Reassessment of the principal characteristics of gastroesophageal reflux during the recumbent period using integrated actigraphy-acquired information

Wake up to gastro-oesophageal reflux disease: The interplay between arousal and night-time reflux

This review examines the temporal association between nocturnal gastro-oesophageal reflux and sleep-arousal cycles. Most nocturnal gastro-oesophageal reflux events occur during the awake cycle, and arousals precede most nocturnal gastro-oesophageal reflux events, indicating that arousal from sleep predisposes to nocturnal gastro-oesophageal reflux. This sheds light on the complex relationship between nocturnal gastro-oesophageal reflux and sleep, and has implications for managing nocturnal gastro-oesophageal reflux symptoms. The appearance of symptoms and the pathophysiology of nocturnal gastro-oesophageal reflux are influenced by sleep hygiene, sleep disturbances and the misalignment of circadian rhythms. Nocturnal gastro-oesophageal reflux and its related sleep disorders are prevalent and negatively impact the quality of life. There is conflicting evidence on whether nocturnal gastro-oesophageal reflux and sleep disturbances are causally linked, and whether sleep disturbances drive nocturnal gastro-oesophageal reflux. Poor sleep quality increases oesophageal hypersensitivity and overall acid exposure. The nocturnal gastro-oesophageal reflux is linked to the more severe forms of gastro-oesophageal reflux disease, especially with atypical/extra-oesophageal manifestations and complications of mucosal damage such as oesophagitis and stricture, Barret's oesophagus, and oesophageal adenocarcinoma. This review highlights the role of sleep problems in presenting nocturnal gastro-oesophageal reflux, and the potential benefits of treating sleep disturbances in enhancing patient care and quality of life.

Relationship between gastroesophageal reflux disease and objective sleep quality

STUDY OBJECTIVES

To objectively characterize (1) the relationship between gastroesophageal reflux disease (GERD) and sleep quality, and (2) the influence of sleep position on this relationship, using in-laboratory polysomnography.

METHODS

We retrospectively analyzed first-night diagnostic in-laboratory polysomnography data for 3411 patients (median age 55 years; 48% male). Medication use and medical condition data were obtained through self-reported questionnaires. Associations between sleep quality and the presence of GERD, and the influence of sleep position on these associations, were analyzed using multivariable linear regression models.

RESULTS

After adjusting for age, sex, body mass index, and relevant comorbidities, GERD was associated with a 3.0% decrease in sleep efficiency, 8.8-minute increase in wake after sleep onset, 24.4-minute increase in rapid eye movement (REM) latency, 13.4-minute decrease in total sleep time, 1.4% decrease in %REM sleep, and 1.5% increase in %N3 sleep. Having both GERD and the majority of sleep on the right side was associated with an 8.6% decrease in sleep efficiency, 27.5-minute increase in wake after sleep onset, 35.6-minute decrease in total sleep time, 2.1% decrease in %REM sleep, and 3.5% increase in %N3 sleep. Having both GERD and the majority of sleep on the left side was associated with an 8.7-minute increase in sleep onset latency.

CONCLUSIONS

GERD is associated with an impairment in objective sleep quality. These associations were more pronounced in right-sided sleep and mostly ameliorated in left-sided sleep. Physicians should recognize the potential for poor sleep quality in patients with GERD and the effect of body position on this relationship.

CITATION

Gurges P, Murray BJ, Boulos MI. Relationship between gastroesophageal reflux disease and objective sleep quality. J Clin Sleep Med. 2022;18(12):2731-2738.

Temporal Relationship Between Night-Time Gastroesophageal Reflux Events and Arousals From Sleep

INTRODUCTION

Night-time gastroesophageal reflux (nGER) symptoms are commonly associated with interrupted sleep. Most studies attempting to understand the relationship between sleep, arousal, and nGER events have been performed so using accelerometry; however, this technology is limited in its ability to precisely determine the temporal association between sleep and reflux events. We aimed to examine the temporal relationships between nGER events and arousal/awakening from sleep using high resolution, in-laboratory polysomnography (PSG).

METHODS

Individuals between 18 and 70 years who had undergone a gastroscopy within 12 months underwent simultaneous 24-hour pH/impedance monitoring and in-laboratory PSG. The temporal relationship between each nGER event and sleep/arousals/awakenings was determined for each participant. Analyses were limited to the sleep period (between "lights out" and time of final waking).

RESULTS

Analyses were conducted on the data from 25 individuals, 64% of whom had nGER episodes (5 ± 5 events per person, range 1-18) and 64% of whom had obstructive sleep apnea (OSA, mean apnea-hypopnea index 20 ± 11 events/hr, range 6-44). There were no differences in PSG-determined sleep duration, sleep efficiency, sleep architecture, arousals/awakenings, or sleep apnea severity between those with nGER and those without. Most nGER events (82%) occurred during a PSG epoch that had been classified as wake. Arousals/awakenings preceded almost all events (73/76), whereas fewer had an arousal/awakening after the event (15/76).

DISCUSSION

As opposed to what is typically assumed, nGER does not seem to cause arousal from sleep, but rather arousal from sleep predisposes to nGER.

Discounting the duration of bolus exposure in impedance testing underestimates acid reflux

Background

Combined impedance-pH testing (MII) allows for detection of reflux episodes regardless of pH. However impedance-based diagnosis of reflux may not routinely account for duration of the reflux episode. We hypothesize that impedance testing may be less sensitive than pH-testing in detecting acid reflux off therapy as a result of discounting duration of exposure.

Methods

Baseline characteristics and reflux parameters of MII studies performed off-anti-secretory medications were analyzed. Studies on acid suppressive medication and those with recording times less than 20 h or low baseline impedance were excluded.

Results

A total of 73 consecutive MII studies were analyzed of which 31 MII studies had elevated acid exposure while 16 were abnormal by impedance criteria. MII testing off-therapy was more likely to be abnormal by pH criteria (percent time pH < 4) than impedance criteria (total reflux):[42 vs 22 % (p =0.02)]. Acid exposure (percent time pH < 4) identified more studies as abnormal than MII-detected acid reflux episodes [42 vs 34 % (p < 0.01)]. Mean acid clearance time (pH-detected) was significantly longer than median bolus clearance time (impedance-detected) in the total [98.7 s vs 12.6 s (p < 0.01)], upright [58.6 s vs 13.1 s (p < 0.01)], and recumbent positions [136.7 s vs 14.2 s (p < 0.01)] with the greatest difference seen in the recumbent position. The mean ratio of mean acid clearance time (pH-detected) and the median bolus clearance time (impedance-detected) was significantly higher in the recumbent position compared to the upright position [11. vs 5.3 (p = 0.01)].

Conclusion

Ambulatory impedance testing underestimates acid reflux compared to esophageal acid exposure by discounting the prolonged period of mucosal contact with each acid reflux episode, particularly in the recumbent position.

Characteristics of nighttime reflux assessed using multichannel intraluminal impedance pH monitoring and a portable electroencephalograph

Gastroesophageal reflux disease (GERD) is strongly associated with sleep disturbances. Although the mechanisms of this association have not been fully elucidated, nighttime reflux plays a central role. However, the detailed characteristics of nighttime reflux occurring during sleep are unknown. The aim of the present study was to examine the characteristics and prevalence of nighttime reflux in the natural sleep environment of GERD patients. Seventeen patients experiencing daily moderate-to-severe heartburn and/or regurgitation were studied using multichannel intraluminal impedance pH monitoring and electroencephalography off-proton pump inhibitor treatment. Nighttime reflux was divided based on reflux type (liquid or gas), acidity (acidic, weakly acidic, or alkaline) and extent (distal only or proximal migration) according to the standard criteria. Nighttime phases were divided as follows: recumbent-awake before falling asleep, nonrapid eye movement, rapid eye movement, awakening from sleep, and post-awakening in the morning. Among 184 nighttime refluxes, 43 (23%) occurred during recumbent-awake before falling asleep, 28 (15%) during nonrapid eye movement, 14 (8%) during rapid eye movement, 86 (46%) during awakening from sleep, and 13 (7%) during post-awakening in the morning. Liquid reflux was more common in awakening during sleep (92%), nonrapid eye movement (100%), and rapid eye movement (100%) compared with awakening before falling asleep (68%). The prevalence of proximal migration was significantly lower in nonrapid eye movement and rapid eye movement than in the other phases. There were no differences in acidity and bolus clearance time among the phases. Thirteen (65%) of 20 events with GERD symptoms had nighttime reflux, suggesting that only 7.1% (13 of 184) of nighttime refluxes were symptomatic. Nighttime reflux was observed in 48 (11%) of 425 awakening episodes during sleep. Different reflux patterns at each phase during nighttime might explain the pathogenesis of GERD and its related sleep disturbances.

Naps are associated more commonly with gastroesophageal reflux, compared with nocturnal sleep

BACKGROUND & AIMS

Acid reflux during nighttime sleep has been associated with more severe gastroesophageal reflux disease (GERD). Napping is common, especially after lunch time, in many cultures. We aimed to compare reflux characteristics between nighttime sleep and naps in patients with GERD.

METHODS

We performed a study of 15 patients (mean age, 58.5 ± 18.4 y; 10 men) with heartburn and/or regurgitation at least 3 times/week for the past 3 months, who experienced a nap in addition to regular nighttime sleep. All were evaluated using the demographics and GERD Symptoms Checklist questionnaires. Patients underwent pH testing concomitantly with actigraphy when they were not receiving antireflux treatment; only patients with abnormal results from pH tests were included in the study. Raw data from actigraphy analyses were superimposed over those collected from pH monitoring, matched by time. Integrative software was used to determine recumbent-awake, recumbent-asleep, and naps alongside pH monitoring data.

RESULTS

The mean duration of nocturnal sleep time and nap time were 446.0 ± 100.7 minutes and 61.9 ± 51.8 minutes, respectively. The mean number of reflux events per hour was significantly greater during nap than nocturnal sleep time (40.1 ± 69.9/h vs 3.5 ± 4.2/h; P < .05). The mean duration of reflux events was longer during nap than nocturnal sleep time (1.9 ± 2.8 min vs 1.5 ± 2.7 min). The percentage of time spent at a pH less than 4 was significantly greater during naptime than nocturnal sleep time (36.2% ± 38.8% vs 8.9% ± 11.6%; P < .05). Arousals from naps were rare, compared with nocturnal sleep (mean, 0.7 ± 1.1 vs 4.2 ± 2.9; P < .05). Patients also experienced more acid reflux associated with symptoms during nap than nocturnal sleep (mean, 8.08% vs 0.45%; P < .05).

CONCLUSIONS

We associated naps with significantly greater numbers of, and duration of, esophageal acid exposure and symptoms, compared with nocturnal sleep. Naps therefore might have important effects on disease severity.

Systematic review: relationships between sleep and gastro-oesophageal reflux

BACKGROUND

Gastro-oesophageal reflux disease (GERD) adversely impacts on sleep, but the mechanism remains unclear.

AIM

To review the literature concerning gastro-oesophageal reflux during the sleep period, with particular reference to the sleep/awake state at reflux onset.

METHODS

Studies identified by systematic literature searches were assessed.

RESULTS

Overall patterns of reflux during the sleep period show consistently that oesophageal acid clearance is slower, and reflux frequency and oesophageal acid exposure are higher in patients with GERD than in healthy individuals. Of the 17 mechanistic studies identified by the searches, 15 reported that a minority of reflux episodes occurred during stable sleep, but the prevailing sleep state at the onset of reflux in these studies remains unclear owing to insufficient temporal resolution of recording or analysis methods. Two studies, in healthy individuals and patients with GERD, analysed sleep and pH with adequate resolution for temporal alignment of sleep state and the onset of reflux: all 232 sleep period reflux episodes evaluated occurred during arousals from sleep lasting less than 15 s or during longer duration awakenings. Six mechanistic studies found that transient lower oesophageal sphincter relaxations were the most common mechanism of sleep period reflux.

CONCLUSIONS

Contrary to the prevailing view, subjective impairment of sleep in GERD is unlikely to be due to the occurrence of reflux during stable sleep, but could result from slow clearance of acid reflux that occurs during arousals or awakenings from sleep. Definitive studies are needed on the sleep/awake state at reflux onset across the full GERD spectrum.

Gastroesophageal reflux disease and sleep

There is strong evidence of a bidirectional relationship between gastroesophageal reflux disease and sleep disturbances. Gastroesophageal reflux (GER) events during the night result in sleep disturbances that include difficulty in falling asleep, sleep fragmentation, and early morning awakenings. In addition, sleep deprivation per se induces hyperalgesia of the esophageal mucosa in response to acid. Treatment includes lifestyle modifications, proton-pump inhibitors (PPIs), γ-aminobutyric acidB agonists, hypnotics, and antireflux surgery. Among these, PPIs are considered first-line treatment for the control of nighttime gastric acid secretion; however, the timing and dosing of PPI administration should be individualized for each patient.

Gastroesophageal reflux disease and sleep disturbances

Nighttime reflux during sleep plays a crucial role in several conditions associated with gastroesophageal reflux disease (GERD). Reflux patterns during arousal and sleep are different because of delayed gastric emptying, reduced esophageal peristalsis, decreases in swallowing and salivary secretion, and prolonged esophageal clearance during sleep. Clinical evidence strongly suggests that GERD is associated with sleep disturbances such as shorter sleep duration, difficulty falling asleep, arousals during sleep, poor sleep quality, and awakening early in the morning. New mechanisms on how GERD affects sleep have been recently identified by using actigraphy, and sleep deprivation was found to induce esophageal hyperalgesia to acid perfusion. Thus, the relationship between GERD and sleep disturbances is bidirectional. Among lifestyle modifications, avoidance of a late night meal plays a role in prevention of nighttime reflux. Treatment with a proton pump inhibitor (PPI) improves both nighttime symptoms and subjective sleep parameters, but its effects on objective sleep parameters remain unclear. Better control of nighttime acid secretion by administering a PPI at different times or by providing a double-dose PPI, adding H(2) receptor antagonists, or other new agents is proposed. The effects of such treatments on sleep disturbances remain to be elucidated. GERD patients with sleep disturbances report more severe symptoms and poorer quality of life as compared to those without sleep disturbances. Consequently, GERD should also be classified as GERD with sleep disturbance and GERD without sleep disturbance.

Advancements in the analysis of esophageal pH monitoring in GERD

Ambulatory 24 h esophageal pH monitoring enables quantification of esophageal acid exposure and assessment of the temporal relationship between symptoms and acid reflux events. Analysis of pH monitoring is currently divided into upright and recumbent periods based on the patient's body position. However, in this Review, we demonstrate that physiologic studies have shown that sleep, and not recumbency, has a greater impact on gastroesophageal reflux during night-time. The physiologic studies are further supported by clinical trials demonstrating that gastroesophageal reflux characteristics during the recumbent-awake period are similar to those in the upright rather than the recumbent-asleep period. The introduction of the integrated pH monitoring and actigraphy data analysis program offers better separation of the recumbent-awake and recumbent-asleep periods. The physiologic studies and clinical trials, as well as the availability of a better tool to measure pH during sleep, support a paradigm shift in the analysis of pH monitoring data from body position (upright or recumbent) to state of consciousness (awake or asleep).

Conscious awakenings are commonly associated with Acid reflux events in patients with gastroesophageal reflux disease

BACKGROUND & AIMS

More than half of patients with gastroesophageal reflux disease (GERD) report heartburn that awakens them from sleep. We aimed to determine the frequency of conscious awakenings associated with acid reflux events during sleep and their relationship with symptoms in patients with GERD compared with normal subjects.

METHODS

The study included 39 patients with heartburn and/or regurgitation at least 3 times each week and 9 healthy individuals as controls. Subjects underwent pH testing concomitantly with actigraphy. Novel software simultaneously integrated raw actigraphy and pH data matched by time to determine patients' conscious awakenings during sleep and their temporal relationship with acid reflux events and GERD-related symptoms.

RESULTS

A total of 104 and 11 conscious awakenings were recorded in 89.7% of patients and 77.8% of normal controls, respectively. The mean number of conscious awakenings was significantly higher in the group with GERD compared with controls (3.0 ± 0.3 vs 1.8 ± 0.4, P < .05). Of the conscious awakenings, 51.9% (51/104) were associated with an acid reflux event in GERD patients and 0 in controls (P < .01). Only 16.3% of total conscious awakenings were symptomatic. In most of the conscious awakenings that were associated with an acid reflux event (85.6%), the awakening preceded the reflux event.

CONCLUSIONS

Acid reflux events occur primarily after an awakening episode. Conscious awakenings from sleep are common among patients with GERD and are frequently associated with acid reflux events. However, conscious awakenings associated with reflux events are seldom symptomatic.

Increased oesophageal acid exposure at the beginning of the recumbent period is primarily a recumbent-awake phenomenon

BACKGROUND

A significant increase in oesophageal acid exposure during early recumbent period has been demonstrated.

AIM

To determine if acid reflux during the early recumbent period occurs in the recumbent-asleep or recumbent-awake period using a novel integrative actigraphy and pH programme.

METHOD

Thirty-nine subjects with heartburn at least three times a week were included. Subjects underwent pH testing concomitantly with actigraphy. Simultaneously recorded actigraphy and pH data were incorporated using a novel integrative technique to determine sleep and awake periods. Characteristics of acid reflux were compared between the recumbent-awake and recumbent-asleep periods.

RESULTS

Seventeen (44.7%) subjects had acid reflux events during recumbent-awake period as compared to seven (18.4%) in the corresponding recumbent-asleep period (P = 0.046). The mean number of acid reflux events in recumbent-awake period was significantly higher than in the corresponding recumbent-asleep period (8.1 +/- 4.4 vs. 3.2 +/- 1.5, P < 0.001). In the recumbent-awake period, 38.4% of acid reflux events were associated with GERD-related symptoms as compared with 3.7% of acid reflux events during the corresponding recumbent-asleep period (P = 0.01).

CONCLUSION

Increased acid reflux in the early recumbent period occurs primarily during the recumbent-awake and not during the recumbent-asleep period.

Gastroesophageal reflux disease and sleep disorders: evidence for a causal link and therapeutic implications

Gastroesophageal reflux disease (GERD) and sleep disturbances are both common health problems. There is a significant association between disturbed sleep and GERD, and this may be bidirectional. Sleep disorders may induce gastrointestinal (GI) disturbances, while GI symptoms also may provoke or worsen sleep derangements. Reflux of gastric acid is a less frequent event during sleep, however, acid clearance mechanisms (including swallowing, salivation and primary esophageal motility) are impaired during sleep resulting in prolongation of acid contact time. Nighttime reflux can lead to sleep disturbance and sleep disturbance may further aggravate GERD by prolonged acid contact time and heightened sensory perception. This may facilitate the occurrence of complicated GERD and decreased quality of life. However, the interplay between sleep problems and GERD is complex, and there are still relatively limited data on this issue. Further investigation of sleep-related GERD may identify common pathophysiological themes and new therapeutic targets.