Walking and chewing reduce postprandial acid reflux

Pediatric Esophageal Disorders: Diagnosis and Treatment of Reflux and Eosinophilic Esophagitis

Gastroesophageal reflux (GER) occurs frequently in infants, generally at its worst at 4 months of age, with approximately two-thirds of infants spitting up daily. GER typically improves after 7 months of age, with only ∼5% of infants continuing to have reflux at 1 year of age. The diagnosis can often be made based on clinical symptoms. Upper GI (UGI) study has low sensitivity and specificity and should not be ordered as a diagnostic test for reflux. UGI study is best for evaluating other anatomic causes of vomiting. GER becomes problematic gastroesophageal reflux disease (GERD) when complications are present, including feeding difficulties and poor weight gain. Conservative treatment and thickened formula can be helpful for treating GERD. Proton pump inhibitors (PPIs) are frequently prescribed for treating reflux. However, studies do not show a definite benefit in infants, and there are potential side effects. Older children with GERD may present with regurgitation, heartburn, chest discomfort, dysphagia, abdominal pain, vomiting, poor appetite, or poor weight gain. Upper endoscopy is considered for children with concerning symptoms, persistent symptoms despite treatment, and relapse of symptoms after treatment. Other esophageal disorders can have a similar clinical presentation as GERD, notably eosinophilic esophagitis (EoE). EoE is a chronic immune-mediated disorder of the esophagus, which may present as dysphagia, food impaction, heartburn, vomiting, abdominal pain, feeding difficulties, or failure to thrive. Diagnosis is made histologically by the presence of esophageal eosinophilia on endoscopic biopsies in the correct clinical setting.

Unmet needs in treating laryngo-pharyngeal reflux disease: where do we go from here?

INTRODUCTION

Many patients experience ear, nose and throat symptoms associated with their gastroesophageal reflux disease. These symptoms are purportedly caused by reflux of gastroduodenal contents into the larynx, which leads to laryngopharyngeal reflux (LPR). Various modalities are used to diagnose LPR, including ambulatory pH monitoring, laryngoscopy, and esophagogastroduodenoscopy, as well as a few new emerging diagnostic tests. However, there are still no established diagnostic criteria or gold standard methodologies that can reliably distinguish LPR from other conditions.

AREAS COVERED

In this review, we will evaluate currently available diagnostic tests and therapeutic options for patients with laryngeal signs and symptoms of reflux and briefly discuss the development and emergence of new treatments. Numerous studies have investigated the role of proton pump inhibitor therapy in this patient population, but have led to disparate and often inconsistent results. Expert commentary: While a subgroup of patients with LPR appears to respond to PPI therapy, many patients show no symptomatic improvement, particularly with respect to extraesophageal symptoms. As such, there is a vital need to explore alternative treatment options, including anti-reflux surgery, lifestyle changes, and other classes of medications to better address LPR.

The influence of physical strain on esophageal motility in healthy volunteers studied with gas-perfusion manometry

BACKGROUND

The influence of physical strain on the esophageal motility has already been examined in a number of studies. It was found that high physical strain compromises the sufficient contractility of the esophagus. However, it needs more examinations to verify these findings.

METHODS

To validate these results healthy volunteers were examined using gas-perfusion manometrie. Bicycle ergometry was performed to generate an exactly defined physical exercise. After a pilot study, the changing of the contraction amplitude was determined as the main variable to evaluate the esophageal motility, and the sample size was calculated. Eight subjects without esophageal diseases or symptoms were examined by simultaneous gas-perfusion esophageal manometry and bicycle ergometry.

KEY RESULTS

The results showed that high physical strain during bicycle ergometry can induce a significant decrease of the contraction amplitude (α = 5%, β = 10%). The 95% confidence interval of the quotient of contraction amplitude at rest and under physical strain is (1.074; 1.576). This effect is more pronounced in liquid acts of swallowing than in dry and is also more obvious at the middle measuring point (7.8 cm above the lower esophageal sphincter) than at the distal and proximal point (2.8 and 12.8 cm). Furthermore, a decreasing tendency of the contraction duration could be found.

CONCLUSIONS & INTERFERENCES

Gas-perfusion manometry is an inexpensive examination method, which enables the evaluation of the esophageal motility in moving test subjects under conditions of physical strain. It could be proved that physical strain negatively influences the esophageal motility by a decrease of the contraction amplitude.

Management of gastroesophageal reflux disease in pediatric patients: a literature review

Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, is a physiologic process that occurs throughout the day in healthy infants and children. Gastroesophageal reflux disease (GERD) occurs when gastric contents flow back into the esophagus and produce symptoms. The most common esophageal symptoms are vomiting and regurgitation. Lifestyle changes are the first-line therapy in both GER and GERD; medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. The laparoscopic Nissen antireflux procedure is the gold standard for the treatment of this pathology. A literature search on PubMed and Cochrane Database was conducted with regard to the management of GERD in children to provide a view of state-of-the-art treatment of GERD in pediatrics.

Influence of exercise testing in gastroesophageal reflux in patients with gastroesophageal reflux disease

Background

Gastroesophageal reflux disease is a worldwide prevalent condition that exhibits a large variety of signs and symptoms of esophageal or extra-esophageal nature and can be related to the esophagic adenocarcinoma. In the last few years, greater importance has been given to the influence of physical exercises on it. Some recent investigations, though showing conflicting results, point to an exacerbation of gastroesophageal reflux during physical exercises.

Aim

To evaluate the influence of physical activities in patients presenting with erosive and non erosive disease by ergometric stress testing and influence of the lower esophageal sphincter tonus and body mass index during this situation.

Methods

Twenty-nine patients with erosive disease (group I) and 10 patients with non-erosive disease (group II) were prospectively evaluated. All the patients were submitted to clinical evaluation, followed by upper digestive endoscopy, manometry and 24 h esophageal pH monitoring. An ergometric testing was performed 1 h before removing the esophageal pH probe. During the ergometric stress testing, the following variables were analyzed: test efficacy, maximum oxygen uptake, acid reflux duration, gastroesophageal reflux symptoms, influence of the lower esophageal sphincter tonus and influence of body mass index in the occurrence of gastroesophageal reflux during these physical stress.

Results

Maximum oxigen consumption or VO 2 max, showed significant correlation when it was 70% or higher only in the erosive disease group, evaluating the patients with or without acid reflux during the ergometric testing (p=0,032). The other considered variables didn't show significant correlations between gastroesophageal reflux and physical activity (p>0,05).

Conclusions

1) Highly intensive physical activity can predispose the occurrence of gastroesophageal reflux episodes in gastroesophageal reflux disease patients with erosive disease; 2) light or short sessions of physical activity have no influence on reflux, regardless of body mass index; 3) the lower esophageal sphincter tonus does not influence the occurrence of reflux disease episodes during exercise testing.

Dinner-to-bed time and post-dinner walk: new potential independent factors in esophageal cancer development

PURPOSE

Esophageal squamous cell carcinoma (ESCC) remains a significant cause of morbidity and mortality worldwide. The aim of the study was to investigate the effects of shorter dinner-to-bed time and post-dinner walk on ESCC risk.

METHODS

A matched case-control study with 232 ESCC patients and 286 age- and gender-matched healthy controls enrolled was conducted. Conditional logistic regression was used to calculated odds ratio (OR) and 95 % confidence intervals (95 % CI).

RESULTS

The adjusted ORs of ESCC for subjects with shorter dinner-to-bed time (<3 h) were 2.84 (95 % CI 1.64-4.29), relative to those with longer dinner-to-bed time (≥4 h). While post-dinner walk was associated with a decreased ESCC risk (adjusted OR 0.64; 95 % CI 0.41-0.89). What's more, when reflux symptom was added into the multivariate models, risk estimate for shorter dinner-to-bed time still remained statistically significant (p = 0.003), and risk estimate for post-dinner walk changed slightly. In the subgroup analysis stratified by post-dinner walk, subjects with shorter dinner-to-bed time experienced similar risk (adjusted ORs 2.71 vs. 2.82).

CONCLUSIONS

Shorter dinner-to-bed time is a potential risk factor for ESCC and post-dinner walk is a protective factor, providing evidence for the effect of lifestyle factors on ESCC risk.

Gastroesophageal reflux: management guidance for the pediatrician

Recent comprehensive guidelines developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition define the common entities of gastroesophageal reflux (GER) as the physiologic passage of gastric contents into the esophagus and gastroesophageal reflux disease (GERD) as reflux associated with troublesome symptoms or complications. The ability to distinguish between GER and GERD is increasingly important to implement best practices in the management of acid reflux in patients across all pediatric age groups, as children with GERD may benefit from further evaluation and treatment, whereas conservative recommendations are the only indicated therapy in those with uncomplicated physiologic reflux. This clinical report endorses the rigorously developed, well-referenced North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines and likewise emphasizes important concepts for the general pediatrician. A key issue is distinguishing between clinical manifestations of GER and GERD in term infants, children, and adolescents to identify patients who can be managed with conservative treatment by the pediatrician and to refer patients who require consultation with the gastroenterologist. Accordingly, the evidence basis presented by the guidelines for diagnostic approaches as well as treatments is discussed. Lifestyle changes are emphasized as first-line therapy in both GER and GERD, whereas medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. Recent black box warnings from the US Food and Drug Administration are discussed, and caution is underlined when using promoters of gastric emptying and motility. Finally, attention is paid to increasing evidence of inappropriate prescriptions for proton pump inhibitors in the pediatric population.

Therapeutic strategies for laryngeal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease is increasingly associated with ear, nose, and throat symptoms, including laryngitis. Many patients are unaware of the gastroesophageal etiology of their symptoms. A variety of criteria are used to diagnose this condition, including laryngoscopy, esophagogastroduodenoscopy, and the use of ambulatory pH and impedance monitoring. However, no test serves as the gold standard for the diagnosis given their lack of sensitivity and specificity for reflux disease. Numerous trials have assessed the role of proton pump inhibitor therapy in patients with laryngopharyngeal reflux and most have revealed no benefit to acid suppression over placebo. Despite many uncertainties there has been some progress regarding the role of acid-suppressive therapy as well as other agents in this unique group of patients. In this review we explore therapeutic options and their rationale for patients with laryngeal signs and symptoms.

Gum chewing during pre-anesthetic fasting

Many ad hoc fasting guidelines for pre-anesthetic patients prohibit gum chewing. We find no evidence that gum chewing during pre-anesthetic fasting increases the volume or acidity of gastric juice in a manner that increases risk, nor that the occasional associated unreported swallowing of gum risks subsequent aspiration. On the contrary, there is evidence that gum chewing promotes gastrointestinal motility and physiologic gastric emptying. Recommendations against pre-anesthetic gum chewing do not withstand scrutiny and miss an opportunity to enhance comfort and sense of wellbeing for patients awaiting anesthesia. Gum chewing during the pre-anesthetic nil per os (NPO) period would also permit the development of gum-delivered premedications and should be permitted in children old enough to chew gum safely. Gum chewing should cease when sedatives are given and all patients should be instructed to remove any chewing gum from the mouth immediately prior to anesthetic induction.

Change of gastric emptying with chewing gum: evaluation using a continuous real-time C breath test (BreathID system)

Background/Aims

There are few reports on the correlation between chewing gum and the gastrointestinal functions. But previous report showed use of chewing gum to be an effective method for controlling gastrointestinal symptoms. The aim of this study was to determine the correlation between chewing gum and gastric emptying using the continuous real time ¹³C breath test (BreathID system).

Methods

Ten healthy male volunteers participated in this randomized, 2-way crossover study. The subjects fasted overnight and were randomly assigned to chewing gum (Xylish, 2-3/1 tablet) for an hour following intake of a test meal (200 kcal/200 mL) or intake of the test meal alone. Gastric emptying was monitored for 4 hours after administration of the test meal by the ¹³C-acetic acid breath test performed continually using the BreathID system.

Results

No significant differences in the calculated parameters, namely, T_1/2 (median, 111.82 vs 109.26 minutes; P = 0.575), T_lag (median, 53.28 vs 56.53 minutes; P = 0.333), gastric emptying coefficient (median, 3.58 vs 3.65; P = 0.285), regression-estimated constant β (median, 1.85 vs 1.80; P = 0.575) and regression-estimated constant κ (median, 0.61 vs 0.62; P = 0.959) were observed between the test meal alone group and the test meal and chewing gum group.

Conclusions

This study showed that chewing gum had no effect on the rate of gastric emptying. Therefore, since chewing gum did not enhance the speed of gastric emptying, it may ameliorate gastrointestinal symptoms through other mechanisms, such as saliva and autonomic nervous system.

Assessment and management of dental erosion

Studies have shown a growing trend toward increasing prevalence of dental erosion, associated with the declining prevalence of caries disease in industrialized countries. Erosion is an irreversible chemical process that results in tooth substance loss and leaves teeth susceptible to damage as a result of wear over the course of an individual's lifetime. Therefore, early diagnosis and adequate prevention are essential to minimize the risk of tooth erosion. Clinical appearance is the most important sign to be used to diagnose erosion. The Basic Erosive Wear Examination (BEWE) is a simple method to fulfill this task. The determination of a variety of risk and protective factors (patient-dependent and nutrition-dependent factors) as well as their interplay are necessary to initiate preventive measures tailored to the individual. When tooth loss caused by erosive wear reaches a certain level, oral rehabilitation becomes necessary.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Dental Erosion

There is some evidence that dental erosion is steadily spreading. To diagnose erosion, dental professionals have to rely on clinical appearance, as there is no device available to detect it. Adequate preventive measures can only be initiated if the different risk factors and potential interactions between them are known. When substance loss, caused by erosive tooth wear, reaches a certain degree, oral rehabilitation becomes necessary. Prior to the most recent decade, the severely eroded dentition could only be rehabilitated by the provision of extensive crown and bridgework or removable dentures. As a result of the improvements in composite restorative materials and in adhesive techniques, it has become possible to rehabilitate eroded dentitions in a less invasive manner.

Diet and lifestyle modifications in the management of gastroesophageal reflux disease

Gastroesophageal reflux disease is a chronic condition affecting 44% of the American population at least once a month, with daily occurrences affecting about 7% of the population. It is the most common gastrointestinal-related diagnosis given by physicians during clinic visits in the United States. Treatment of this disease is a step-wise approach that includes diet and lifestyle interventions as well as medications titrated based on symptom severity. This article reviews dietary and lifestyle factors that contribute to the physiology and symptoms of gastroesophageal reflux disease and modification of these factors as an adjunctive therapy.

Influencia del estilo de vida en la enfermedad por reflujo gastroesofágico

The prevalence of the symptoms of reflux (hearthburn and acid regurgitation) and of gastro-esophageal reflux disease is high. Numerous lifestyle modifications have been advocated in the prognosis of reflux. Obesity, the decubitus, eating rapidly, tobacco, alcohol and exercise provoke symptoms of the reflux (hearthburn and acid regurgitation). The proportion of fat in the food and stress aren't factors associated with reflux. Some works point at the chocolate, at the acid juices, at the carbonated beverages and at the onions as factors that unleash symptoms of reflux. Nevertheless larger prospective controlled trials are warranted. Gum-chewing after eating, keep standing up and to go to bed 4 h after dinner improves the symptoms of the reflux and the gastro-esophageal reflux disease.

The effect of chewing sugar-free gum on gastro-esophageal reflux

Regurgitated acid entering the mouth in gastro-esophageal reflux disease can cause dental erosion. Chewing gum could induce increased swallowing frequency, thus improving the clearance rate of reflux within the esophagus. The null hypothesis of this study was that chewing gum does not have any effect on the clearance of reflux from the distal esophagus. Thirty-one subjects presenting with symptoms of reflux were given a refluxogenic meal twice and were randomly selected to chew gum for half an hour after eating the meal. Esophageal pH was measured, and pH data were analyzed and compared during the postprandial periods for 2 hrs on the 2 occasions. The median (IQ range) values for the % time pH < 4 during the postprandial period without chewing gum were 5.7 (1.7-13.5) and, with chewing gum, 3.6 (0.3-7.3), respectively (p = 0.001). Chewing sugar-free gum for half an hour after a meal can reduce acidic postprandial esophageal reflux.

The MediChew®technology platform

A few decades ago, chewing gum was rarely considered when industry searched for an applicable delivery vehicle for an active pharmaceutical substance. Yet, the 1980s and 1990s saw gum become the most successful nicotine delivery form; unawareness changed to cautious scepticism, and today the merits of chewing gum drug delivery technologies are generally appreciated. MediChew is the registered trademark of Fertin Pharma's medical chewing gum technology platform. Based on patent-protected technologies, it offers unique taste-masking possibilities and allows control of drug molecule release. Medical chewing gum products based on these technologies are specifically suitable for convenient administration on demand, for active substances providing a topical effect in the oral cavity and throat, and for systemic delivery of drug molecules that readily cross the oromucosal membranes.

[Reflux esophagitis]

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