Value of heartburn for diagnosing gastroesophageal reflux disease in severely obese patients

An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity

Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).

Impacts of sleeve gastrectomy on gastroesophageal reflux disease in severely obese Korean patients

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has established popularity as a bariatric and metabolic surgery. However, the incidence of gastroesophageal reflux disease (GERD) following LSG is controversial. This study aims to describe the prevalence of de novo GERD after LSG.

METHODS

A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms.

RESULTS

The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p = 0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B = 15 (11.5%), C = 4 (3.1%), and D = 6 (4.6%).

CONCLUSION

In this study, 42.3% (n = 55) of total patients developed newly developed GERD, and 7.7% (n = 10) had LA grade C or D esophagitis.

Disruption of the brain-esophagus axis in obese patients with heartburn

Obesity is a risk factor for gastroesophageal reflux disease. Studies addressing the brain-esophagus axis in obese are lacking. In obese with and without heartburn, we assessed: (i) the brain responses to esophageal acid perfusion during functional brain imaging; (ii) esophageal impedance baseline before and after acid perfusion; and (iii) abdominal fat distribution. In this exploratory study, 26 obese underwent functional magnetic resonance imaging (fMRI) of the brain combined with esophageal acid perfusion. Esophageal impedance baseline was determined before and after fMRI, followed by tomographic quantification of the abdominal fat. Among 26 obese (54% men, 39.7 years old, 33.5 kg/m2), there were 17 with heartburn and 9 without heartburn. Before fMRI, the esophageal impedance baseline was lower in obese with heartburn than without heartburn (median 1187 vs. 1890 Ω; P = 0.025). After acid perfusion, impedance baseline decreased in obese with heartburn (from 1187 to 899 Ω; P = 0.011) and was lower in this group than in obese without heartburn (899 vs. 1614 Ω; P = 0.001). fMRI task-residual analysis showed that obese with heartburn presented higher functional connectivity in several brain regions than obese without heartburn. Abdominal fat area did not differ between obese with and without heartburn either for total (72.8 ± 4.4% vs. 70.3 ± 6.0%; P = 0.280), subcutaneous (42.2 ± 9.0% vs. 37.4 ± 9.0%; P = 0.226), or visceral (30.6 ± 7.9% vs. 33.0 ± 7.8%; P = 0.484). In subjects with obesity, the brain-esophagus axis is disrupted centrally with higher functional brain connectivity and peripherally with decreased esophageal mucosa integrity in the presence of heartburn.

Role of Non-pharmacological Interventions and Weight Loss in the Management of Gastroesophageal Reflux Disease in Obese Individuals: A Systematic Review

With the increasing prevalence of obesity, the worldwide risk of gastroesophageal reflux disease (GERD) has also increased. Abdominal obesity increases intragastric pressure, disturbing the integrity of the gastroesophageal junction, thus facilitating reflux. Other than obesity, some lifestyle factors also cause GERD, including smoking, consumption of alcohol and caffeine, late-night meals, and high fat intake. This review study aimed to assess the impact of weight loss and lifestyle modifications on GERD. In this systematic review, the databases used were PubMed, PubMed Central (PMC), Science Direct, and Google Scholar. Boolean system and Medical Subject Headings (MeSH) strategy were used to form suitable keywords. Patients from the pediatric and geriatric populations were excluded from the study and quality assessment was done using different assessment tools. A positive association between obesity and GERD was found. It was also found that the long-term use of proton pump inhibitors (PPIs) causes complications, so lifestyle interventions should be used more than PPIs for treating GERD, especially in obese patients. We concluded that weight loss could lead to the resolution of gastroesophageal reflux disease, and therefore, conservative measures, including dietary modifications such as reducing the consumption of alcohol, caffeine, and chocolate, behavioral changes such as smoking cessation and elevation of the head of the bed, and weight loss, should be used as first-line management for GERD. Although awareness has increased regarding the adverse effects of proton pump inhibitors, future studies are required to assess these negative effects.

Do Preoperative Esophageal pH Monitoring and High-Resolution Manometry Predict Symptoms of GERD After Sleeve Gastrectomy?

BACKGROUND

Predictive factors of evolution or appearance of gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) have not been identified to date. We aimed to assess the evolution of GERD symptoms 1 year after SG and to determine preoperative predictive factors using high-resolution manometry (HRM) and ambulatory 24-h esophageal pH monitoring (APM).

METHODS

We included 160 patients who underwent SG between 2013 and 2017 and performed preoperative APM and HRM. Positive APM was defined according to the Lyon consensus. Symptoms of GERD, proton pump inhibitors (PPI) use, weight loss (WL), and diet were recorded in all patients before and 1 year after surgery.

RESULTS

One year after surgery, 58 patients (36.3%) complained of GERD symptoms compared to 52 patients (32.5%) preoperatively (p=0.48). Among patients with preoperative GERD symptoms, only 26/52 patients (50%) still had symptoms, whereas 32/108 (29.6%) asymptomatic patients developed de novo GERD symptoms after surgery. PPI use increased after surgery reaching 36.9% of patients against 15.0% before (p<0.0001). Only preoperative symptoms of GERD were predictive of postoperative symptoms (OR= 2.47 [1.14-5.45]; p=0.023) in multivariate analysis. Preoperative manometric parameters, postoperative diet, and WL were not related to postoperative symptoms. In asymptomatic patients before surgery, silent GERD (positive APM without symptom) was predictive of postoperative GERD symptoms (OR=2.69 [1.00-7.25]; p=0.049).

CONCLUSION

Evolution of GERD symptoms after SG reveals improvement for half of the patients and de novo GERD symptoms in one-third of patients. Predictive factors of postoperative symptoms are preoperative symptoms and positive preoperative APM in asymptomatic patients.

Erosive Esophagitis and Symptoms of Gastroesophageal Reflux Disease in Patients with Morbid Obesity with and without Type 2 Diabetes: a Cross-sectional Study

BACKGROUND

Type 2 diabetes (T2DM) is associated with gastroesophageal reflux disease (GERD) in the general population, but the relationship between these conditions in candidates for bariatric surgery is uncertain. We compared the prevalence of GERD and the association between GERD symptoms and esophagitis among bariatric candidates with and without T2DM.

METHODS

Cross-sectional study of baseline data from the Oseberg study in Norway. Both groups underwent gastroduodenoscopy and completed validated questionnaires: Gastrointestinal Symptom Rating Scale and Gastroesophageal Reflux Disease Questionnaire. Participants with T2DM underwent 24-h pH-metry.

RESULTS

A total of 124 patients with T2DM, 81 women, mean (SD) age 48.6 (9.4) years and BMI 42.3 (5.5) kg/m², and 64 patients without T2DM, 46 women, age 43.0 (11.0) years and BMI 43.0 (5.0) kg/m², were included. The proportions of patients reporting GERD-symptoms were low (< 29%) and did not differ significantly between groups, while the proportions of patients with esophagitis were high both in the T2DM and non-T2DM group, 58% versus 47%, p = 0.16. The majority of patients with esophagitis did not have GERD-symptoms (68-80%). Further, 55% of the patients with T2DM had pathologic acid reflux. Among these, 71% also had erosive esophagitis, whereof 67% were asymptomatic.

CONCLUSIONS

The prevalence of GERD was similar in bariatric patients with or without T2DM, and the proportion of patients with asymptomatic GERD was high independent of the presence or absence of T2DM. Accordingly, GERD may be underdiagnosed in patients not undergoing a preoperative endoscopy or acid reflux assessment.

TRIAL REGISTRATION

Clinical Trials.gov number NCT01778738.

The role of upper gastrointestinal endoscopy in bariatric procedure selection: A case series and literature review

Background:

Bariatric surgery leads to a significant improvement in obesity and associated comorbidities. Safe surgical outcomes are especially desirable in bariatric, as most patients perceive it as an aesthetic surgery, while an intestinal/gastric surgery may be associated with morbidity. A detailed pre-operative evaluation is required to avoid surgical surprises and post-operative complications. Besides other routine investigations, pre-surgery upper gastrointestinal (GI) endoscopy has always been a topic of debate. Some surgeons perform it routinely before the surgery, whereas others perform it selectively. It is mostly accepted that pre-operative diagnosis of gastro-oesophageal reflux disease could change the plan of surgery in favour of Roux-en-Y gastric bypass although similar consensus does not exist in favour of Sleeve gastrectomy if a gastric/duodenal pathology is detected pre-operatively in a planned roux-en-y gastric bypass patient.

Aim:

Through this case series, we want to highlight the role of routine pre-operative upper GI endoscopy in selecting the bariatric surgery.

Cases:

We present four cases, from amongst many others, where endoscopy changed the course of bariatric surgery.

Conclusion:

Upper GI endoscopy should be performed before bariatric surgery, even in asymptomatic patients, to avoid post-operative surprise/complication.

Gastroesophageal reflux disease, obesity and laparoscopic sleeve gastrectomy: The burning questions

Obesity is a global health epidemic with considerable economic burden. Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk. Sleeve gastrectomy accounts for almost half of all bariatric surgeries worldwide but concerns regarding its relationship with gastroesophageal reflux disease (GERD) has been a topic of debate. GERD, including erosive esophagitis, is highly prevalent in the obese population. The role of pre-operative endoscopy in bariatric surgery has been controversial. Two schools of thought exist on the matter, one that believes routine upper endoscopy before bariatric surgery is not warranted in the absence of symptoms and another that believes that symptoms are poor predictors of underlying esophageal pathology. This debate is particularly important considering the evidence for the association of laparoscopic sleeve gastrectomy (LSG) with de novo and/or worsening GERD compared to the less popular Roux-en-Y gastric bypass procedure. In this paper, we try to address 3 burning questions regarding the inter-relationship of obesity, GERD, and LSG: (1) What is the prevalence of GERD and erosive esophagitis in obese patients considered for bariatric surgery? (2) Is it necessary to perform an upper endoscopy in obese patients considered for bariatric surgery? And (3) What are the long-term effects of sleeve gastrectomy on GERD and should LSG be done in patients with pre-existing GERD?

Discoordination of Autonomic Support of Functions in the Pathogenesis Gastroesophageal Reflux Disease

A cross-sectional study performed on a continuous sample of 32 patients (mean age 46.36±3.31 years) with gastroesophageal reflux disease and excess body weight showed that the disturbance of sympathetic/parasympathetic relationships, disruption of segmental and compensatory increase in the suprasegmental mechanisms of autonomic regulation determines the course of gastroesophageal reflux disease in these patients.

De novo gastroesophageal reflux disease after sleeve gastrectomy: role of preoperative silent reflux

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become the most frequently performed bariatric procedure to date. However, LSG is known to worsen pre-operative and result in de novo gastroesophageal reflux disease (GERD). Pre-operative evaluation reveals a high percentage of silent GERD of so far unknown influence on post-operative GERD.

METHODS

Prospective data of patients undergoing primary LSG between 01/2012 and 12/2015 were evaluated. Pre-operative GERD-specific evaluation consisted of validated questionnaires, upper endoscopy, 24 h-pH-manometry, and esophagograms. Patients were followed-up with questionnaires every 6 months, upper endoscopies after 1 year and 24 h-pH-metry after 2 years. Silent GERD was defined as esophagitis grade > B and/or abnormal esophageal acid exposure in absence of symptoms. LSG was performed over a 32F bougie, hiatal hernias > 1 cm were addressed with posterior hiatoplasty. Excluded were patients with hiatal hernias > 4 cm, patients with incorrect anatomy (stenosis, fundus too large) and conversion to RYGB for early leaks.

RESULTS

222 patients were included. Mean follow-up was 32 ± 16 months, mean preoperative body mass index 49.6 ± 7.2 kg/m². 116 patients (52%) presented with post-operative GERD-symptoms, of which 85 (73%) had de novo symptoms. Of those, 48 (of 85, 56%) had no preoperative GERD and 37 (of 85, 44%) silent GERD. 57 patients (26%) had neither pre- nor post-operative GERD, 7 (3%) had silent pre-operative and no postop GERD, and in 19 patients (9%) GERD was cured with LSG. 31 patients (14%) stayed symptomatic. Of 56 patients (25%) with pre-operative silent GERD, 37 (of 54, 66%) became symptomatic.

CONCLUSION

LSG leads to a considerable rate of post-operative GERD. De novo-GERD consist of around half of pre-operative silent GERD and completely de novo-GERD. Most patients with pre-operative silent GERD became symptomatic.

Decreased Esophageal Sensitivity to Acid in Morbidly Obese Patients: A Cause for Concern?

Background/Aims

To evaluate esophageal sensitivity to acid between morbidly obese (MO) patients and non-MO controls with abnormal esophageal acid exposure.

Methods

We conducted a cross-sectional study of 58 patients: 30 MO (cases) and 28 non-MO (controls). Esophageal symptoms and esophageal sensitivity to 0.1 M hydrochloric acid solution (Bernstein test) were compared between MO and non-MO patients with a prior diagnosis of abnormal esophageal acid exposure.

Results

MO patients were less symptomatic than non-MO controls (14% vs 96%; odds ratio [OR], 0.006; 95% confidence interval [CI], 0.001 to 0.075; p=0.000). MO patients were more likely to present with decreased esophageal sensitivity to the instillation of acid than non-MO controls (57% vs 14%; OR, 8; 95% CI, 1.79 to 35.74; p=0.009). Subgroup analysis revealed no differences in esophageal sensitivity in MO patients with and without abnormal esophageal acid exposure (43% vs 31%; p=0.707).

Conclusions

Silent gastroesophageal reflux disease (GERD) is common among MO individuals, likely due to decreased esophageal sensitivity to acid. The absence of typical GERD symptoms in these patients may delay discovery of precancerous conditions, such as Barrett’s esophagus. We believe that these patients may require a more aggressive diagnostic work-up to rule out the presence of silent GERD.

Symptoms, endoscopic findings and reflux monitoring results in candidates for bariatric surgery

BACKGROUND

Gastroesophageal reflux disease (GERD) is common in patients with obesity. Diagnosing GERD is important as bariatric operations have different influence on GERD. We assessed reflux symptoms and objective findings prior to surgery.

METHODS

Work-up included esophageal symptoms quantification by VAS-scores, esophagogastroduodenoscopy (EGD) and 24-h impedance-pH (imp-pH) monitoring off PPI therapy. Imp-pH was classified as abnormal if either %time pH<4 was abnormal, total number of reflux episodes was elevated or symptom index (SI) was positive.

RESULTS

Among 100 consecutive patients (68F, age 40±11years, BMI 44.9±6.9kg/m²) 54% reported heartburn and/or regurgitation, 71% had objective evidence of GERD (38% endoscopic lesions and 33% only abnormal imp-pH results). Imp-pH was superior to EGD in identifying GERD (sensitivity 85% vs. 54%, p<0.01). Symptomatic and asymptomatic patients had similar prevalence of esophageal lesions (37% vs. 39%) and abnormal imp-pH findings (68% vs. 50%). Sixty nine percent of patients with abnormal %time pH<4 had a normal number of reflux episodes.

CONCLUSION

Half of patients with obesity reported typical GERD symptoms and >70% had evidence of GERD. Poor acid clearance was the main mechanisms. Since typical reflux symptoms don't predict objective findings, endoscopy and reflux monitoring should be part of the surgery work-up especially before restrictive procedures.

Zero-Inflated Models for Identifying Relationships Between Body Mass Index and Gastroesophageal Reflux Symptoms: A Nationwide Population-Based Study in China

BACKGROUND AND AIM

That obesity leads to gastroesophageal reflux is a widespread notion. However, scientific evidence for this association is limited, with no rigorous epidemiological approach conducted to address this question. This study examined the relationship between body mass index (BMI) and gastroesophageal reflux symptoms in a large population-representative sample from China.

METHODS

We performed a cross-sectional study in an age- and gender-stratified random sample of the population of five central regions in China. Participants aged 18-80 years completed a general information questionnaire and a Chinese version of the Reflux Disease Questionnaire. The zero-inflated Poisson regression model estimated the relationship between body mass index and gastroesophageal reflux symptoms.

RESULTS

Overall, 16,091 (89.4 %) of the 18,000 eligible participants responded. 638 (3.97 %) and 1738 (10.81 %) experienced at least weekly heartburn and weekly acid regurgitation, respectively. After adjusting for potential risk factors in the zero-inflated part, the frequency [odds ratio (OR) 0.66, 95 % confidence interval (95 % CI) 0.50-0.86, p = 0.002] and severity (OR 0.66, 95 % CI 0.50-088, p = 0.004) of heartburn in obese participants were statistically significant compared to those in normal participants. In the Poisson part, the frequency of acid regurgitation, overweight (OR 1.10, 95 % CI 1.01-1.21, p = 0.038) and obesity (OR 1.19, 95 % CI 1.04-1.37, p = 0.013) were statistically significant. BMI was strongly and positively related to the frequency and severity of gastroesophageal reflux symptoms. Additionally, gender exerted strong specific effects on the relationship between BMI and gastroesophageal reflux symptoms.

CONCLUSIONS

The severity and frequency of heartburn were positively correlated with obesity. This relationship was presented distinct in male participants only.

The Impact of Gastric Bypass on Gastroesophageal Reflux Disease in Morbidly Obese Patients

OBJECTIVE

To assess the impact of Roux-en-Y gastric bypass (GBP) on gastroesophageal reflux disease (GERD) in morbidly obese patients.

BACKGROUND

Recently, authors have reported that early results of GBP can control GERD. However, longer follow-ups based on objective parameters for GERD are missing.

METHODS

Fifty-three patients [15 men (28%), 39 years old (range, 18-59), body mass index = 46 ± 7.7 kg/m2] were consecutively evaluated for GERD irrespectively of related symptoms, before the operation (E1) and at 6 (E2) and 39 ± 7 months postoperatively (E3). The end points were (1) esophageal syndromes based on the Montreal Consensus and (2) an esophageal acid exposure assessment.

RESULTS

Body mass index dropped from 46 ± 7.7 kg/m2 at E1 to 30 ± 5.2 kg/m2 at E3. Typical reflux syndrome displayed a significant decrease from 31 (58%) at E1 to 8 (15%) at E2 and 5 (9%) at E3. Statistically significant differences occurred between E1 and both postoperative evaluations (P < 0.001). Reflux esophagitis was detected in 24 (45%), 17 (32%), and 10 patients (19%) at E1, E2, and E3, respectively (P = 0.002). The incidence of GERD decreased in 34 (64%) and 21 (40%) patients at E1 and E2, respectively, and then in 12 (23%) patients at E3. DeMeester scores reduced from 28.6 (E1) to 9.4 (E2) and 1.2 (E3) (P < 0.001).

CONCLUSIONS

For most morbidly obese patients, in addition to causing significant weight loss, GBP reduces GERD symptoms, improves reflux esophagitis, and decreases esophageal acid exposure for longer than 3 years.

Body mass index association with functional gastrointestinal disorders: differences between genders. Results from a study in a tertiary center

BACKGROUND

Obesity is considered as a risk factor for many functional gastrointestinal disorders. The aim of the study was to evaluate if functional digestive disorders are associated with specific body mass index groups and gender.

METHODS

A total of 1074 patients (50.3 ± 16.5 years, 67 % females) filled out a standard Rome III questionnaire (79 % acceptance rate). The patients were assigned to five groups according to their body mass index: underweight (6 %), normal (49 %), overweight (28 %), obese (12 %), and morbidly obese (5 %). Data analysis was performed using multinomial logistic regression; subjects with the normal weight were the reference group.

RESULTS

Patients presented specific demographic and clinical characteristics according to the weight groups. Underweight patients were younger (p < 0.001), and presented a female predominance (p = 0.006), dysphagia (p = 0.013) and soiling (p = 0.021). Overweight patients were older (p = 0.001), and reported more frequently globus (p = 0.001), regurgitation (p = 0.004), postprandial distress syndrome (p = 0.009). Obese patients reported more frequently regurgitation (p < 0.001). Morbid obese patients reported dyspepsia (p = 0.046). In patients, the odds of regurgitation increased with body mass index from underweight to obesity, but not when compared to morbid obesity. The probability of globus and regurgitation increased with body mass index and presented a steeper increase in females.

CONCLUSIONS

In patients with functional gastrointestinal disorders, globus and regurgitation are associated with body mass index, mainly in female patients.

Esophageal abnormalities in morbidly obese adult patients

BACKGROUND

An increase in body mass index has been found to be associated with an increase in the prevalence of gastroesophageal reflux disease (GERD) symptoms, esophageal mucosal injury, and GERD complications. Few systematic studies with objective tests have evaluated esophageal disorders in the morbidly obese population.

OBJECTIVES

To define more precisely in morbidly obese people the incidence of esophageal symptoms and characterize the esophageal disorders using objective data.

SETTING

University Hospital, Spain.

METHODS

Two hundred twenty-four presurgical morbidly obese patients were submitted to a protocol including a clinical history and objective tests (endoscopy, stationary esophageal manometry, 24-hour esophageal pH monitoring and isotopic emptying of the esophagus).

RESULTS

In a morbidly obese population, heartburn (50.9%) and regurgitation (28.6%) were the most prevalent symptoms of GERD. Endoscopy registered hiatus hernia (12.5%) and reflux esophagitis (17.3%). Manometry was often abnormal (33.4%), with a hypotensive lower esophageal sphincter as the most common finding. Esophageal pH-metry was abnormal in 54.2% of the cases. Finally, 9.1% of the patients presented with abnormal isotopic esophageal emptying. A correlation between the degree of obesity and the severity of symptoms/objective tests for esophageal abnormalities could not be found.

CONCLUSIONS

In morbidly obese patients, GERD is common, symptoms are unspecific, and there is a high prevalence of pH-metry and manometric abnormalities, unrelated to the degree of obesity.

Chemoprevention in Barrett's Esophagus: Current Status

Chemoprevention in Barrett's esophagus is currently applied only in research settings. Identifying pathways that can be targeted by safe, pharmaceutical or natural compounds is key to expanding the scope of chemoprevention. Defining meaningful surrogate markers of cancer progression is critical to test the efficacy of chemopreventive approaches. Combinatorial chemoprevention that targets multiple components of the same pathway or parallel pathways could reduce the risk and improve the efficacy of chemoprevention. Here we discuss the role of chemoprevention as an independent or an adjuvant management option in BE-associated esophageal adenocarcinoma.

Chemoprevention in Barrett's oesophagus

Increasing incidence of oesophageal adenocarcinoma along with poor survival entails novel preventive strategies. Agents that target pro-oncogenic pathways in Barrett's mucosa could halt this neoplastic transformation. In this review, we will use epidemiological associations and molecular mechanisms to identify novel chemoprevention targets in Barrett's oesophagus. We will also discuss recent chemoprevention trials.

Gastroesophageal reflux disease and obesity: do we need to perform reflux testing in all candidates to bariatric surgery?

INTRODUCTION

Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and esophageal erosions. However the relationship between obesity and GERD is still a subject of debate. In fact, if in most cases bariatric surgery can diminish reflux by losing a large amount of fat, on the other hand some restrictive procedure can worsen or cause the presence of GERD. Thus, it is unclear if patients candidate to bariatric surgery have to perform pre-operative reflux testing or not.

AIM

of the study was to verify the presence of GERD patterns in patients candidate to surgery and the need of pre-operative reflux testing.

METHODS

All patients underwent to a standardized questionnaire for symptoms severity (GERQ), upper endoscopy, high resolution manometry (HRiM) and impedance pH-monitoring (MII-pH). Patients were stratified into: group 1 (negative for both GERQ and endoscopy), group 2 (positive for GERQ and negative for endoscopy), group 3 (positive for both GERQ and endoscopy). A healthy-volunteers group (HV) was assessed.

RESULTS

One hundred thirty-nine subjects (obese, 124; HV normal weight, 15) were studied. Group 1 showed comparable mean LES pressure, peristaltic function, bolus transport and presence of hiatal hernia than HV. Group 2 showed a reduction of these parameters, while group 3 showed a statistical significant reduction in LES pressure, peristaltic function, bolus transport and increase in presence of hiatal hernia. At MII-pH, Group 1 showed a not significant increase in reflux patterns; group 2 and 3 showed a significant increase in esophageal acid exposure and in number of refluxes (both acid and weakly acid), with group 3 showing the higher grade of reflux pattern.

CONCLUSIONS

Obese subjects with pre-operative presence of GERD symptoms and endoscopical signs could be tested with HRM and MII-pH before undergoing bariatric surgery, especially for restrictive procedures. On the other hand, obese patients without any sign of GERD could not be tested for reflux, showing similar patterns to HV.

On-demand proton pump inhibitory treatment in overweight/obese patients with gastroesophageal reflux disease: are there pharmacodynamic arguments for using higher doses?

BACKGROUND

Increased body mass index (BMI) is associated with a higher risk of gastroesophageal reflux disease (GORD).

AIM

To investigate whether overweight/obesity affects proton pump inhibitor pharmacodynamics when used in a single dose in patients with GORD.

METHODS

Post hoc analyses by patient BMI were performed on data from two single-center, double-blind, single-dose, crossover studies comparing the pharmacodynamics of rabeprazole 20 mg and pantoprazole 40 mg in GORD patients with a history of nocturnal heartburn. The primary endpoint was the mean percentage of time with intragastric pH >4 between lean and overweight/obese patients (BMI <25 and ≥25).

RESULTS

24 h baseline intragastric pH values were not different between BMI groups. The pharmacodynamic effects of both proton pump inhibitors were not significantly different between BMI groups, and no evidence was found for an interaction between BMI and treatment. As compared with pantoprazole, rabeprazole showed a significantly greater effect on the antisecretory response for both BMI groups.

CONCLUSIONS

Overweight/obesity in GORD patients does not appear to affect the antisecretory efficacy of a single dose of rabeprazole and pantoprazole. These data do not support adapting the dosage of rabeprazole and pantoprazole according to BMI in GORD patients when administered as an on-demand therapy schedule.

Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial

OBJECTIVE

Weight gain is an important risk factor for gastroesophageal reflux disease (GERD); however, whether weight loss can lead to resolution of GERD symptoms is not clear. Our aim was to measure the impact of weight loss on GERD symptoms.

DESIGN AND METHODS

In a prospective cohort study at a tertiary referral center, overweight/obese subjects (BMI 25-39.9 kg/m2) were enrolled in a structured weight loss program. Weight loss strategies included dietary modifications, increased physical activity and behavioral changes. At baseline and at 6 months, BMI and waist circumference were measured and all participants completed a validated reflux disease questionnaire.

RESULTS

A total of 332 adult subjects, mean age 46 years and 66% women were prospectively enrolled. At baseline, the mean body weight, BMI, and waist circumference were 101 (±18) kg, 35 (±5) kg/m2 and 103 (±13) cm. At 6 months, majority of the subjects (97%) lost weight (average weight loss: 13 ± 7.7 kg) and as compared with baseline, there was a significant decrease in the overall prevalence of GERD (15 vs. 37%; P < 0.01) and the mean GERD symptom score (1.8 vs. 5.5; P < 0.01). Overall, 81% of the subjects had reduction in GERD symptom scores; 65% had complete resolution and 15% had partial resolution of reflux symptoms. There was a significant correlation between % body weight loss and reduction in GERD symptom scores (r = 0.17, P < 0.05).

CONCLUSIONS

In conclusion, the overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects. A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of these subjects.

Functional heartburn: clinical characteristics and outcome

OBJECTIVES

Patients with heartburn and normal upper gastrointestinal endoscopy, normal oesophageal acid exposure, no symptom-reflux association and who fail to respond to a proton-pump inhibitor are classified as having functional heartburn (FH). This study aimed (i) to characterize the symptoms and functional abnormalities of patients with FH and (ii) to describe their clinical outcome.

MATERIALS AND METHODS

Among all patients referred for 24 h multichannel intraluminal impedance-pH (MII-pH), patients with FH were identified. The clinical characteristics and high-resolution oesophageal pressure topography recordings of FH patients were analyzed at the time of the 24-h MII-pH test. A symptom-related and health-related quality-of-life questionnaire was then sent to FH patients to assess the long-term outcome.

RESULTS

Forty patients fulfilled the criteria for FH, representing 8.5% of the referred population. Twenty-two months after initial testing, 66% of patients still suffered from heartburn. The rate of mixed reflux (liquid/gas) was higher in patients with persisting heartburn at the final evaluation (63 vs. 50%, P=0.04). Sixty-six per cent of patients had one or more manometric abnormalities. Acid clearance time in MII-pH was significantly higher in patients with weak peristalsis than patients with normal peristalsis (60 ± 45 vs. 31 ± 19 s, P=0.03). A high rate of mixed reflux and/or a manometric abnormality were associated with a higher risk of persistent heartburn.

CONCLUSION

FH is a chronic disorder with persisting symptoms in two-thirds of patients. An increased rate of mixed reflux and/or the presence of manometric abnormalities are associated with a higher risk of persisting symptoms and may help to identify the population with unmet therapeutic needs.

Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial

OBJECTIVE

Weight gain is an important risk factor for gastroesophageal reflux disease (GERD); however, whether weight loss can lead to resolution of GERD symptoms is not clear. Our aim was to measure the impact of weight loss on GERD symptoms.

DESIGN AND METHODS

In a prospective cohort study at a tertiary referral center, overweight/obese subjects (BMI 25-39.9 kg/m2) were enrolled in a structured weight loss program. Weight loss strategies included dietary modifications, increased physical activity and behavioral changes. At baseline and at 6 months, BMI and waist circumference were measured and all participants completed a validated reflux disease questionnaire.

RESULTS

A total of 332 adult subjects, mean age 46 years and 66% women were prospectively enrolled. At baseline, the mean body weight, BMI, and waist circumference were 101 (±18) kg, 35 (±5) kg/m2 and 103 (±13) cm. At 6 months, majority of the subjects (97%) lost weight (average weight loss: 13 ± 7.7 kg) and as compared with baseline, there was a significant decrease in the overall prevalence of GERD (15 vs. 37%; P < 0.01) and the mean GERD symptom score (1.8 vs. 5.5; P < 0.01). Overall, 81% of the subjects had reduction in GERD symptom scores; 65% had complete resolution and 15% had partial resolution of reflux symptoms. There was a significant correlation between % body weight loss and reduction in GERD symptom scores (r = 0.17, P < 0.05).

CONCLUSIONS

In conclusion, the overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects. A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of these subjects.

Impact of body mass index and gender on quality of life in patients with gastroesophageal reflux disease

AIM: To investigate the symptom presentation and quality of life in obese Chinese patients with gastroesophageal reflux disease (GERD).

METHODS: Data from patients diagnosed with GERD according to the Montreal definition, were collected between January 2009 to March 2010. The enrolled patients were assigned to the normal [body mass index (BMI) < 25 kg/m²], overweight (25-30 kg/m²), and obese (BMI > 30 kg/m²) groups. General demographic data, endoscopic findings, and quality of life of the three groups of patients were analyzed and compared.

RESULTS: Among the 173 enrolled patients, 102, 56 and 15 patients were classified in the normal, overweight, and obese, respectively. There was significantly more erosive esophagitis (73.3% vs 64.3% vs 39.2%, P = 0.002), hiatal hernia (60% vs 33.9% vs 16.7%, P = 0.001), and males (73.3% vs 73.2% vs 32.4%, P = 0.001) in the obese cases. The severity and frequency of heartburn, not acid regurgitation, was positively correlated with BMI, with a significant association in men, but not in women. Obese patients were prone to have low quality of life scores, with obese women having the lowest scores for mental health.

CONCLUSION: In patients with GERD, obese men had the most severe endoscopic and clinical presentation. Obese women had the poorest mental health.

Laparoscopic treatment of obese patients with gastroesophageal reflux disease and Barrett's esophagus: a prospective study

BACKGROUND

Short-segment Barrett's esophagus (SSBE) or long-segment Barrett's esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett's esophagus reaches up to 9% of patients.

METHODS

In this prospective study, we evaluate the postoperative results after three different procedures--calibrated fundoplication + posterior gastropexy (CFPG), fundoplication + vagotomy + distal gastrectomy + Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)--among obese patients.

RESULTS

In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagitis was observed in 15% and 20.2% of them, respectively. Patients with LSBE were submitted to FVDGRYGJ or LRRYGBP which significantly improved their symptoms and erosive esophagitis. No modifications of LESP were observed in patients who submitted to LRRYGBP before or after the operation. Acid reflux diminished after the three types of surgery were employed. Patients who submitted to LRRYGBP presented a significant reduction of BMI from 41.5 ± 4.3 to 25.7 ± 1.3 kg/m(2) after 12 months.

CONCLUSIONS

Among patients with LSBE, FVDGRYGJ presents very good results in terms of improving GERD and Barrett's esophagus, but the reduction of weight is limited. LRRYGBP improves GERD disease and Barrett's esophagus with proven reduction in body weight and BMI, thus becoming the procedure of choice for obese patients.

Gastroesophageal reflux disease is inversely related with glycemic control in morbidly obese patients

BACKGROUND

The link between diabetes mellitus and gastroesophageal reflux disease (GERD) is controversial. We assessed the relationship between glycemic control (GC) and GERD in morbidly obese patients.

METHODS

Consecutive patients with morbid obesity (n = 86) underwent manometry, pH-metry, endoscopy, and contrasted X-ray after responding to a GERD questionnaire and dosing fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Patients with poor GC (HbA1c, 6.1-10% and FPG < 140 mg/dl) and those with very poor GC (HbA1c > 10% or FPG > 140 mg/dl) were compared.

RESULTS

There were 63 patients with poor GC and 17 with very poor GC. Compared to patients with very poor GC, patients with poor GC showed higher heartburn scores [8 (0-12) vs. 0 (0-4); P = 0.003]; higher total esophageal acid exposure [5.2% (2.5-10.5%) vs. 2.3% (0.8-7.5%); P = 0.041]; lower distal esophageal amplitude (105 ± 38 vs. 134 ± 63 mmHg; P = 0.019); higher expiratory gastroesophageal pressure gradient (GEPG, 7 ± 3.4 vs. 5.2 ± 3 mmHg; P = 0.050); lower ventilatory gradient (inspiratory-expiratory GEPG, 10.9 ± 3.8 vs. 13.6 ± 4.1 mmHg; P = 0.012); lower waist-to-hip ratio (0.95 vs. 1; P = 0.040); and more hiatal hernia (38% vs. 6%; P = 0.016).

CONCLUSIONS

This study suggests an inverse relation between glycemic control and GERD in morbidly obese patients. This can be partially explained by a lower frequency of hiatal hernia in patients with very poor glycemic control.

Influence of obesity on the risk of esophageal disorders

Obesity is associated with an increased risk of esophageal disorders, including esophageal adenocarcinoma, Barrett esophagus and GERD. For reasons yet unknown, the association between obesity and esophageal adenocarcinoma seems to be stronger than that for other types of obesity-related cancers. Predominantly abdominal or intra-abdominal adiposity (representing visceral fat and other fat within the abdominal cavity), which is more frequently observed in men than in women, is more strongly linked with these esophageal disorders than BMI alone, a finding that might contribute to the striking male predominance of esophageal adenocarcinoma. Research has identified potential mechanisms underlying the strong link between obesity and esophageal conditions. These findings are summarized in this Review, but more research remains to be carried out before these mechanisms are established.

Population based study to assess prevalence and risk factors of gastroesophageal reflux disease in a high altitude area

AIM

We did a population-based cross-sectional study to investigate the prevalence and risk factors of gastroesophageal reflux disease (GERD) in a high altitude area.

METHODS

An observational study using a validated questionnaire consisting of demographic, lifestyle and dietary characteristics was administered in an interview based format by two clinicians on a sample of adult population residing in urban area and rural high altitude areas of Ladakh. Presence of GERD was defined as a score of ≥4 using a previously validated symptom score based on the severity and frequency of heartburn and regurgitation. Other factors studied were body mass index (BMI), oxygen saturation levels by pulse oximetry and serum lipid profile. A multivariate analysis was done to find out risk factors for symptomatic GERD.

RESULTS

Of the 905 subjects analyzed, there were 399 (44.1%) men; 469 (51.8%) were from rural background and 722 (79.8%) lived in areas 3,000 m above sea level. Symptomatic GERD was present in 169 (18.7%) subjects. Regurgitation occurred once a week in 34.8% and heartburn occurred in 42.9% of subjects. Sixteen (9.5%) had moderate-severe disease activity while 153 (90.5%) had mild disease. Three hundred and eighty-eight (42.7%) and 315 (34.8%) subjects had symptom of heartburn and regurgitation (at least once a week), respectively. On multivariate analysis, risk factors for GERD were age ≤50 years (OR: 1.508, 95% CI: 1.028-2.213), sedentary lifestyle (OR: 2.78, 95% CI: 1.016-7.638), lower intake of salt tea (OR: 1.663, 95% CI: 1.014-2.726); whereas the protective factors were no intake of meat (OR: 0.841, 95% CI: 0.715-0.990), intake of fresh fruits ≥1/week (OR: 0.631, 95% CI: 0.409-0.973), and serum LDL ≤150 mg/dL (OR: 0.435, 95% CI: 0.218-0.868).

CONCLUSION

This population-based study in a high altitude area in India suggests a high prevalence (18.7%) of GERD. A younger age group, sedentary lifestyle, serum LDL >150 mg/dL, high consumption of meat, low consumption of salted tea and low consumption of fresh fruits were significant risk factors for development of GERD.

24-h pH-metry and multichannel intraluminal impedance monitoring in obese patients with and without gastroesophageal reflux disease symptoms

BACKGROUND

The 24-h ambulatory pH-metry with multichannel intraluminal impedance monitoring (24-h pH-metry+MII) allows the simultaneous assessment of chemical and physical properties of esophageal refluxes and the detection of its proximal migration.

METHODS

Gastroesophageal reflux (GER) was investigated in obese symptomatic (obese gastroesophageal reflux disease, GERD) and asymptomatic (obese non-GERD) patients. The data were compared with those obtained from non-obese GERD patients and a control group. Thirty-five (20 non-GERD, 15 GERD) obese patients and 15 non-obese GERD were investigated with 24-h pH-metry+MII. Ten normal weight subjects with normal 24-h pH-metry+MII were used as control group.

RESULTS

The percent time acid exposure was significantly higher in obese non-GERD than controls (p = 0.007). Acid reflux episodes were increased vs. controls in obese non-GERD (p = 0.005) and obese GERD (p = 0.034). Upright position showed a significant increase of reflux episodes in non-obese GERD (p = 0.034) and in obese non-GERD (p = 0.027) vs. controls. Recumbent position showed reflux episodes significantly increased vs. controls in obese non-GERD (p = 0.002), obese GERD (p = 0.021), and non-obese GERD (p = 0.033). In obese non-GERD, waist circumference (WC) correlated negatively with upright position episodes (r = -0.53; p = 0.043) and with proximal migration episodes, i.e., total (r = -0.60; p = 0.018), acid (r = -0.55; p = 0.033), and weakly acidic refluxes (r = -0.56; p = 0.031).

CONCLUSIONS

Obese patients showed an increased number of refluxes with acid content. Refluxes with proximal extent were significantly higher in obese non-GERD than in controls and non-obese GERD patients. No difference was observed between the two obese patient groups. In asymptomatic obese patients, the WC correlated with proximal extent episodes.

Metabolic syndrome is associated with gastroesophageal reflux disease based on a 24-hour ambulatory pH monitoring

Several studies have focused on the relationship between metabolic syndrome and gastroesophageal reflux disease (GERD). They were based on GERD complications, whereas little is known about the association between metabolic syndrome and objectively measured esophageal acid exposure. The aim of our study was to assess the relationship between metabolic syndrome and GERD based on a 24-hour pH testing. It was a cross-sectional study including 100 consecutive patients who underwent a 24-hour pH-metry monitoring and were assessed for the five metabolic syndrome components as well as for body mass index (BMI). Among the 100 patients, 54 had a pathological acid GERD. The 46 GERD-free patients represented control group. Sex distribution was comparable between both groups but GERD patients were older than controls (44.59 vs. 37.63 years, P= 0.006) and more often obese or with overweight (83.3 vs. 60.9%, P= 0.01). Frequency of metabolic syndrome as a whole entity was higher among patients with GERD than those without GERD (50 vs. 19.56%; P= 0.002) with a crude odds ratio of 4.11 (95% confidence interval: 1.66-10.14). Multivariate regression analysis showed that metabolic syndrome as well as an age ≥ 30 years were independent factors associated to GERD but not BMI and sex. Abnormal waist circumference and fasting glucose level ≥ 100 mg/L were the only independent factors among the five components of metabolic syndrome. Metabolic syndrome but not BMI was an independent factor associated to GERD. These results confirm the hypothesis that central obesity is associated to GERD.

The relationship between visceral adiposity and the risk of erosive esophagitis in severely obese Chinese patients

A higher prevalence of erosive esophagitis is found in obese than in nonobese patients; however, it remains unclear why some obese patients develop this disease, whereas others do not. Accordingly, we elucidated the risk factors associated with erosive esophagitis in severely obese Chinese patients. Between June 2007 and January 2009, a total of 260 Chinese patients with morbid obesity referred for bariatric surgery were enrolled in this cross-sectional study. All patients received preoperative endoscopy for evaluation of the presence and severity of erosive esophagitis. Demographic variables, anthropometric measurements, and metabolic factors were included in a logistic regression model to identify the factors predictive of erosive esophagitis. The prevalence of erosive esophagitis was 32.3%. Multiple logistic regression showed that increased waist circumference (odds ratio (OR) = 1.03, 95% confidence interval (CI) = 1.01-1.04), increased insulin resistance (OR = 1.57, 95% CI = 1.06-2.31), and presence of reflux symptoms (OR = 2.40, 95% CI = 1.22-4.74) were independent risk factors associated with erosive esophagitis. In conclusion, among Chinese patients with morbid obesity, increased waist circumference and insulin resistance were risk factors for erosive esophagitis, which highlights the critical role of visceral adiposity in the pathogenesis of erosive esophagitis.

The role of gastro-oesophageal pressure gradient and sliding hiatal hernia on pathological gastro-oesophageal reflux in severely obese patients

BACKGROUND AND AIMS

The relationship between gastro-oesophageal pressure gradient (GOPG), sliding hiatal hernia (SHH) and gastro-oesophageal reflux disease (GORD) is under investigation. We assessed whether GOPG and SHH are predictors of pathological reflux in severely obese patients.

METHODS

Ninety-four consecutive patients were prospectively studied with oesophageal manometry, 24-h pH monitoring, upper gastrointestinal endoscopy and barium swallow X-ray. Inspiratory and expiratory GOPGs were measured at manometry testing, whereas SHH was characterized by X-ray. Patients were classified as having physiological or pathological reflux depending on pH monitoring. Patients with oesophagitis but normal pH testing were excluded.

RESULTS

Eighty-nine patients composed the study sample (25 men, 38.3+/-11.1 years; BMI 45+/-6.9 kg/m). Sixty-two patients (70%) had pathological reflux, whereas 27 patients (30%) had physiological reflux. Pathological reflux was predicted either by inspiratory GOPG [prevalence ratio (PR) =1.05; 95% confidence interval (CI): 1.03-1.08; P<0.001] or by expiratory GOPG (PR=1.07; 95% CI: 1.03-1.11; P=0.001). Accordingly, an increment of 1 mmHg in inspiratory and expiratory GOPGs raises the risk of pathological reflux in 5 and 7%, respectively. Pathological reflux was also predicted by SHH (PR: 1.54, 95% CI: 1.19-2.00; P=0.001), which increases the risk of abnormal reflux in 54%.

CONCLUSION

In severely obese patients, either inspiratory GOPG, expiratory GOPG or SHH are predictors of pathological reflux. These findings give pathophysiological support to the high prevalence of GORD in this population.

[Review of the association between obesity and gastroesophageal reflux and its complications]

Esophageal adenocarcinoma and its precursor Barrett's esophagus are increasing in incidence in western populations. Gastroesophageal reflux and high body mass index (BMI) are known risk factors. Studies about Barrett's esophagus in obese patients have emphasised the role of central adiposity as a stronger risk factor than BMI in the development of specialized intestinal metaplasia and subsequently esophagus adenocarcinoma. The proinflammatory impact of adipocytokines of the abdominal fat associated with the metabolic syndrome is also relevant. Except cardiovascular diseases, type 2 diabetes and non alcoholic steatohepatitis, abdominal obesity and metabolic syndrome are responsible of an increase of prevalence of esophageal adenocarcinoma, but also other cancer sites. In this review, we study the up to date main epidemiologic and physiopathologic data concerning this association that could be important in future for a preventive action in obese patients, especially when metabolic syndrome is present.

Heartburn during sleep: a clinical marker of gastro-oesophageal reflux disease in morbidly obese patients

Gastro-oesophageal reflux disease (GORD) and morbid obesity are entities with increasing prevalence. New clinical strategies are cornerstones for their management. The aim of this study was to assess the prevalence of heartburn during sleep (HDS) and whether this symptom predicts the presence of objective GORD parameters and increased heartburn perception in morbidly obese patients. Ninety-one consecutive morbidly obese patients underwent clinical evaluation, upper gastrointestinal endoscopy and oesophageal pH monitoring. HDS was characterized when patients replied positively to the question, 'Does heartburn wake you from sleep?'. A General Score for Heartburn (GSH) ranging between 0 and 5 was assessed with the question 'How bad is your heartburn?'. HDS was reported by 33 patients (36%). More patients with HDS had abnormal acid contact time or reflux oesophagitis than patients without HDS (94%vs 57%, P < 0.001). HDS had a positive predictive value of 94% (0.95 CI 82-98), sensitivity of 48% (0.95 CI 37-60%) and specificity of 93% (0.95 CI 77-98%) for detection of GORD. A higher proportion of patients with HDS perceived heartburn preceded by acid reflux in diurnal (39%vs 9%; P < 0.001) periods during pH-metry. HDS patients showed higher GSH (2.4 +/- 0.5 vs 1.7 +/- 0.4; P < 0.0001) compared with patients who denied HDS but reported diurnal heartburn. HDS occurs in a significant minority of patients with morbid obesity and has high positive predictive value for GORD. Symptomatic reflux during the sleep seems to be a marker of increased heartburn perception in this population.

The effect of Roux-en-Y gastric bypass on gastroesophageal reflux disease in morbidly obese Chinese patients

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Eastern and Western countries. Obesity is recognized as a risk factor of gastroesophageal reflux disease. However, little information is available on the prevalence of gastroesophageal reflux disease in morbidly obese Chinese patients. The aim of this study was to compare the prevalence of GERD in Chinese patients with morbid obesity and age- and sex-matched controls, and we also assessed the effect of Roux-en-Y gastric bypass on reflux symptoms and erosive esophagitis.

METHODS

Between November 2006 and February 2008, 150 morbidly obese Chinese patients underwent laparoscopic Roux-en-Y gastric bypass. Gastroesophageal reflux disease questionnaires and esophagogastroduodenoscopy results were assessed in all cases before surgery. The prevalence of reflux symptoms and erosive esophagitis was compared with the prevalence in a database of 300 age- and sex-matched controls. We also compared baseline and postoperative characteristics at 12 months after operation.

RESULTS

Patients with morbid obesity had higher frequencies of reflux symptoms (16% vs. 8%, P = 0.01) and erosive esophagitis (34% vs. 17%, P < 0.01) than those of controls. Twelve months after laparoscopic Roux-en-Y gastric bypass, 26 patients received follow-up evaluations. In addition to substantial weight loss, the prevalence of reflux symptoms and erosive esophagitis decreased significantly after operation (19.2% vs. 0%, P = 0.05, and 42.3% vs. 3.8%, P < 0.01, respectively).

CONCLUSIONS

Gastroesophageal reflux disease is pervasive in Chinese patients with morbid obesity and Roux-en-Y gastric bypass substantially improves not only the reflux symptoms but also the erosive esophagitis.

Developments in pathogenesis and diagnosis of gastroesophageal reflux disease

PURPOSE OF REVIEW

Although gastroesophageal reflux is a common disorder, diagnosis is still imprecise. Moreover, its pathogenesis is incompletely understood. This review summarizes recent progress in diagnosis and our understanding of the pathogenesis of gastroesophageal reflux disease.

RECENT FINDINGS

Recent studies have focused on the pattern of reflux in the distal esophagus, just above the esophago-gastric junction, challenging its importance on the genesis of reflux symptoms. New techniques, such as impedance, could improve the diagnostic yield, especially in patients with nonacid reflux. Esophageal sensitivity and motility, transient lower esophageal sphincter relaxations, and hiatus hernia are important pathogenic mechanisms of reflux disease. Studies showed that obesity plays a role in the pathogenesis of reflux symptoms; a disruption of the esophago-gastric junction (leading to hiatus hernia) could allow reflux to occur. The association between reflux (particularly nonacid) and extraesophageal manifestations of gastroesophageal reflux disease has been further evaluated.

SUMMARY

Improvement of diagnostic techniques and better understanding of the pathogenesis of reflux may lead to new or better therapeutic modalities. Our understanding of some of the risk factors for reflux has been increased. Extra-esophageal manifestations and their association with gastroesophageal reflux are still a very controversial and promising area of research.