Long-term prospective follow-up of endoscopic oesophagitis in southern Chinese--prevalence and spectrum of the disease

Consensus statements and recommendations on the management of mild-to-moderate gastroesophageal reflux disease in the Southeast Asian region

This paper reports the proceedings from the first consensus meeting on the management of mild-to-moderate gastroesophageal reflux disease (GERD) in the Southeast Asian (SEA) region. Seventeen statements were drawn up by a steering committee that focused on epidemiology, mechanism of action, diagnostic investigations, and treatment. Voting on the recommendations used the Delphi method with two rounds of voting among the 10 panel members. The consensus panel agreed that GERD is mostly a mild disease in the SEA region with predominantly non-erosive reflux disease (NERD). Complicated GERD and Barrett's esophagus are infrequently seen. The panel recommended endoscopy in patients with alarm or refractory symptoms but cautioned that the incidence of gastric cancer is higher in SEA. pH and impedance measurements were not recommended for routine assessment. The acid pocket is recognized as an important pathogenic factor in GERD. Lifestyle measures such as weight reduction, avoidance of smoking, reduction of alcohol intake, and elevation of the head of the bed were recommended but strict avoidance of specific foods or drinks was not. Alginates was recommended as the first-line treatment for patients with mild-to-moderate GERD while recognizing that proton-pump inhibitors (PPIs) remained the mainstay of treatment of GERD. The use of alginates was also recommended as adjunctive therapy when GERD symptoms were only partially responsive to PPIs.

The global prevalence of Barrett's esophagus: A systematic review of the published literature

BACKGROUND

Determining the prevalence of Barrett's esophagus is important for defining screening strategies. We aimed to synthesize the available data, determine Barrett's esophagus prevalence, and assess variability.

METHODS

Three databases were searched. Subgroup, sensitivity, and meta-regression analyses were conducted and pooled prevalence was computed.

RESULTS

Of 3510 studies, 103 were included. In the general population, we estimated a prevalence for endoscopic suspicion of Barrett's esophagus of (a) any length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.85-1.07), (b) ≥1 cm of length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.75-1.18) and (c) for any length with histologic confirmation of columnar metaplasia as 3.89% (95% confidence interval: 2.25-5.54) . By excluding studies with high-risk of bias, the prevalence decreased to: (a) 0.70% (95% confidence interval: 0.61-0.79) and (b) 0.82% (95% confidence interval: 0.63-1.01). In gastroesophageal reflux disease patients, we estimated the prevalence with afore-mentioned criteria to be: (a) 7.21% (95% confidence interval: 5.61-8.81) (b) 6.72% (95% confidence interval: 3.61-9.83) and (c) 7.80% (95% confidence interval: 4.26-11.34). The Barrett's esophagus prevalence was significantly influenced by time period, region, Barrett's esophagus definition, Seattle protocol, and study design. There was a significant gradient East-West and North-South. There were minimal to no data available for several countries. Moreover, there was significant heterogeneity between studies.

CONCLUSION

There is a need to reassess the true prevalence of Barrett's esophagus using the current guidelines in most regions. Having knowledge about the precise Barrett's esophagus prevalence, diverse attitudes from educational to screening programs could be taken.

Safety and long-term outcomes of early gastric cardiac cancer treated with endoscopic submucosal dissection in 499 Chinese patients

AIMS

Early gastric cardiac cancer (EGCC) has a low risk of lymph node metastasis with the potential for endoscopic therapy. We aimed to evaluate the short- and long-term outcomes of endoscopic submucosal dissection (ESD)-resected EGCCs in a large cohort of Chinese patients and compare endoscopic and clinicopathologic features between EGCC and early gastric non-cardiac cancer (EGNC).

METHODS

We retrospectively studied 512 EGCCs in 499 consecutive patients and 621 EGNCs in 555 consecutive patients between January 2011 and March 2018 at our center. We investigated clinicopathological characteristics of EGCC tumors, ESD treatment results, adverse events, and postresection patient survival.

RESULTS

Compared with EGNC patients, EGCC patients were significantly older (average age: 66 years versus 62 years, p < 0.001). The percentage of the gross 0-IIc pattern was higher in EGCCs (46.1%) than in EGNCs (41.5%), while the frequency of the 0-IIa pattern was lower in EGCCs (14.9%) than in EGNCs (22.4%) (p = 0.001). Compared with EGNCs, EGCCs showed smaller size, deeper invasion, fewer ulcerated or poorly differentiated tumors, but more cases with gastritis cystica profunda. The prevalence of ESD-related complications was higher in EGCCs (6.1%) than in EGNCs (2.3%) (p = 0.001). In EGCCs, the disease-specific survival rate was significantly higher in patients of the noncurative resection group with surgery (100%), compared with that (93.9%) without surgery (p < 0.001).

CONCLUSION

Clinicopathological characteristics were significantly different between EGCCs and EGNCs. ESD is a safe and effective treatment option with favorable outcomes for patients with EGCC. Additional surgery improved survival in patients with noncurative ESD resection.

Systematic review and meta-analysis of prevalence and risk factors for Barrett's esophagus

BACKGROUND AND AIMS

Although screening for Barrett's esophagus (BE) is recommended in individuals with multiple risk factors, the type and number of risk factors necessary to trigger screening is unclear. In this systematic review and meta-analysis, we aimed to assess the relationship between number of risk factors and prevalence of BE.

METHODS

Through October 17, 2018 we searched studies that described the prevalence of BE in the general population and based on presence of risk factors that included GERD, male gender, age >50 years, family history of BE and esophageal adenocarcinoma, and obesity (defined as body mass index >35). Risk of BE based on number of risk factors was assessed using meta-regression while controlling for potential confounders.

RESULTS

Of 2741 studies, 49 were included in the analysis (307,273 individuals, 1948 with biopsy specimen-proven BE). Indications varied by study. The prevalence of BE for various populations was as follows: low-risk general population, .8% (95% confidence interval [CI], .6%-1.1%); GERD, 3% (95% CI, 2.3%-4%); GERD plus presence of any other risk factor, 12.2% (95% CI, 10.2%-14.6%); family history, 23.4% (95% CI, 13.7% -37.2%); age >50, 6.1% (95% CI, 4.6%-8.1%); obesity, 1.9% (95% CI, 1.2%-3%); and male sex, 6.8% (95% CI, 5.3%-8.6%). Prevalence of BE varied significantly between Western and non-Western populations. In a meta-regression, controlling for the region of the study, age, and gender, there was a positive linear relationship between the number of risk factors and the prevalence of BE.

CONCLUSIONS

Results of this study provide estimates of BE prevalence based on the presence and the number of risk factors. These results add credence to current guidelines that suggest screening in the presence of multiple risk factors.

Helicobacter pylori infection reduces the risk of Barrett's esophagus: A meta-analysis and systematic review

INTRODUCTION

The prevalence of Helicobacter pylori infection (HPI) has been decreasing in developed countries, with an increasing prevalence of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) at the same time. The aim of our meta-analysis was to quantify the risk of BE in the context of HPI.

METHODS

A systematic search was conducted in 3 databases for studies on BE with data on prevalence of HPI from inception until December 2016. Odds ratios for BE in HPI were calculated by the random effects model with subgroup analyses for geographical location, presence of dysplasia in BE, and length of the BE segment.

RESULTS

Seventy-two studies were included in the meta-analysis, including 84 717 BE cases and 390 749 controls. The overall analysis showed that HPI reduces the risk of BE; OR = 0.68 (95% CI: 0.58-0.79, P < .001). Subgroup analyses revealed risk reduction in Asia OR = 0.53 (95% CI: 0.33-0.84, P = .007), Australia OR = 0.56 (95% CI: 0.39-0.80, P = .002), Europe OR = 0.77 (95% CI: 0.60-0.98, P = .035), and North-America OR = 0.59 (95% CI: 0.47-0.74, P < .001). The risk was significantly reduced for dysplastic BE, OR = 0.37 (95% CI: 0.26-0.51, P < .001) for non-dysplastic BE, OR = 0.51 (95% CI: 0.35-0.75, P = .001), and for long segment BE, OR = 0.25 (95% CI: 0.11-0.59, P = .001) in case of HPI.

CONCLUSIONS

This extensive meta-analysis provides additional evidence that HPI is associated with reduced risk of BE. Subgroup analyses confirmed that this risk reduction is independent of geographical location. HPI is associated with significantly lower risk of dysplastic, non-dysplastic, and long segment BE.

Weight loss and waist reduction is associated with improvement in gastroesophageal disease reflux symptoms: A longitudinal study of 15 295 subjects undergoing health checkups

BACKGROUND

General obesity and abdominal obesity is an established risk factor of gastroesophageal reflux disease (GERD). However, the influence of weight or waist change on improvement of GERD is unclear. Our aim was to investigate if weight loss or waist reduction improves GERD symptoms and esophagitis.

METHODS

A retrospective longitudinal study of 15 295 subjects who underwent gastroscopy for a health checkup and reported GERD symptoms between 2011 and 2013, and repeated a checkup until 2014 was conducted. The improvement of GERD symptoms and esophagitis according to weight loss (≥-2, -0.5 to -2 kg/m² in body mass index [BMI]), waist reduction (≥-5, -0.1 to -0.5 cm) and baseline BMI/waist circumference (WC) categories was assessed using logistic regression.

KEY RESULTS

Weight loss or waist reduction was associated with improvement in GERD symptoms only in subjects with general or abdominal obesity. Among subjects with general obesity (BMI ≥25 kg/m² ) and decreased ≥2 kg/m² in BMI, the adjusted odds ratio (OR) of improvement in GERD symptoms was 2.34 (95% confidence interval [CI] 1.70-2.83). Among subjects with abdominal obesity (WC ≥90 cm) and decreased ≥5 cm in WC, the corresponding OR was 2.16 (95% CI 1.56-2.90). There was no association between weight loss or waist reduction and improvement in esophagitis.

CONCLUSIONS & INFERENCES

Weight loss or waist reduction was associated with improvement in GERD symptoms only in subjects with general or abdominal obesity. Weight loss or waist reduction will be an important treatment option in obese patients.

Application of the Prague C and M criteria for endoscopic description of columnar-lined esophagus in South Korea

AIM: To ascertain whether the Prague circumferential (C) length and maximal (M) length criteria for grading the extent of Barrett’s esophagus can be applied prior to its widespread application in South Korea.

METHODS: Two hundred and thirteen consecutive cases with endoscopic columnar-lined esophagus (CLE) were included and classified according to the Prague C and M criteria.

RESULTS: Of 213 cases with CLE, the distribution of maximum CLE lengths was: 0.5-0.9 cm in 99 cases (46.5%); 1.0-1.4 cm in 63 cases (29.6%); 1.5-1.9 cm in 15 cases (7.0%); 2.0-2.4 cm in 14 cases (6.6%); 2.5-2.9 cm in 1 case (0.5%); and 7.0 cm in 1 case (0.5%). Twenty cases (9.4%) had columnar islands alone. Two hundred and eight cases (97.7%) lacked the circumferential CLE component (C0Mx). Columnar islands were found in 70 cases (32.9%), of which 20 cases (9.4%) had columnar islands alone.

CONCLUSION: In regions where most CLE patients display short or ultrashort tongue-like appearance, more detailed descriptions of CLE’s in < 1.0 cm lengths and columnar islands, as well as avoidance of repeating the prefix “C0” need to be considered in parallel with the widespread application of the Prague system in South Korea.

Prevalence of Barrett's Esophagus in Asian Countries: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The prevalence and risk factors of Barrett's esophagus (BE) in Asian countries are unclear. Studies report a wide range of BE prevalence in Asian countries. We conducted a systematic review and meta-analysis to examine the prevalence of BE and its temporal changes and risk factors in Asian countries.

METHODS

Two investigators performed independent literature searches by using PubMed and EMBASE databases, and subsequent data abstraction for studies had to meet several set inclusion and exclusion criteria. Pooled BE prevalence was calculated by using a random-effect model. Estimates of relative risk for possible risk or protective factors were also calculated.

RESULTS

A total of 51 studies (N = 453,147), mainly from Eastern Asia, were included. The pooled prevalence of endoscopic BE was 7.8% (95% confidence interval, 5.0-12.1; 23 studies) and of histologically confirmed BE was 1.3% (95% confidence interval, 0.7-2.2; 28 studies). Most of histologic BE (82.1%) was short-segment BE (<3 cm). There was a trend toward an increase in prevalence of BE over time from 1991 to 2014, especially in Eastern Asian countries. Within BE cohorts, pooled prevalence of low-grade dysplasia, high-grade dysplasia, and esophageal adenocarcinoma was 6.9%, 3.0%, and 2.0%, respectively. Reflux symptoms, male sex, hiatus hernia, and smoking were associated with a significantly increased risk of histologic BE in patients with BE compared with patients without BE. However, half of the patients with histologic BE did not have reflux symptoms.

CONCLUSIONS

BE is not uncommon in Asian countries and seems to share similar risk factors and potential for neoplastic progression to those seen in Western countries.

Comparison of gastro-oesophageal junction carcinomas in Chinese versus American patients

AIMS

To compare the clinical and pathological features of gastro-oesophageal junction (GEJ) carcinomas in Chinese and American patients.

METHODS AND RESULTS

Eighty consecutive patients with a GEJ carcinoma (43 from mainland China, and 37 from the USA) were evaluated for association with Barrett oesophagus (BO), chronic Helicobacter pylori gastritis, intestinal metaplasia, and outcome. GEJ carcinomas were defined as tumours that were located within 20 mm of, and crossed, the GEJ. Overall, GEJ carcinomas from Chinese patients revealed significantly more frequent location in the proximal stomach, higher pathological stage, larger size, younger patient age, and association with chronic H. pylori gastritis. In contrast, GEJ cancers from American patients showed a strong association with distal oesophageal location, BO, and associated intestinal metaplasia and dysplasia. Pathologically, GEJ carcinomas from American patients were predominantly adenocarcinomas, whereas Chinese patients showed a higher proportion of mucinous, adenosquamous, acinar or neuroendocrine tumours. Overall, 3- and 5-year survival rates were statistically similar between both patient groups, but upon multivariate analysis, Chinese patients showed statistically better survival rates for stage III tumours.

CONCLUSIONS

Most GEJ carcinomas in patients from China represent proximal gastric cancers associated with chronic H. pylori gastritis, and BO-associated carcinomas are rare among this patient population.

Barrett's oesophagus in Asians--are ethnic differences due to genes or the environment?

Ethnic differences in the prevalence of gastro-oesophageal reflux disease (GORD) and its complications, including Barrett's oesophagus (BO), are well described in multiracial Asian patient populations. These findings together with familial aggregation of GORD symptoms and twin studies suggest the possibility of a genetic component to GORD. Nevertheless, environmental factors, e.g. Helicobacter pylori infection, abdominal adiposity and metabolic syndrome, could equally account for these differences. Indian (South Asian) race is a risk factor for Barrett' oesophagus. This may be related to the Caucasian genetic make-up of Indians as opposed to an Oriental one as is the case of most other Asians. The HLA-B07 gene commonly found in South Asian and Caucasian populations, but not Orientals, may confer an increased risk for BO. Nevertheless, the high prevalence of H. pylori in South Asians and the consequent atrophic gastritis and hypochlorhydria may partially ameliorate this genetic predisposition to BO. The higher prevalence of obesity and the metabolic syndrome amongst certain Asiatic races may also contribute to the observed increased risk for BO. Future research should target the search for GORD/BO genes, ethnic differences in parietal cell mass and hiatal hernia, H. pylori colonization factors (e.g. MUC1 and MUC2) and adhesion molecules (BabA). Racial differences in lifestyle factors, i.e. abdominal adiposity, consumption of fruit and vegetables as well as smoking, should all be investigated as potential causes for this interethnic variation in GORD and BO. Nature or nurture, the clues are teasing and tantalizing and illustrate the complex relationship between the genetic make-up of man and the environment.

Risk factors for Barrett's esophagus in Indian patients with gastroesophageal reflux disease

BACKGROUND AND AIMS

Barrett's esophagus (BE) is reported to be infrequent in Asians, with no data from India regarding its prevalence and risk factors. We investigated the frequency and risk factors of columnar mucosa with or without specialized intestinal metaplasia (SIM) in Indian patients with gastroesophageal reflux disease (GERD).

METHODS

A total of 278 GERD patients over 2 years underwent gastroscopy and completed a questionnaire for possible BE risk factors. Patients with columnar mucosa on endoscopy underwent four-quadrant biopsy; BE was histologically defined as columnar mucosa with or without SIM. Patients without columnar mucosa at endoscopy were considered as controls and compared to patients with BE and those with SIM.

RESULTS

Forty-six patients with GERD had columnar mucosa on histology (16.54%); 25 (8.99%) of these had SIM. The risk factors for BE were the presence of hiatus hernia (odds ratio [OR]: 3.14; 95% confidence interval [CI]: 1.2-8.17) and a history of eructation (OR: 2.28; CI: 1.11-4.66). The risk factors for SIM were age ≥ 45 years (OR: 2.63; CI: 1.03-6.71), hiatus hernia (OR: 3.95; CI: 1.24-12.56), and a history of eructation (OR: 3.41; CI: 1.19-9.78). Sex, severity of symptoms, dietary factors, tobacco or alcohol use, and body mass index were not associated with BE. The median circumferential segment length was 2 (1-10) cm, and the maximal length was 3 (2-11) cm in both groups.

CONCLUSION

BE is not an uncommon finding among Indian GERD patients. Age ≥ 45 years, history of eructation, and the presence of hiatus hernia are associated with SIM.

Barrett's Esophagus in an Area with an Exceptionally Low Prevalence of Helicobacter pylori Infection

Objective. This study was undertaken to gain an insight into the relationship between Helicobacter pylori (H. pylori) infection, Barrett's esophagus and reflux esophagitis in an area of exceptionally low prevalence of H. pylori infection. Methods. A total of 1895 consecutive upper endoscopies performed between January 2005 and July 2007 were reviewed. 120 cases of columnar-lined esophagus and endoscopic esophagitis were evaluated. H. pylori infection was determined using the urease test and/or histology. Results. The rate of endoscopic esophagitis was 5.49% (80 Malays, 24 non-Malays) while histological reflux esophagitis was found in 3.75% (56 Malays, 15 non-Malays). Barrett's esophagus was present in 0.79% (11 Malays, 4 non-Malays). H. pylori infection was present in 8/120 or 6.67% subjects. Conclusion. The low rate of Barrett's esophagus in this population does not support the hypothesis that the absence of H. pylori infection is more than a minor risk factor for Barrett's esophagus.

From GERD to Barrett's esophagus: is the pattern in Asia mirroring that in the West?

Gastroesophageal reflux disease (GERD) is a known predisposing factor for Barrett's esophagus. Amongst individuals with symptomatic GERD, the prevalence of Barrett esophagus is estimated to be more than 10%, and an individual with Barrett's esophagus is more likely than the general population to develop esophageal adenocarcinoma. In Western Europe and North America, incidence of esophageal adenocarcinoma had been on the upward trend for many decades. In comparison, although the prevalence of GERD and reflux esophagitis has increased several fold in some parts of Asia, the prevalence of esophageal adenocarcinoma and Barrett's esophagus remains generally low in the region. Rising incidence of esophageal adenocarcinoma has been observed in regions witnessing increasing prevalence of GERD. If the recent increase in prevalence of GERD in parts of urbanized Asia is any indication of the beginning of an upsurge in the incidence of Barrett's esophagus and associated adenocarcinoma, would we be witnessing a pattern of epidemiological shift mirroring that in the West? Given that more than 90% of Barrett's esophagus in Asian patients is of the short-segment type, which is reported to have lesser propensity to develop to adenocarcinoma, could the ongoing epidemiologic transition take Asia on the same trail as that which the West has taken? This article will draw on relevant findings from various parts of Asia and take an in-depth look at prevailing disease trends to see where Asia stands now in the changing epidemiology of GERD, Barrett's esophagus and associated adenocarcinoma.

Current status of Barrett's esophagus research in Asia

In Western countries, the epidemiology of esophageal cancer has changed considerably over the past decades with a rise in the ratio of adenocarcinoma to squamous cell carcinoma. Although the prevalence of gastroesophageal reflux is increasing in Asia, the prevalences of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) have remained low in most Asian countries. The Asian Barrett's Consortium recently conducted a review of published studies on BE from Asia to assess the current status of BE research in Asia, and to recommend potential areas for future BE research in the region. Differences in study design, enrolled population, and endoscopic biopsy protocols used have led to substantial variability in the reported BE prevalence (0.06% to 19.9%) across Asia. In particular, some Japanese studies used diagnostic criteria that differed considerably from what was used in most Asian studies. As in Western countries, increased age, male sex, tobacco smoking, reflux symptoms, and erosive esophagitis have been found to be risk factors for BE in several case-control studies from Asia. The Prague C and M criteria, developed to provide better interobserver reliability in diagnosis and grading of BE, are currently under extensive evaluation in the Asian population. There is a need for standardized protocols for endoscopic and histopathologic diagnosis before initiating collaborative projects to identify etiologic determinants of BE and its ensuing malignant transformation. At present, data regarding the management and long-term outcome of BE are extremely limited in Asia. More studies of BE in this geographic area are warranted.

Gastroesophageal reflux disease in Asia: A historical perspective and present challenges

Gastroesophageal reflux disease (GERD), previously uncommon in Asia, has now become an important disease in the region. Although much variability exists between studies, most endoscopy-based studies show a prevalence of erosive esophagitis of more than 10%. Symptom-based studies also show a prevalence of 6-10%. Two longitudinal follow-up studies on GERD symptoms have shown an increase with time, and several endoscopy-based time trend studies have also shown a significant increase in erosive reflux esophagitis. Studies on Barrett's esophagus have been confounded by the description of short (SSBE) and long segment (LSBE) Barrett's esophagus. Great variation in prevalence rates has been reported. SSBE vary from 0.1% to more than 20% while LSBE vary from 1-2%. Of the putative causative factors, obesity has been the most important. Many studies have linked GERD-esophagitis as well as occurrence of reflux symptoms with an increase in body mass index (BMI), obesity, especially visceral or central obesity, and metabolic syndrome. A decline in Helicobacter pylori infection with growing affluence in Asia has been broadly thought to result in healthier stomachs and a higher gastric acid output resulting in reflux disease. However, variable results have been obtained from association and H. pylori eradication studies.

[Diagnosis of gastroesophageal reflux disease: a systematic review]

The prevalence of gastoesophageal reflux disease (GERD) has been rapidly increased in Korea during last 20 years. However, there has been no systematic review regarding this disease. The aim of this article was to provide a review of available diagnostic modalities for GERD. This review includes proton pump inhibitor (PPI) test, endoscopy, ambulatory pH monitoring, impedance pH monitoring, and esophageal manometry in order to provide a basis for the currently applicable recommendations in the diagnosis of GERD in Korea. With weekly heartburn or acid regurgitation, the prevalence of GERD has been reported as 3.4% to 7.9%, indicating an increase of GERD in Korea. As the prevalence of Barrett's esophagus has been reported to be low, the screening endoscopy for Barrett's esophagus is not recommended. Several recent meta-analyses re-evaluated the value of the PPI test in patients with typical GERD symptoms and non-cardiac chest pain. That is, the PPI test has been proven to be a sensitive tool for diagnosing GERD in patients with non-cardiac chest pain and in some preliminary trials regarding extraesophageal manifestations of GERD. Ambulatory pH monitoring of the esophagus helps to confirm gastroesophageal reflux in patients with persistent symptoms (both typical and atypical) in the absence of esophageal mucosal damage, especially when a trial of acid suppression has failed. Impedance pH test is useful in refractory reflux patients with primary complaints of typical GERD symptoms, but this value has not been proved in patients with non-cardiac chest pain or extraesophageal symptoms. This systematic review is targeted to establish the strategy of GERD diagnosis, which is essential for the current clinical practice.

Trends of Gastrointestinal Diseases at a Single Institution in Korea over the Past Two Decades

Background/Aims

The lifestyle changes that have accompanied economic growth have influenced disease patterns in Korea. Changing patterns of gastrointestinal (GI) diseases over the past two decades were investigated in the present study.

Methods

Data from inpatients with specific GI diseases, as defined by the International Classification of Diseases code, were extracted from the database at a tertiary medical facility for 1990, 1996, and 2006.

Results

Admission rates for GI diseases increased between 1990 and 2006. The most prevalent disease in 1990 was gastric cancer, followed by appendicitis and colorectal cancer. However, by 2006, gastric cancer, colon cancer, and colon adenoma or polyps had become the most prevalent diseases. Although gastric cancer showed a decreasing trend, the rate of colon cancer doubled over two decades. Furthermore, rates of detection and endoscopic treatment of early gastric cancer and adenoma of the stomach and colon have increased noticeably. Newly emerging diseases include inflammatory bowel disease and gastroesophageal reflux. There was no change in the incidence of peptic ulcer, but ulcer-related complications and the numbers treated surgically decreased.

Conclusions

The findings of this study indicate that the clinical trends of GI diseases in Korea have changed in a similar way to those in the West. Early detection of a GI neoplasm will continue to increase with the establishment of cancer-screening programs, resulting in a rising need for minimally invasive treatments.

The prevalence of and risk factors for Barrett's esophagus in a Korean population: A nationwide multicenter prospective study

OBJECTIVE

The aim of this study was to evaluate the prevalence of Barrett's esophagus (BE) in the general Korean population by evaluating screening esophagogastroduodenoscopy. In addition, the risk factors for BE were identified.

METHOD

An esophagogastroduodenoscopy examination was performed in 25,536 subjects who had upper endoscopy screening from January 2006 to July 2006.

RESULTS

Two hundred and fifteen subjects were confirmed to have BE by pathology, thus the prevalence of BE was calculated to be 0.84%. The endoscopic findings were subdivided into 2 groups: BE without reflux esophagitis (RE), which included 167 (77.7%), and BE with RE, which included 48 (22.3%). The analysis of symptoms showed that only 60.1% of the subjects with BE had reflux symptoms. Chest pain [odds ratio (OR): 1.48, 95% confidence interval (CI): 1.04-2.11] and epigastric soreness (OR: 1.42, 95% CI: 1.05-1.93) were found more frequently in the subjects with BE compared with the normal subjects. The multivariate analysis showed that the risk factors for all subjects with BE were a male sex (OR: 1.82, 95% CI: 1.32-2.50), nonsteroidal anti-inflammatory drug use (OR: 2.02, 95% CI: 1.28-3.20), hiatal hernia (OR: 5.66, 95% CI: 3.70-8.66), and an age > or = 60 compared with an age < 40 (OR: 1.81, 95% CI: 1.07-3.09). There was no significant difference associated with RE.

CONCLUSIONS

The prevalence of BE in Korean patients presenting for a routine health check-up was 0.84%, lower than reported in Western countries. Among the subjects with BE 77.7% did not have endoscopic erosions and there were no reflux symptoms in 39.9%. These results suggest that regular endoscopic screening with a high index of suspicion is necessary for the diagnosis of BE.

Clinical spectrum of reflux esophagitis among 25,536 Koreans who underwent a health check-up: a nationwide multicenter prospective, endoscopy-based study

BACKGROUND

Gastroesophageal reflux is a commonly encountered condition, but detailed data on reflux symptoms in Asian countries are lacking.

GOALS

To evaluate the prevalence and to document the clinical spectrum of endoscopic reflux esophagitis (RE).

STUDY

A total 25,536 subjects underwent an upper gastrointestinal endoscopic examination as part of a health check, and completed a gastroesophageal reflux questionnaire. Endoscopic findings classified according to the Los Angeles (LA) classification and the data from gastroesophageal reflux questionnaire were analyzed.

RESULTS

On the basis of endoscopic findings, 2019 subjects (7.91%) were found to have RE: 5.87% in LA-A; 1.84% in LA-B; 0.18% in LA-C; and 0.02% in LA-D. Heartburn, acid regurgitation, chest pain, hoarseness, globus sensation, cough, and epigastric soreness were found to be associated with RE (P<0.05). Heartburn, acid regurgitation, and epigastric soreness were more frequent in LA-B than in LA-A (P<0.05). Epigastric soreness was most bothersome in LA-A and LA-B, and acid regurgitation was most bothersome in LA-C and LA-D (P<0.01). Heartburn, hoarseness, and globus sensation were more frequent in men with RE, and acid regurgitation was most common in women.

CONCLUSIONS

The prevalence of RE was found to be 7.91% in Korea, and the profiles of reflux symptoms were found to depend on grade of RE and sex.

Comparison of risk factors and clinical responses to proton pump inhibitors in patients with erosive oesophagitis and non-erosive reflux disease

BACKGROUND

There has been no report on the response to proton pump inhibitor (PPI) therapy and on-demand or the relapse rate of non-erosive reflux disease (NERD) and erosive oesophagitis in Korea.

AIM

To compare the risk factors, clinical symptoms and PPI responses between patients with erosive oesophagitis and NERD patients.

METHODS

A survey was performed prospectively in the erosive oesophagitis (205 patients) and NERD group (200 patients). Clinical symptoms, risk factors and PPI responses were analysed. On-demand therapy and the relapse rate of GERD symptoms were investigated during a one-year follow-up.

RESULTS

BMI > or = 25 (OR 3.0, 95% CI 1.1-8.3), alcohol use (OR 2.9, 95% CI 1.0-8.3), hiatal hernia (OR 5.0, 95% CI 1.2-20) and triglyceride > or =150 mg/dL (OR 4.0, 95% CI 1.7-10) were more common in the erosive oesophagitis group than in the NERD group by multivariate analysis. The ratio of oesophageal to extra-oesophageal symptoms was higher in the erosive oesophagitis group compared with the NERD group (P < 0.001). The PPI response rates at 8 weeks were different (P = 0.02); refractory rates were higher in the NERD group (16.7%) compared with the erosive oesophagitis group (6.0%). However, there was no significant difference between the two groups in on-demand therapy or the relapse rate.

CONCLUSION

These results suggest that the underlying pathogenic mechanisms of erosive oesophagitis and NERD are distinct.

Prevalence of complicated gastroesophageal reflux disease and Barrett's esophagus among racial groups in a multi-center consortium

AIMS

The Clinical Outcomes Research Initiative database was used to evaluate ethnic trends in complicated reflux disease and suspected Barrett's esophagus among various racial groups.

METHODS

Endoscopic findings for procedures performed January 2000-December 2005 for any indication and for reflux-related indications were reviewed by racial group.

RESULTS

Of 280,075 procedures examined, Hispanics were the most likely to have esophagitis (Hispanic 19.6%, white 17.3%, black 15.8%, Asian/Pacific Islander 9.5%, P-value<0.0001), and white subjects were most likely to have suspected BE (white 5.0%, Hispanic 2.9%, Asian/Pacific Islander 1.8%, black 1.5%, P-value<0.0001). Endoscopies performed for reflux-related indications had similar trends for esophagitis and esophageal stricture. Among reflux/Barrett's screening procedures adjusted for age and gender, Hispanics were most likely to have esophagitis (OR=1.28, P-value<0.0001) compared to Caucasians.

CONCLUSION

Our results demonstrate an association of suspected Barrett's esophagus and stricture with white patients and esophagitis with Hispanic patients. These findings need to be followed-up with further study.

Epidemiology of esophageal cancer: Orient to Occident. Effects of chronology, geography and ethnicity

Esophageal adenocarcinoma (EAC) has been rapidly increasing in Western countries during the past half century, especially in white men. Esophageal squamous cell carcinoma (ESCC) used to be the dominant type of esophageal malignancy both in Western and Asian countries. The rapid increase of EAC in Western countries has occurred in parallel with an increased prevalence of gastroesophageal reflux disease (GERD) and its major determinant, obesity. Such an increase in EAC has not yet been observed in Asia, despite a recent increase in prevalence of GERD. In this mini-review, we analyze possible factors influencing such east-west ('Orient to Occident') differences, particularly possible roles of ethnicity and environmental factors, such as Helicobacter pylori infection and nutritional factors, and how these might interact with socioeconomic differences. Development of Barrett's esophagus and esophageal adenocarcinoma appears to be strongly affected by ethnic factors, with populations resident at the west end of the Eurasian continent, such as Anglo-Celtics, being more prone to both conditions. On the other hand, ethnic groups from the eastern and southern ends of Eurasia, such as Chinese, Koreans and Japanese, and Africans might be more prone to developing esophageal squamous cell carcinoma. Future trends will also be discussed.

Esophageal and gastric cardia cancers on 4238 Chinese patients residing in municipal and rural regions: a histopathological comparison during 24-year period

BACKGROUND

Nutrition deficiencies or poverty traditionally have been recognized to be related with increased risk for esophageal cancer (EC) in rural regions at junction of Henan, Hebei, and Shanxi provinces in northern China--the highest incidence area for esophageal squamous cell carcinoma (ESCC) and gastric cardia adenocarcinoma (GCA). Since the 1980s, economic and nutrition condition in these areas have been improved greatly. However, the histopathological types, staging pattern, and occurrence of ESCC and GCA, especially for esophageal adenocarcinoma (EAC), which have been rarely examined in the Chinese population during the past decades in these areas have not been well characterized to date.

METHODS

Yearly diagnosed new esophageal cancer (ESCC and EAC) and GCA patients from Beijing Tongren Hospital (in municipal low-risk region) and Cixian People Hospital (in rural high-risk region) during 24-year period (1982-2005) were studied retrospectively. Only local resident patients with surgical resection were included. Age at diagnosis, tumor stage and site, and histopathological pattern were recorded for each patient from the tumor registry database in these hospitals.

RESULTS AND CONCLUSIONS

This study demonstrated that the common ESCC sites were different in municipal (chiefly in lower third of the esophagus) and in rural (chiefly in middle third of the esophagus) regions. The peak age of ESCC, EAC, and GCA patients in rural region was 10 years younger than in municipal region. Eighty-six percent of ESCC and 90% of GCA in municipal region were diagnosed at middle and advanced stage; similarly, more than 95% of ESCC and GCA in rural region were diagnosed at middle and advanced stage during the 24-year study period. An increasing tendency in number of yearly diagnosed new patients with ESCC and GCA was observed in municipal region, but not in rural region. However, an increasing tendency for EAC was observed both in municipal and rural regions during the past 24-year period. The present results demonstrate the difference in municipal and rural regions of ESCC, ECA, and GCA in histopathological types, and suggest that there may be different etiological factors involved in esophageal and gastric cardia carcinogenesis in these different areas.

Gastroesophageal reflux disease: an Asian perspective

The prevalence of gastroesophageal reflux disease (GERD) ranges from 2.5% to 7.1% in most population-based studies in Asia. There is evidence that GERD and its complications are rising, coinciding with a decline in Helicobacter pylori (H. pylori) infection. Asian GERD patients share similar risk factors and pathophysiological mechanisms with their Western counterparts. Possible causes for the lower prevalence of GERD include less obesity and hiatus hernia, a lesser degree of esophageal dysmotility, a high prevalence of virulent strains of H. pylori, and low awareness. Owing to the lack of precise translation for 'heartburn' in most Asian languages, reflux symptoms are often overlooked or misinterpreted as dyspepsia or chest pain. Furthermore, a symptom-based diagnosis with a therapeutic trial of the proton pump inhibitor (PPI) may be hampered by the high prevalence of H. pylori-related disease. The risk stratification for prompt endoscopy, use of a locally-validated, diagnostic symptom questionnaire, and response to H. pylori'test and treat' help improve the accuracy of the PPI test for diagnoses. PPI remain the gold standard treatment, and 'on-demand' PPI have been shown to be a cost-effective, long-term treatment. The clinical course of GERD is benign in most patients in Asia. The risk of progression from non-erosive reflux disease to erosive esophagitis is low, and treatment response to a conventional dose of PPI is generally higher. Although H. pylori eradication may lead to more resilient GERD in a subset of patients, the benefits of H. pylori eradication outweigh the risks, especially in Asian populations with a high incidence of gastric cancer.

Prevalence and clinical characteristics of Barrett's esophagus in a Chinese general population

BACKGROUND

The prevalence of Barrett esophagus (BE) remains elusive in the general populations.

GOALS

The purpose of this study was to identify the prevalence and clinical characteristics of BE in a Chinese general population.

STUDY

Between June 2003 and December 2006, consecutive subjects were evaluated via upper gastrointestinal endoscopy during a routine health examination. Patients were evaluated for any abnormalities, including endoscopically suspected esophageal metaplasia (ESEM) and erosive esophagitis (EE). Biopsies were attained from patients with ESEM to confirm a diagnosis of BE. The demographic data and endoscopic findings were retrospectively analyzed.

RESULTS

Of the 19,812 endoscopies performed, 56 patients (0.28%) were diagnosed with ESEM and 3129 patients (15.7%) with EE. Twelve of the 56 patients diagnosed with ESEM (0.06% of the total number of patients who underwent endoscopy) were confirmed to have BE after histologic analysis of the biopsies. Patients with BE were older than patients without BE (61.6 vs. 51.7 y), and only one of the 12 patients diagnosed with BE (8.3%) reported typical gastroesophageal reflux symptoms. A majority of the BE patients were categorized as short-segment BE (91.7%) and concomitant EE was found in 4 (33.3%). Smoking, alcohol, and metabolic disorders seemed to be associated with the presence of BE and EE.

CONCLUSIONS

The prevalence of BE in a Chinese general population was lower than that in other reported studies, particularly in comparison with the studies originating from Western countries. Patients with advanced age and metabolic disorders are risk factors for developing BE.

Racial and geographic issues in gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common chronic disorder that is associated with a huge economic burden in the western countries and significantly decreased quality of life. This review focuses on the various multicultural issues in the epidemiology, pathophysiology, diagnosis, and treatment of GERD. The prevalence of GERD appears to be highest in North America and Europe, whereas epidemiologic data from the Indian subcontinent, Africa, South America, and the Middle East are sparse. A limited number of studies have elucidated ethnic differences in GERD in multiracial populations. African Americans and Asians appear to be at a lower risk for the development of complicated GERD including Barrett's esophagus (BE). Whether the pathophysiology of GERD differs among different populations remains to be answered satisfactorily. It appears that most of the factors involved in the pathogenesis of GERD, as described in western populations, are present in Asians but at a lower scale. The current recommendations for the management of GERD by the American College of Gastroenterology may not meet the need for different ethnic groups or for different geographic regions. Recognition of language barriers in understanding the common terms used to describe reflux symptoms should be borne in mind while treating GERD patients with different ethnic backgrounds. In addition, a universally accepted definition for treatment success in GERD patients is lacking. Given the negative impact on health-related quality of life, significant cost ramifications, and increased risk for BE and esophageal adenocarcinoma, the study of multicultural issues in GERD should be considered.

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.

Gastro-oesophageal reflux disease in Asia : birth of a 'new' disease?

Gastro-oesophageal reflux disease (GORD) is one of the most common gastrointestinal diseases in the Western world and imposes a heavy burden on society. Although its prevalence in Asia is much lower, there is evidence that this is rapidly rising in Asia. The reported population prevalence of GORD in Eastern Asia ranges from 2.5% to 6.7% for at least weekly symptoms of heartburn and/or acid regurgitation. In general, Asians tend to have a milder spectrum of the disease. Most Asian patients have non-erosive GORD; erosive oesophagitis is less commonly seen than in the Western population. Complicated GORD, such as oesophageal stricture and Barrett's oesophagus, is seldom encountered. The mechanisms of GORD may be different in the Chinese population compared with the Western population. Chest pain is the most predominant extra-oesophageal manifestation of GORD in China, whereas an association with asthma has been shown in Japanese patients. The prevalence of GORD appears to be increasing and possible factors for GORD in Asian populations include Helicobacterpylori infection, obesity and increasing dietary fat intake. The adoption of a Western lifestyle in many developing Asian countries may account for the increasing prevalence of GORD. Proton pump inhibitors remain the most effective medical treatment for GORD. GORD will undoubtedly be a great challenge to clinicians both in primary care and in gastroenterology practice in the Asia-Pacific region in the coming years.

Low proportion of Barrett's esophagus in Asian Americans

OBJECTIVES

To determine the proportion of Barrett's esophagus (BE) in Asians versus non-Asians and the predictors of BE in patients with upper gastrointestinal (GI) symptoms.

METHODS

We performed a cross-sectional study to determine the proportion of BE from all consecutive patients who underwent esophagogastroduodenoscopy (EGD) for various indications at an outpatient, community-based gastroenterology practice in northern California from February 2000 to September 2006. BE was defined as endoscopically recognized presence of salmon-pink mucosa in the distal esophagus and intestinal metaplasia on biopsy. We also performed a nested case-control study to determine potential predictors of BE.

RESULTS

In total, 5,293 patients were reviewed. BE was more common in non-Asians (31/1464, 2.1%) than Asians (29/3829, 0.76%) (P < 0.001). In multivariate analysis controlling for increasing age, male gender, ethnicity, smoking, and alcohol, the strongest predictor of the presence of BE was non-Asian ethnicity (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.85-6.85), followed by male gender (OR 2.68, 95% CI 1.32-5.45).

CONCLUSION

BE is uncommon in Asian Americans; non-Asian ethnicity and male gender are significant independent predictors of BE.

Gastroesophageal reflux disease in Asia: a condition in evolution

Widespread epidemiological changes, rising prevalence and gradual shifts in patterns of disease manifestations: this is the changing face of gastroesophageal reflux disease (GERD) in Asia. Are we witnessing a disease in evolution or merely the result of increased and more accurate case reporting that comes with advancing diagnostic technology, better medical facilities and heightened awareness of the disease? Do the figures reported really reflect the actual scenario or is there more to it than meets the eye? In this article, we take you back in time to review relevant developments over the past decade or so. We will draw on findings from across Asia, take an in-depth look at prevailing trends and patterns and examine some of the most plausible explanations behind the dynamics of this epidemiological transition.

Decreasing trend of esophageal adenocarcinoma in Hong Kong

BACKGROUND

The incidence of esophageal adenocarcinoma was increasing in the Western Europe and United States, but not in East Asian countries. Population based study on the trend of esophageal adenocarcinoma in Hong Kong was not available.

MATERIALS AND METHODS

Population-based data of Hong Kong Cancer Registry from 1984 to 2003 were used. Cases were grouped into four 5-year periods. Average age standardized rate (WSR) of each period was calculated by averaging the WSR of the 5 years in each period, basing on the world standard population, with adjustment made for cases with missing histology.

RESULTS

10,751 new cases of esophageal neoplasm were studied (8,637 males and 2,114 females). Esophageal adenocarcinoma declined among both males and females, with the total number decreased from 224 in 1984 to 1988 to 131 in 1998 to 2003. WSR decreased from 1.10 of 100,000 in 1984 to 1988 to 0.34 of 100,000 in 1998 to 2003. The decline was faster than that for esophageal squamous cell carcinoma so that the relative ratio of esophageal adenocarcinoma decreased from 11.7% in 1984 to 1988 to 6.4% in 1998 to 2003.

CONCLUSIONS

The incidence of esophageal adenocarcinoma and ratio of esophageal adenocarcinoma versus esophageal squamous cell carcinoma decreased in Hong Kong.

Barrett's esophagus: incidence and prevalence estimates in a rural Mid-Western population

BACKGROUND AND AIMS

Barrett's esophagus (BE) predisposes to adenocarcinoma of the esophagus and survival in esophageal adenocarcinoma is low. We studied patients diagnosed with BE in the Marshfield Epidemiologic Study Area (MESA). Our objectives were to estimate the prevalence of diagnosed BE, estimate the annual incidence of initial diagnosis of BE, and characterize the demographics of patients diagnosed with BE.

METHODS

We retrospectively reviewed medical records of patients diagnosed with BE until December 31, 2002. The esophagogastroduodenoscopy (EGD) reports were reviewed to establish the presence of columnar epithelium. All slides were retrieved and reviewed by a gastrointestinal pathologist to establish the presence of intestinal metaplasia and dysplasia. Chart abstraction was conducted using a standardized form.

RESULTS

BE was histologically confirmed in 216 patients. All were white, 165 (76%) were male, and 81% had a hiatal hernia. Median age at diagnosis was 65.5 yr (range 17-94). Long-segment BE (LSBE) was present in 112 (51.9%) patients. The prevalence of histologically confirmed BE in MESA was 261.8 (95% CI 222.5-301.1) per 100,000 people. The incidence of an initial diagnosis of BE between 1996 and 2002 was 32.7 per 100,000 person-years (95% CI 27.1-38.2) and did not change significantly over the study period despite an increase in EGD rates. At the initial diagnosis, 41.7% of the patients were on proton pump inhibitors. Dysplasia was present in 24.5% of patients.

CONCLUSION

The incidence of initial diagnosis of BE in a stable white population did not change significantly over a 7-yr period, despite an increase in EGD rates.

The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea

BACKGROUND

Prospective nationwide multicentre studies that have evaluated endoscopic findings and reflux symptoms using a well-designed questionnaire are very rare.

AIM

To compare the prevalence rates of and risk factors for erosive oesophagitis and non-erosive reflux disease (NERD) in the Korean population.

METHODS

A gastroscopic examination was performed on 25 536 subjects who visited 40 Healthcare Centers for a health check-up. A gastro-oesophageal reflux questionnaire and multivariate analysis were used to determine the risk factors for erosive oesophagitis and NERD.

RESULTS

2019 (8%) and 996 subjects (4%) had erosive oesophagitis and non-erosive reflux disease, respectively; only 58% of subjects with erosive oesophagitis had reflux symptoms. Multivariate analysis showed that the risk factors for erosive oesophagitis and NERD differed, i.e. those of erosive oesophagitis were male, a Helicobacter pylori eradication history, alcohol, body mass index > or =25 and hiatal hernia. In contrast, the risk factors for NERD were female, age <40 and > or =60 vs. 40-59 years, body mass index <23 and a monthly income <$1000, glucose > or =126 mg/dL, smoking, a stooping posture at work and antibiotic usage.

CONCLUSIONS

The prevalence rates of erosive oesophagitis and NERD were 8% and 4%, respectively, in Korean health check-up subjects. The risk factors for erosive oesophagitis and NERD were found to differ, which indicates that their underlying pathogeneses are distinct.

Asia-Pacific consensus on the management of gastroesophageal reflux disease: update

BACKGROUND AND AIMS

Since the publication of the Asia-Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed.

METHODS

A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded.

RESULTS

GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On-demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non-GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials.

CONCLUSIONS

Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy.

The current management of esophageal cancer

The divergence in epidemiology between the East and West has made interpretation of data in the literature more difficult and has affected the choice of the most appropriate surgical technique and treatment strategies. The management of esophageal cancer certainly has evolved, and many more options are available. Stage-directed strategies and individualization of treatment are important considerations. Surgeons play a central role in directing management of this disease by advising how best to integrate surgical therapy with nonoperative programs. Surgeons should aim at improving their results further, so that the best results of surgery are compared with seemingly "safer" nonsurgical therapies. Low death rates have been achieved in specialized centers, but there still is much room for improvement in morbidity rates. Even with the best surgical resection and chemoradiation therapy, distant failure remains a barrier to improved survival rates. Therapeutic improvements will require more effective systemic drugs and a better ability to predict responders with precision. Management strategies will evolve further, with improvements in molecular techniques, imaging methods, and introduction of more novel tumoricidal agents. The challenge for the future is to test strategies critically in a scientific, unbiased manner and to explore other innovative treatments.

Influence of cytochrome P450 2C19 genetic polymorphism and dosage of rabeprazole on accuracy of proton-pump inhibitor testing in Chinese patients with gastroesophageal reflux disease

BACKGROUND AND AIM

To evaluate the optimal dosage of rabeprazole for proton-pump inhibitor (PPI) testing of gastroesophageal reflux disease (GERD) and to test the influence of cytochrome P450 (CYP) 2C19 polymorphism in a population with a high prevalence of people who metabolize PPI poorly.

METHODS

In this randomized, open-label trial, patients with symptoms suggestive of GERD were randomized to receive a 2-week test with 20- or 40-mg rabeprazole after diagnostic endoscopy. Symptom response was assessed with a four-grade daily record; in addition, DNA from peripheral blood leukocytes was genotyped for CYP2C19 polymorphism with the polymerase chain reaction-restriction fragment length polymorphism technique.

RESULTS

Of the 164 patients who completed the study, 69 (42.1%) were endoscopically positive for esophagitis; the remaining 95 (57.9%) were diagnosed with endoscopy-negative reflux disease. Based on the best cut-off value for 50% symptom reduction, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for detecting erosive esophagitis were 68%, 70%, 66%, 72%, and 69%, respectively, for the 20-mg regimen, and 84%, 71%, 64%, 88%, and 76%, respectively, for the 40-mg regimen, a non-significant difference. Regarding the genotype, 60 (39%) patients had two wild-type alleles, 63 (40.9%) had one variant allele, and 31 (20.1%) had two variant CYP2C19 alleles. The presence of a variant allele did not alter the diagnostic efficacy of PPI testing.

CONCLUSIONS

Both dose levels of rabeprazole proved efficacious in the diagnosis of GERD. Various measures of test accuracy were unrelated to the status of the CYP2C19 genotype.

Esophageal stricture: incidence, treatment patterns, and recurrence rate

OBJECTIVES

We aimed to determine the incidence, natural history, and recurrence rate of esophageal stricture diagnosed in primary care.

METHODS

From the U.K. General Practice Research Database, we identified patients with a stricture diagnosis recorded between 1994 and 2000. Diagnoses were confirmed by general practitioner-completed questionnaires. Patients with stricture were compared to an age- and sex-matched sample of controls from the original source population. We estimated the incidence of stricture, potential risk factors, and comorbidities, and relative risk (RR) for subsequent stricture recurrence and mortality.

RESULTS

The incidence of esophageal stricture was 1.1 per 10,000 person-years and increased markedly with age. Incidence of stricture decreased from 1994 to 2000, concomitant with a substantial increase in proton pump inhibitor (PPI) use. The majority of stricture cases (68%) were peptic. Prior dysphagia, gastroesophageal reflux disease (GERD), hiatus hernia, peptic ulcer disease, and heavy alcohol use were associated with an increased risk of stricture. The rate of stricture recurrence was 11.1 per 100 person-years. Risk of recurrence associated with long-term PPI use adjusting for other factors was 0.6 (95% CI 0.3-1.1). Mortality in patients with peptic stricture was similar to that in the control population.

CONCLUSIONS

Esophageal stricture is a rare event, and most cases in primary care are peptic strictures. Prior GERD, hiatus hernia, and peptic ulcer are associated with an increased risk of peptic stricture. Incidence of stricture decreased from 1994 to 2000.

The influence of Helicobacter pylori infection on the prevalence of endoscopic erosive esophagitis

OBJECTIVES

This study aimed to determine the frequency of endoscopic esophagitis and Helicobacter pylori infection in a large Turkish population over a 6-year period.

METHODS

We studied a consecutive series of 14,380 patients who had been newly referred for diagnostic esophagogastroduodenoscopy from 2000 to 2006. The mean age value was 45 +/- 10 (18-89) years. All endoscopic findings were retrospectively evaluated. Two antral and two corpus biopsies were taken from patients for rapid urease test. Endoscopic esophagitis was defined as the presence of erosions and/or ulceration. The relationship between erosive esophagitis and various relevant factors was analyzed.

RESULTS

The overall prevalence of endoscopic esophagitis was 7.8% (95% CI, 6.9-8.1). The prevalence of positive rapid urease test was 49% (95% CI, 38-53) in patients with esophagitis and 85% (95% CI, 70-96) in patients without esophagitis (p < .001). From 2000 to 2006, the frequency of endoscopic esophagitis and the rate of positive rapid urease test remained unchanged. After adjusting for the effects of mean age, male gender, and percentage of hiatal hernia, there was a 0.785% risk reduction in esophagitis with every 1% increase in the rate of positive rapid urease test result.

CONCLUSIONS

The frequency of endoscopic esophagitis is significantly lower in patients with a positive rapid urease test result. This negative correlation with H. pylori infection reflects a protective effect of H. pylori from endoscopic esophagitis in a Turkish population and deserves further investigation.

Genetic polymorphisms in glutathione S-transferases T1, M1 and P1 and susceptibility to reflux esophagitis

Recent studies indicate that the prevalence of reflux esophagitis (RE) in China is increasing. RE is one of the most common esophageal complications associated with gastroesophageal reflux disease (GERD) and RE-Barrett's esophagus-esophageal adenocarcinoma (EAC) sequence has been considered as an histogenesis model for EAC in Western countries. RE is only present in a subset of patients with GERD, suggesting an altered susceptibility to RE may exist in these GERD individuals. However, the genetic changes related with high susceptibility to RE is largely unknown. The polymorphisms in glutathione S-transferases (GSTs) T1, M1 and P1 have been reported with high susceptibity to esophageal cancer in Chinese people. The present case-control study was thus undertaken to characterize the genetic polymorphisms of GSTs and their correlation with susceptibility to RE. One hundred and nine patients with RE, 97 patients with nonerosive reflux disease (NERD) and 97 normal controls were recruited in this study. All the subjects were from Beijing, China, and received endoscopic examination and questionnaires for RE. Genomic DNA was extracted from the lymphocytes of peripheral blood for each subject. Genotypes of the GSTM1 and GSTT1 genes were analyzed by a multiplex PCR method. A-->G polymorphism of codon 104 of the GSTP1 gene was detected using PCR-based restriction fragment length polymorphisms (RFLP). The variant GSTP1 genotypes (*A/*Bomicron*B/*B) was found with a high frequency in the case with RE (40%), and followed by NERD (25%) and normal control (22%). The differences were statistically significant (P < 0.05). The risk for RE increased 2.42-fold [odds ratio (OR); 95% confidence interval (95% CI), 2.42 (1.22-4.80)] in the subjects with variant GSTP1 genotype. The subjects with positive variant GSTP1 genotypes and negative H. pylori infection showed increasing tendency for risk of RE [OR (95% CI), 2.67 (1.06-6.70)]. However, the subjects with GSTT1 and GSTM1 polymorphisms did not show any correlation with high risk for RE or NERD. No significant interactions were identified between the variant GSTs and cigarette smoking, or alcohol drinking and subtype of RE. The present result suggests that GSTP1 genetic polymorphism may be one of the high susceptibility factors involved in the mechanisms of RE. H. pylori infection may play a protective role against RE.

Esomeprazole 40 mg once a day in patients with functional dyspepsia: the randomized, placebo-controlled "ENTER" trial

OBJECTIVE

The etiologies of functional dyspepsia (FD) are unclear, but in some studies, treatment with a proton pump inhibitor has been beneficial. The objective of this study was to evaluate the efficacy of esomeprazole 40 mg once a day compared to placebo in achieving symptom relief in primary care patients with FD.

METHODS

This was a randomized, placebo-controlled trial in adult FD patients, who had at least moderate severity of symptoms, defined as a score of > or =4 on a 7-point Global Overall Symptom (GOS) scale. Patients were excluded if they had predominant symptoms of heartburn or regurgitation; after a normal baseline endoscopy, patients were randomized to esomeprazole 40 mg once daily or placebo for 8 wk. The primary outcome measure was symptom relief (GOS < or =2) at 8 wk.

RESULTS

Of the 502 enrolled patients, 224 were randomized. The main reasons for exclusion were abnormal endoscopic findings, especially esophagitis. A significantly greater proportion of patients in the esomeprazole group achieved symptom relief at 4 but not at 8 wk compared to placebo: 4 wk esomeprazole 50.5% versus placebo 32.2%, p= 0.009; 8 wk esomeprazole 55.1% versus placebo 46.1%, p= 0.16. A similar relationship at 4 and 8 wk was seen for symptom resolution (GOS = 1) and improvement (DeltaGOS > or =2).

CONCLUSION

For the primary outcome measure of symptom relief at 8 wk, there was no statistically significant difference between esomeprazole 40 mg once a day and placebo. However, at 4 wk, esomeprazole was significantly more effective than placebo for symptom relief. The difference in therapeutic gain between 4 and 8 wk was largely due to a higher placebo response rate at 8 wk.

Gastroesophageal reflux disease in Asian countries: disorder of nature or nurture?

Gastroesophageal reflux disease (GERD) is less prevalent in Asia than in the West, but there is now evidence to suggest that its frequency is rapidly rising in Asia. The different prevalence rates reported in various Asian studies may represent different points in the 'rising' phase of GERD. The cause for the lower but increasing prevalence of GERD in Asia is not known, but genetics and to some extent environmental factors, may have initially protected Asians against GERD. However, with the recent globalization of economies, the associated lifestyle changes in many developing Asian countries may have tipped the balance in favor of the development of GERD.