 1-9%).

CONCLUSIONS

Reflux is the predominant risk factor for BO, and proximal gastric colonization of H. pylori seems to amplify this risk.

Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins

BACKGROUND & AIMS

Lifestyle and genetic factors dominate the etiology of gastroesophageal reflux disease. We investigated associations between lifestyle factors and gastroesophageal reflux (GER) symptoms, with and without controlling for genetic predisposition.

METHODS

In 1967 and 1973, questionnaires including lifestyle exposures were mailed to twins in the Swedish Twin Registry, and data on GER symptoms were collected by telephone interview during 1998-2002. Two analytic methods were used: external control analysis (4083 twins with GER symptoms and 21,383 controls) and monozygotic co-twin control analysis (869 monozygotic twin pairs discordant for GER symptoms).

RESULTS

In the external control analysis, leanness (body mass index [BMI] <20), upper normal weight (BMI 22.5-24.9), overweight (BMI 25-29.9), and obese (BMI > or =30) conferred -19%, 25%, 46%, and 59% increased risk of frequent GER symptoms compared with normal weight (BMI 20-22.4), respectively, among women, whereas no such associations were evident among men. When adjusted for genetic and nongenetic familial factors, these estimates were -28%, 44%, 187%, and 277%, respectively, among men. Frequent smoking rendered a 37% increased risk of frequent GER symptoms among women and 53% among men compared with nonsmokers. Physical activity at work was dose dependently associated with increased risk of frequent GER symptoms, and recreational physical activity decreased this risk.

CONCLUSIONS

BMI, tobacco smoking, and physical activity at work appear to be risk factors for frequent GER symptoms, whereas recreational physical activity appears to be beneficial. Association between BMI and frequent GER symptoms among men seems to be attenuated by genetic factors.

Review article: Barrett's oesophagus and carcinoma in Japan

In Asia, oesophageal diseases, such as Barrett's oesophagus and oesophageal carcinoma, have traditionally been less common than in America and Europe. In recent years, however, the number of reported cases of these conditions in Japan has increased. Two large prospective studies, the Sendai Barrett's Esophagus Study (S-BEST) and the Far East Study (FEST), on the geographic prevalence of Barrett's oesophagus, have recently investigated the epidemiology of Barrett's oesophagus in Japan. Results from both studies showed that overall prevalence of the condition is lower than in the West: 0.9-1.2% in Japan compared with 1-4% in Europe and 5-12% in USA. Similar to the situation in the West, the condition was shown to be most prevalent in elderly male patients and least prevalent in patients with Helicobacter pylori. Adenocarcinoma of the oesophagus is still rare in this region, although there has been an increase in the annual death rate from 3.7 (1960) to 6.9 (1995) per 100,000 population. Risk factors for oesophageal carcinoma include a strong association with the prevalence of gastro-oesophageal reflux disease (GERD). With the increasing prevalence of GERD in the Japanese population, continued surveillance of changes in the epidemiology of columnar-lined oesophagus (a precursor of Barrett's oesophagus), Barrett's oesophagus and adenocarcinoma of the oesophagus is strongly recommended.

Prevalence of gastro-oesophageal reflux symptoms and the influence of age and sex

BACKGROUND

Most previous studies of reflux symptom prevalence are of small sample size. No reliable data concerning age- and sex-stratified prevalence are available.

METHODS

Among 65,363 adult participants in a public health survey in Nord-Trondelag, Norway, 58,596 (90%) responded concerning occurrence and severity of heartburn or regurgitation during the past 12 months. The prevalence of minor, severe and any reflux symptoms was calculated, including stratification for age and sex. In order to examine whether the relative risk of reflux symptoms between sexes, in different age groups, was affected by other potential risk factors for reflux, confounding effects were tested using multivariate logistic regression. Odds ratios and their 95% confidence intervals were used to estimate relative risks.

RESULTS

Total prevalence of reflux symptoms was 31.4%, whereof 26.0% were minor symptoms and 5.4% severe symptoms. The prevalence of symptoms occurring at least weekly was 11.6%. Among women, the prevalence increased gradually from 22.1% in the youngest age category to 37.5% in the oldest, while among men it gradually increased from 25.8% in the youngest age group to peak at 36.0% between the ages of 50 and 60 years, after which it declined to 33.8% after age 70. A higher prevalence among women compared to men in the oldest age groups was not explained by confounding by body mass, tobacco smoking, alcohol consumption, dietary factors, or physical exercise.

CONCLUSIONS

About every third adult person suffered from reflux symptoms. The prevalence increases linearly with age among women, while among men it peaked between the age of 50 and 70 years and thereafter declined.

Obesity and estrogen as risk factors for gastroesophageal reflux symptoms

CONTEXT

Gastroesophageal reflux and obesity are both increasing in prevalence. The scientific evidence for an association between these conditions is sparse and contradictory. A difference between sexes concerning this relation has been proposed.

OBJECTIVE

To evaluate the relation between body mass and gastroesophageal reflux symptoms and determine how this relation is influenced by female sex hormones.

DESIGN

Population-based, cross-sectional, case-control study.

SETTING

Two consecutive public health surveys within the county of Nord-Trondelag, Norway, conducted in 1984-1986 and 1995-1997.

PARTICIPANTS

Among 65 363 adult participants in the second survey, 3113 individuals who reported severe heartburn or regurgitation during the last 12 months were defined as cases, whereas 39 872 persons without reflux symptoms were defined as controls.

MAIN OUTCOME MEASURE

Risk of reflux, estimated using multivariate logistic regression, with odds ratios (ORs) and 95% confidence intervals (CIs) as measures of association.

RESULTS

There was a dose-response association between increasing body mass index (BMI) and reflux symptoms in both sexes (P for trend <.001), with a significantly stronger association in women (P<.001). Compared with those with a BMI less than 25, the risk of reflux was increased significantly among severely obese (BMI >35) men(OR, 3.3; 95% CI, 2.4-4.7) and women (OR, 6.3; 95% CI, 4.9-8.0). The association between BMI and reflux symptoms was stronger among premenopausal women compared with postmenopausal women (P<.001), although use of postmenopausal hormone therapy increased the strength of the association (P<.001). Reduction in BMI was associated with decreased risk of reflux symptoms.

CONCLUSIONS

There is a significant association between body mass and symptoms of gastroesophageal reflux. The association is stronger among women, especially premenopausally, and use of hormone therapy strengthens the association, suggesting that estrogens may play an important role in the etiology of reflux disease.

Barrett's esophagus and esophageal adenocarcinoma: pathogenesis, diagnosis, and therapy

Gastric juice that refluxes into the esophagus can injure esophageal squamous epithelium. When the injury heals through a metaplastic process in which an abnormal columnar epithelium replaces the injured squamous one, the resulting condition is called Barrett's esophagus. Gastroesophageal reflux disease and Barrett's esophagus are the most important risk factors for esophageal adenocarcinoma. This article examines such issues as the treatment, endoscopic surveillance, and chemoprevention of Barrett's esophagus. Also included are published guidelines and recommendations.

Effect of omeprazole on antral duodenogastric reflux in Barrett oesophagus

BACKGROUND

The effect of long-term acid suppression therapy in Barrett oesophagus remains unknown, but the high intragastric pH generated has been shown to increase the cytotoxicity of duodenal refluxate on foregut mucosa. However, recent work suggests that duodenogastric reflux (DGR) may be reduced by omeprazole.

AIM

To investigate the effect of omeprazole on the reflux of duodenal contents into the gastric antrum in Barrett patients and healthy subjects.

METHOD

Fifteen patients with Barrett oesophagus and 14 healthy subjects underwent oesophageal manometry followed by 24-h ambulatory oesophageal and gastric pH and gastric bilirubin monitoring. The bilirubin sensor (modified by the addition of a weighted tip to facilitate manoeuvrability) was sited in the gastric antrum under fluoroscopic control. Combined ambulatory pH and bilirubin monitoring was repeated after 2 weeks on omeprazole 20 mg b.d.

RESULTS

Changes in oesophageal acid reflux and gastric alkaline shift due to omeprazole were as expected (P < 0.001). There was no difference in total antral DGR between the Barrett and control groups (P = 0.56), and omeprazole had no significant effect on DGR in either group (P = 0.77 and 0.27, respectively).

CONCLUSIONS

DGR into the antrum is of a similar level in Barrett patients and healthy controls. Omeprazole does not reduce the reflux of duodenal contents across the pylorus. Further work is required on the increased cytotoxic potential of continuing DGR in those on long-term acid suppression.

No relation between body mass and gastro-oesophageal reflux symptoms in a Swedish population based study

BACKGROUND

There is a widespread notion that obesity leads to gastro-oesophageal reflux but scientific evidence of an association is limited and inconsistent.

AIMS

To estimate the strength of the association between body mass and reflux symptoms, we performed a population based cross sectional interview study.

SUBJECTS

Population based, randomly selected, middle aged or elderly persons in Sweden in 1995-1997.

METHODS

At face-to-face interviews we asked a stratified sample of Swedes about body measures and occurrence of reflux symptoms. Odds ratios (OR) with 95% confidence intervals (CI), calculated by logistic regression with multivariate adjustments for covariates, were the measures of association.

RESULTS

Reflux symptoms occurring at least once a week more than five years before the interview were reported by 135 (16%) of the 820 interviewees. Among those who had ever been overweight during adulthood (body mass index (BMI) > or =25 kg/m(2)), the OR of having recurrent reflux symptoms was 0.99 (95% CI 0.66-1.47) compared with those who were never overweight. There was no association between BMI at age 20, BMI 20 years before the interview, or maximum adult BMI and occurrence of reflux symptoms: ORs per unit increase in BMI were 1. 00 (95% CI 0.93-1.09), 1.03 (95% CI 0.96-1.10), and 1.01 (95% CI=0.95-1.07), respectively. There was no association between BMI and severity or duration of reflux symptoms.

CONCLUSIONS

Gastro-oesophageal reflux symptoms occur independently of body mass index. Weight reduction may not be justifiable as an antireflux therapy.

Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma

BACKGROUND

The causes of adenocarcinomas of the esophagus and gastric cardia are poorly understood. We conducted an epidemiologic investigation of the possible association between gastroesophageal reflux and these tumors.

METHODS

We performed a nationwide, population-based, case-control study in Sweden. Case ascertainment was rapid, and all cases were classified uniformly. Information on the subjects' history of gastroesophageal reflux was collected in personal interviews. The odds ratios were calculated by logistic regression, with multivariate adjustment for potentially confounding variables.

RESULTS

Of the patients interviewed, the 189 with esophageal adenocarcinoma and the 262 with adenocarcinoma of the cardia constituted 85 percent of the 529 patients in Sweden who were eligible for the study during the period from 1995 through 1997. For comparison, we interviewed 820 control subjects from the general population and 167 patients with esophageal squamous-cell carcinoma. Among persons with recurrent symptoms of reflux, as compared with persons without such symptoms, the odds ratios were 7.7 (95 percent confidence interval, 5.3 to 11.4) for esophageal adenocarcinoma and 2.0 (95 percent confidence interval, 1.4 to 2.9) for adenocarcinoma of the cardia. The more frequent, more severe, and longer-lasting the symptoms of reflux, the greater the risk. Among persons with long-standing and severe symptoms of reflux, the odds ratios were 43.5 (95 percent confidence interval, 18.3 to 103.5) for esophageal adenocarcinoma and 4.4 (95 percent confidence interval, 1.7 to 11.0) for adenocarcinoma of the cardia. The risk of esophageal squamous-cell carcinoma was not associated with reflux (odds ratio, 1.1; 95 percent confidence interval, 0.7 to 1.9).

CONCLUSIONS

There is a strong and probably causal relation between gastroesophageal reflux and esophageal adenocarcinoma. The relation between reflux and adenocarcinoma of the gastric cardia is relatively weak.