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Ribolsi M, De Bortoli N, Frazzoni M, Marchetti L, Savarino E, Cicala M. Proximal esophageal impedance baseline increases the yield of impedance-pH and is associated with response to PPIs in chronic cough patients. Neurogastroenterol Motil 2024; 36:e14775. [PMID: 38424679 DOI: 10.1111/nmo.14775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Chronic cough significantly impairs the quality of life. Although various studies focused on MNBI as assessed in the distal esophagus, scarce data are available on the clinical value of proximal measurements. AIM To investigate the role of proximal MNBI in the workup of patients with chronic cough and its ability to predict PPI response. METHODS Demographic, clinical, endoscopy findings, impedance-pH and HRM tracings from consecutive cough patients were evaluated. MNBI was calculated at proximal and distal esophagus. RESULTS One hundred and sixty four patients were included. In addition to traditional variables, when considering also the PSPW index or MNBI at 3 cm or 15 cm, the proportion of patients with pathological impedance-pH monitoring significantly increased. 70/164 patients were responders, while 94 (57.3%) were non-responder to double PPI dose (p < 0.05). Patients with pathologic MNBI at 3 cm and/or 15 cm as well as those with pathologic PSPW index were characterized by a significantly higher proportion of responders than that observed among patients with normal impedance-pH variables (p < 0.001). The proportion of responders with pathological MNBI at 15 cm was significantly higher than the proportion of responders with pathological MNBI at 3 cm (82.8% vs. 64.3%, p < 0.05). At multivariable model, pathological MNBI at both 3 cm and 15 cm as well as PSPW index were associated with PPI responsiveness. The strongest association with PPI response was observed for MNBI at 15 cm. CONCLUSIONS The assessment of MNBI at proximal esophagus increases the diagnostic yield of impedance-pH monitoring and may represent a useful predictor of PPI responsiveness in the cumbersome clinical setting of suspected reflux-related cough.
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Affiliation(s)
- Mentore Ribolsi
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Roma, Italy
| | - Nicola De Bortoli
- Department of New Technologies and Translational Research in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Modena, Italy
| | - Lorenzo Marchetti
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Roma, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua School of Medicine and Surgery, Padova, Italy
| | - Michele Cicala
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Roma, Italy
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Pauwels A, Raymenants K, Geeraerts A, Boecxstaens V, Masuy I, Broers C, Vanuytsel T, Tack J. Clinical trial: a controlled trial of baclofen add-on therapy in PPI-refractory gastro-oesophageal reflux symptoms. Aliment Pharmacol Ther 2022; 56:231-239. [PMID: 35665521 DOI: 10.1111/apt.17068] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/06/2022] [Accepted: 05/20/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPI) have no effect on non-acid reflux events which can continue to provoke gastro-oesophageal reflux disease (GERD) symptoms. Baclofen, a γ-aminobutyric acid agonist, can decrease non-acid reflux but its symptomatic benefit in refractory GERD symptoms is understudied. AIMS To assess the efficacy of baclofen 10 mg t.i.d. vs placebo as add-on therapy in PPI-refractory GERD symptoms, in a randomised, double-blind, placebo-controlled study. METHODS Patients with persisting typical GERD symptoms on b.i.d. PPI therapy were randomised to 4 weeks of baclofen 10 mg or placebo t.i.d. Before and after treatment, patients underwent 24 h impedance-pH monitoring on-PPI. Throughout the study, patients filled out ReQuest diaries. Data were analysed using mixed models. RESULTS About 60 patients were included (age 47.5 years [range 19-73], 41f/19 m), 31 patients were randomised to baclofen. One patient withdrew consent and five in the baclofen group stopped treatment due to side effects. There was a trend towards a better response for general wellbeing in the baclofen-treated group compared to placebo (p = 0.06). When subdividing patients according to symptom association probability (SAP), only the SAP+ (n = 25) group improved significantly with baclofen (pcorr = 0.02), and worsened with placebo (pcorr = 0.008). The total number of reflux events decreased over time (p = 0.01), mainly due to the baclofen condition (pcorr = 0.1). The number of reflux events with a high proximal extent dropped significantly after baclofen (pcorr = 0.009), but not placebo. CONCLUSION Baclofen decreases several reflux parameters in PPI refractory GERD symptoms, but pH-impedance monitoring is necessary before treatment as only SAP+ patients experience clinical benefit after 4 weeks.
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Affiliation(s)
- Ans Pauwels
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Karlien Raymenants
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Annelies Geeraerts
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Veerle Boecxstaens
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
- Oncological and Vascular Access Surgery, Department of Surgical Oncology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Imke Masuy
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Charlotte Broers
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Rome Foundation, Falls of Neuse, Chapel Hill, North Carolina, USA
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Alleleyn AM, Keszthelyi D, Rinsma NF, Csekő K, Kajtár B, Helyes Z, Winkens B, Masclee AA, Conchillo JM. The Potential Role for Impaired Mucosal Integrity in the Generation of Esophageal Pain Using Capsaicin in Humans: An Explorative Study. Clin Transl Gastroenterol 2022; 13:e00488. [PMID: 35351835 PMCID: PMC9132534 DOI: 10.14309/ctg.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Esophageal pain is mediated by sensory nerves, most importantly by the activation of the transient receptor potential vanilloid 1 (TRPV1) capsaicin receptor. TRPV1 is activated and sensitized by a broad range of pungent compounds, as well as inflammatory mediators and tissue irritants. Luminal stressors are suggested to impair the barrier function, which results in consequent activation of these sensory nerve terminals and pain. In this study, we investigated the effect of the perfusion of capsaicin, a TRPV1 agonist, on mucosal impedance and pain in asymptomatic volunteers. METHODS Thirteen asymptomatic volunteers completed a single-blind, saline-controlled, randomized crossover study. Capsaicin or saline was perfused for 30 minutes in the distal esophagus. Visual analog scale pain intensity scores and intraluminal impedance indicating mucosal integrity were determined. Distal and proximal biopsies were obtained 10 minutes later to measure TRPV1 messenger RNA and TRPV1 immunopositivity, as well as the intercellular space area. RESULTS Capsaicin perfusion resulted in significantly greater pain intensity (P = 0.047) and impaired recovery of the mucosal impedance compared with saline-treated controls (P = 0.027). Pain response was significantly associated with decreased mucosal impedance. Similar dynamics were seen in the proximal esophagus, but mucosal impedance recovered entirely to the preinfusion values there. There was a significant association between mucosal impedance and intercellular space width in the distal esophagus. TRPV1 transcription and expression were not significantly altered within this observation period. DISCUSSION Esophageal capsaicin perfusion results in pain, which is likely to be explained by impaired mucosal impedance and defective restoration capacity in the distal esophagus.
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Affiliation(s)
- Annick M.E. Alleleyn
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands;
| | - Daniel Keszthelyi
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands;
| | - Nicolaas F. Rinsma
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands;
| | - Kata Csekő
- Department of Pharmacology and Pharmacotherapy, Medical School, Janos Szentagothai Research Centre & Centre for Neuroscience, University of Pécs, Pécs, Hungary;
| | - Béla Kajtár
- Department of Pathology, Medical School, Clinical Centre, University of Pécs, Pécs, Hungary; and
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, Medical School, Janos Szentagothai Research Centre & Centre for Neuroscience, University of Pécs, Pécs, Hungary;
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.
| | - Adrian A.M. Masclee
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands;
| | - José M. Conchillo
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands;
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RAMOS RI, CERNADAS G, CURVALE C, MATANO R. NORMAL VALUES OF ESOPHAGEAL 24-HOUR IMPEDANCE-PH AMBULATORY IN AN ARGENTINE COHORT OF HEALTHY VOLUNTEERS. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:47-52. [DOI: 10.1590/s0004-2803.202200001-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022]
Abstract
ABSTRACT Background There are no data of reference values on 24-hour multichannel intraluminal impedance and pH (pH-MII) monitoring in Argentinian populations. Objective Our aim was to obtain the normal values of pH-MII variables among healthy asymptomatic volunteers in a metropolitan Health Care Center of Argentina, and to compare them with data already published from other regions around the world. Methods A cross-sectional study was undertaken in a tertiary referral center in Buenos Aires. We enrolled healthy subjects and asked them to undergo esophageal pH-MII 24hours monitoring. pH-MII variables were recorded and described. Results Median reflux events was 20.5 (25-75%, 95%) interquartile range: (14-46, 50) and proximal reflux episodes was 2.5 (0-10, 11). Sixty percent were acid reflux episodes: 12 (5-29, 38), representing a relatively low value when compared to those reported in European, American and Chinese populations. Conclusion Our study shows the first reference of normal values of gastroesophageal reflux in an Argentinian population. We found a total number of reflux events and a total number of proximal reflux events lower than what was reported until this date by other authors.
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Affiliation(s)
- Rosa Isabel RAMOS
- Hospital de Alta Complejidad El Cruce, Argentina; Hospital Británico, Argentina
| | | | | | - Raúl MATANO
- Hospital de Alta Complejidad El Cruce, Argentina
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5
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Ribolsi M, Frazzoni M, De Bortoli N, Tolone S, Arsiè E, Mariani L, De Carlo G, Maniero D, Penagini R, Cicala M, Savarino E. Reflux characteristics triggering post-reflux swallow-induced peristaltic wave (PSPW) in patients with GERD symptoms. Neurogastroenterol Motil 2022; 34:e14183. [PMID: 34051123 PMCID: PMC9285402 DOI: 10.1111/nmo.14183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Esophageal chemical clearance has been evaluated with the post-reflux swallow-induced peristaltic wave (PSPW) index. The factors triggering PSPW in Gastro-esophageal reflux disease (GERD) have not yet been investigated. This multicenter study was aimed at evaluating the characteristics of reflux episodes associated with PSPW occurrence in patients with typical GERD symptoms. METHODS Impedance-pH tracings from patients with typical reflux symptoms were analyzed. Sixteen healthy subjects were included for comparison. Multivariate analysis was performed to determine predictors of PSPW events. KEY RESULTS Impedance-pH tracings from 60 patients and 16 healthy subjects were evaluated. A total of 3454 refluxes were recorded. In patients, comparing reflux episodes followed with those not followed by a PSPW, significantly higher proportions of acid (79% vs. 74%, p: 0.02), mixed (47% vs. 32%, p: 0.0001) and proximal refluxes (34% vs. 20%, p: 0.0001) were observed. A multivariate analysis, acid (OR: 1.3, 95% CI: 1.05-1.6), mixed (OR: 2, 95% CI: 1.6-2.3), and proximal (OR: 2.1, 95% CI: 1.7-2.5) refluxes were independently associated with PSPWs. Reflux episodes followed by a PSPW were characterized by a significantly higher bolus clearing time [(mean ± SD) 41 s ± 6 s vs. 30 s ± 5 s, p < 0.05] whereas nadir pH value of reflux events preceding PSPWs was tangentially but not significantly lower [(mean ± SD) 2.61 ± 1.22 vs. 2.74 ± 1.26, p: 0.057]. CONCLUSIONS AND INFERENCES Acid, mixed and proximal refluxes, and their duration are key factors in eliciting PSPWs. PSPW represents a response to reflux directly related to the potential harmfulness of reflux contents.
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Affiliation(s)
- Mentore Ribolsi
- Department of Digestive DiseasesCampus Bio Medico University of RomeRomaItaly
| | - Marzio Frazzoni
- Digestive Pathophysiology UnitBaggiovara HospitalModenaItaly
| | - Nicola De Bortoli
- Department of Translational Research and New Technology in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Salvatore Tolone
- General and Bariatric Surgery UnitDepartment of Surgery2nd University of NaplesNapoliItaly
| | - Elena Arsiè
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Fondazione IRCCS Ospedale Maggiore PoliclinicoMilanItaly
| | - Lucia Mariani
- Department of Translational Research and New Technology in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Giovanni De Carlo
- Department of Digestive DiseasesCampus Bio Medico University of RomeRomaItaly
| | - Daria Maniero
- Gastroenterology UnitDepartment of Surgery, Oncology and GastroenterologyUniversity of PaduaPadovaItaly
| | - Roberto Penagini
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Fondazione IRCCS Ospedale Maggiore PoliclinicoMilanItaly
| | - Michele Cicala
- Department of Digestive DiseasesCampus Bio Medico University of RomeRomaItaly
| | - Edoardo Savarino
- Gastroenterology UnitDepartment of Surgery, Oncology and GastroenterologyUniversity of PaduaPadovaItaly
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6
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Fass R, Boeckxstaens GE, El-Serag H, Rosen R, Sifrim D, Vaezi MF. Gastro-oesophageal reflux disease. Nat Rev Dis Primers 2021; 7:55. [PMID: 34326345 DOI: 10.1038/s41572-021-00287-w] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 02/07/2023]
Abstract
Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.
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Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical System, Case Western Reserve University, Cleveland, OH, USA.
| | - Guy E Boeckxstaens
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
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7
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Chen J, Guo B, Bin C, Zhang C, Zhan Y. Assessment of the Multiple Rapid Swallows Test for Gauging Esophageal Reflux Burden in Patients with Refractory Gastroesophageal Reflux Disease. Med Sci Monit 2021; 27:e928554. [PMID: 33602889 PMCID: PMC7901159 DOI: 10.12659/msm.928554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The multiple rapid swallows (MRS) test is used to assess esophageal contraction reserve. In this study, we characterized the expression of the MRS test in patients with reflux burden and other symptomatic phenotypes with refractory gastroesophageal reflux disease (rGERD). MATERIAL AND METHODS Patients with rGERD who underwent high-resolution manometry (HRM) and esophageal pH-impedance monitoring (EIM) between September 2018 and January 2020 were retrospectively studied. RESULTS We enrolled 151 patients and divided them into 4 phenotypes according to the results of EIM. In phenotype 1, the MRS distal contractile integral (DCI) was significantly positively correlated with acid-liquid reflux episodes. In phenotype 2, lower esophageal sphincter pressure (LES) length was significantly positively correlated with MRS DCI, and MRS/single-swallow (SS) DCI ratio. In phenotype 3, MRS DCI was negatively correlated with the DeMeester score, acid exposure time (AET), upright AET, long-term acid reflux episodes, acid-mixed reflux episodes, recumbent acid reflux episodes, and total acid reflux episodes. There was a significant negative correlation between MRS/SS DCI and recumbent acid reflux episodes. In phenotype 4, nonacid-liquid episodes and recumbent nonacid reflux episodes were significantly higher in the abnormal MRS group. However, acid-gas episodes, weakly acid-gas episodes, and upright gas reflux episodes were higher in the normal MRS group than in the abnormal MRS group. CONCLUSIONS Esophageal contraction reserve is heterogeneous within the reflux burden and symptomatic phenotypes of patients with rGERD.
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Affiliation(s)
- Jing Chen
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing, China (mainland)
| | - Baona Guo
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing, China (mainland)
| | - Chuxuan Bin
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing, China (mainland)
| | - Chuan Zhang
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yutao Zhan
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing, China (mainland)
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Savarino E, Frazzoni M, Marabotto E, Zentilin P, Iovino P, Costantini M, Tolone S, Battaglia E, Cicala M, Usai-Satta P, de Bortoli N, Penagini R, Savarino V. A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring. Dig Liver Dis 2020; 52:966-980. [PMID: 32513632 DOI: 10.1016/j.dld.2020.04.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.
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Affiliation(s)
- Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Paola Iovino
- Gastroenterology Unit, University of Salerno, Salerno, Italy
| | - Mario Costantini
- Clinica Chirurgica III, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaja Hospital, Asti, Italy
| | - Michele Cicala
- Unit of Digestive Diseases, Campus Bio Medico University, Rome, Italy
| | | | - Nicola de Bortoli
- Gastrointestinal Unit-Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56124 Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit - Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico - University of Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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9
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Griffin N, Rowe CW, Gao F, Jobling P, Wills V, Walker MM, Faulkner S, Hondermarck H. Clinicopathological Significance of Nerves in Esophageal Cancer. THE AMERICAN JOURNAL OF PATHOLOGY 2020; 190:1921-1930. [PMID: 32479822 DOI: 10.1016/j.ajpath.2020.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 05/08/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023]
Abstract
Nerves are emerging promoters of cancer progression, but the innervation of esophageal cancer and its clinicopathologic significance remain unclear. In this study, nerves were analyzed by immunohistochemistry in a cohort of 260 esophageal cancers, including 40 matched lymph node metastases and 137 normal adjacent esophageal tissues. Nerves were detected in 38% of esophageal cancers and were more associated with squamous cell carcinomas (P = 0.04). The surrounding or invasion of nerves by cancer cells (perineural invasion) was detected in 12% of esophageal cancers and was associated with reduced survival (P = 0.04). Nerves were found to express the following receptors for nerve growth factor (NGF): neurotrophic receptor tyrosine kinase 1 and nerve growth factor receptor. An association was suggested between high production of NGF by cancer cells and the presence of nerves (P = 0.02). In vitro, NGF production in esophageal cancer cells was shown by Western blot, and esophageal cancer cells were able to induce neurite outgrowth in the PC12 neuronal cells. The neurotrophic activity of esophageal cancer cells was inhibited by anti-NGF blocking antibodies. Together, these data suggest that innervation is a feature in esophageal cancers that may be driven by cancer cell-released NGF.
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Affiliation(s)
- Nathan Griffin
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia
| | - Christopher W Rowe
- Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia; Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Fangfang Gao
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia
| | - Phillip Jobling
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia
| | - Vanessa Wills
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia; Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Marjorie M Walker
- Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia; Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Sam Faulkner
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia
| | - Hubert Hondermarck
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia.
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10
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Savarino V, Marabotto E, Zentilin P, Furnari M, Bodini G, De Maria C, Tolone S, De Bortoli N, Frazzoni M, Savarino E. Pathophysiology, diagnosis, and pharmacological treatment of gastro-esophageal reflux disease. Expert Rev Clin Pharmacol 2020; 13:437-449. [PMID: 32253948 DOI: 10.1080/17512433.2020.1752664] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Gastro-esophageal reflux disease (GERD) is a highly prevalent, chronic, relapsing disorder, whose knowledge has increased in last years thanks to the advent of new sophisticated techniques, such as 24-h impedance-pH monitoring and high-resolution manometry, for the study of esophageal functions. AREAS COVERED This review provides an overview of our advancements in understanding the complex pathophysiology, improving the diagnosis and defining the modern pharmacological therapeutic approach to GERD. EXPERT OPINION The growing clinical application of impedance-pH testing has allowed us to know the diversity of patients with non-erosive reflux disease (NERD), who nowadays represent about 70% of the whole population with reflux symptoms. We have realized that NERD has to be considered as an umbrella term covering various subgroups with different pathophysiologies. The development of new impedance metrics, in particular mean nocturnal baseline impedance, seems to be promising in the improvement of the diagnostic process of this disease. There are no particularly innovative features in the pharmacological therapy of GERD, unless the interest toward drugs is able to increase the defense properties of esophageal mucosa and/or its protection. These compounds can be of help in combination with proton pump inhibitors in NERD patients with partial response to antisecretory drugs alone.
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Affiliation(s)
| | - Elisa Marabotto
- Department of Internal Medicine, University of Genoa , Genoa, Italy
| | | | - Manuele Furnari
- Department of Internal Medicine, University of Genoa , Genoa, Italy
| | - Giorgia Bodini
- Department of Internal Medicine, University of Genoa , Genoa, Italy
| | | | - Salvatore Tolone
- Department of Surgery, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Nicola De Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa , Pisa, Italy
| | - Marzio Frazzoni
- Department of Gastroenterology, Gastroenterology Digestive Pathophysiology Unit, Baggiovara Hospital , Modena, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua, Italy
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11
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Zachariah RA, Goo T, Lee RH. Mechanism and Pathophysiology of Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:209-226. [PMID: 32146942 DOI: 10.1016/j.giec.2019.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroesophageal reflux (GER) describes a process in which gastric contents travel retrograde into the esophagus. GER can be either a physiologic phenomenon that occurs in asymptomatic individuals or can potentially cause symptoms. When the latter occurs, this represents GER disease (GERD). The process by which GER transforms into GERD begins at the esophagogastric junction. Impaired clearance of the refluxate also contributes to GERD. Reflux causes degradation of esophageal mucosal defense. The refluxate triggers sensory afferents leading to symptom generation.
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Affiliation(s)
- Robin A Zachariah
- H.H. Chao Comprehensive Digestive Disease Center, 333 City Boulevard West, Suite 400, Room 459, Orange, CA 92868, USA
| | - Tyralee Goo
- Tibor Rubin Veterans' Affairs Medical Center, 5901 E. Seventh Street, Long Beach, CA 90822, USA
| | - Robert H Lee
- H.H. Chao Comprehensive Digestive Disease Center, 333 City Boulevard West, Suite 400, Room 459, Orange, CA 92868, USA; Tibor Rubin Veterans' Affairs Medical Center, 5901 E. Seventh Street, Long Beach, CA 90822, USA.
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12
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Reflux esophagitis, functional and non-functional. Best Pract Res Clin Gastroenterol 2019; 40-41:101649. [PMID: 31594653 DOI: 10.1016/j.bpg.2019.101649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 01/31/2023]
Abstract
The pathogenesis of gastroesophageal reflux disease has been explained by acid-peptic model. However, related with the progress of the diagnostic modalities, another phenotypical group of patients were defined and called "functional disorders of the esophagus". These patients are important because diagnosis is particularly difficult, co-morbid disorders especially psychiatric diseases are common, proton pump inhibitor response is low, and surgical results are very poor. Simpler and translational science studies are required in functional groups in order to differentiate from acid-peptic disorders. New and more accurate diagnostic modalities as well as therapeutic approaches are strongly needed in this particularly new and exciting era, especially in the effect of neuromodulators. Current diagnostic modalities should also be evaluated and in fact, normal values should be established. New medications, especially acting at the level of esophageal epithelium and intercellular spaces, might shift the paradigm.
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Hungin APS, Molloy-Bland M, Scarpignato C. Revisiting Montreal: New Insights into Symptoms and Their Causes, and Implications for the Future of GERD. Am J Gastroenterol 2019; 114:414-421. [PMID: 30323266 PMCID: PMC6434899 DOI: 10.1038/s41395-018-0287-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/13/2018] [Indexed: 12/11/2022]
Abstract
The Montreal definition of gastroesophageal reflux disease (GERD) provided a rationale for acid suppression medication without investigation, thus enhancing the management of the substantial symptom burden in these patients. Increased proton-pump inhibitor use has also highlighted their limitations, with one third of "typical" symptoms known to be refractory. Most refractory symptoms are ascribed to reflux hypersensitivity (RH) and functional heartburn (FH). RH may be caused by impaired esophageal mucosal barrier function and sensitization of peripheral esophageal receptors. Central sensitization may also contribute to the perception of non-pathologic reflux in RH, and the perception of physiological stimuli in FH. Importantly, mechanisms underlying GERD, RH, and FH are (in theory) not mutually exclusive, further complicating patient management. Methods used to distinguish GERD from RH and FH are impractical for use in epidemiological studies and pragmatic care and may have limited diagnostic accuracy. This is impeding accurate prevalence estimates and risk factor determination and the identification of new therapies. Direct assessment of mucosal barrier function by measuring impedance is a promising candidate for improved diagnosis. Ultimately though the concept of GERD as a composite, symptom-based entity needs re-evaluation, so that new understandings of upper GI symptoms can direct more precise management.
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Affiliation(s)
- A. Pali S. Hungin
- The Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Parma, Italy
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Wang F, Li G, Ning J, Chen L, Xu H, Kong X, Bu J, Zhao W, Li Z, Wang X, Li X, Ma J. Alcohol accumulation promotes esophagitis via pyroptosis activation. Int J Biol Sci 2018; 14:1245-1255. [PMID: 30123073 PMCID: PMC6097477 DOI: 10.7150/ijbs.24347] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/12/2018] [Indexed: 02/07/2023] Open
Abstract
Gastroesophageal reflux impairs the mucosal barrier in the distal esophagus, allowing chronic exposure of the squamous epithelium to multitudinous stimulations and inducing chronic inflammation. Esophagitis is a response to inflammation of the esophageal squamous mucosa. Our study clarified that alcohol accumulation could aggravate the progress of esophagitis by inducing pyroptosis; however, Ac-YVAD-CMK, an inhibitor of caspase-1, could effectively suppress the expression of IL-1β and IL-18 both in vivo and in vitro, reducing the inflammatory response, which is promised to be an agent to inhibit the progression of esophagitis. Additionally, caspase-1-derived pyroptosis is involved in esophageal cancer.
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Affiliation(s)
- Fengjiao Wang
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, 150001, China
| | - Gang Li
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, China
| | - Jinfeng Ning
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, 150001, China
| | - Lantao Chen
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, 150001, China
| | - Hai Xu
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, 150001, China
| | - Xianglong Kong
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, 150001, China
| | - Jianlong Bu
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, 150001, China
| | - Weiwei Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Harbin Medical University, Harbin, 150086, China
| | - Zhengtian Li
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Xiuyun Wang
- Department of Abdominal Ultrasound, First Hospital of Harbin Medical University, Harbin, 150001, China
| | - Xiaoguang Li
- Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jianqun Ma
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, 150001, China
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Prevalence of Dyspepsia in Individuals With Gastroesophageal Reflux-Type Symptoms in the Community: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2018; 16:39-48.e1. [PMID: 28782675 DOI: 10.1016/j.cgh.2017.07.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/21/2017] [Accepted: 07/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Dyspepsia and gastroesophageal reflux are highly prevalent in the general population, but they are believed to be separate entities. We conducted a systematic review and meta-analysis to estimate the prevalence of dyspepsia in individuals with gastroesophageal reflux symptoms (GERS), and to quantify overlap between the disorders. METHODS We searched MEDLINE, EMBASE, and EMBASE Classic databases to identify population-based studies reporting the prevalence of dyspepsia and GERS in adults, defined using specific symptom-based criteria or based on answers to questionnaires. We calculated pooled prevalence values, according to study location and criteria used to define weekly GERS or dyspepsia, as well as odds ratios (ORs) with 95% CIs. The degree of overlap between dyspepsia and GERS was examined. RESULTS Of 14,132 papers evaluated, 79 reported prevalence of weekly GERS. Nineteen of these study populations, comprising 111,459 participants, also reported the proportion of individuals with dyspepsia. The prevalence of dyspepsia in individuals with weekly GERS was 43.9% (95% CI, 35.1%-52.9%). The pooled OR for dyspepsia in individuals with weekly GERS, compared with those without, was 6.94 (95% CI, 4.33%-11.1%). The OR for dyspepsia in individuals with weekly GERS was significantly higher in all geographical regions studied and for all diagnostic criteria. The pooled degree of overlap between dyspepsia and GERS was 25.9% (95% CI, 19.9%-32.4%). CONCLUSIONS The odds of dyspepsia in individuals with weekly GERS is almost 7-fold that of individuals without GERS; dyspepsia and GERS overlap in more than 25% of individuals. Reasons for this remain speculative, but might include shared pathophysiological mechanisms or residual confounding factors. However, patients with GERS should be questioned about coexistent dyspepsia, to optimize treatment approaches.
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16
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Tack J, Pandolfino JE. Pathophysiology of Gastroesophageal Reflux Disease. Gastroenterology 2018; 154:277-288. [PMID: 29037470 DOI: 10.1053/j.gastro.2017.09.047] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/07/2017] [Accepted: 09/08/2017] [Indexed: 12/13/2022]
Abstract
The pathogenesis of gastroesophageal reflux disease (GERD) is complex and involves changes in reflux exposure, epithelial resistance, and visceral sensitivity. The gastric refluxate is a noxious material that injures the esophagus and elicits symptoms. Esophageal exposure to gastric refluxate is the primary determinant of disease severity. This exposure arises via compromise of the anti-reflux barrier and reduced ability of the esophagus to clear and buffer the refluxate, leading to reflux disease. However, complications and symptoms also occur in the context of normal reflux burden, when there is either poor epithelial resistance or increased visceral sensitivity. Reflux therefore develops via alterations in the balance of aggressive and defensive forces.
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Affiliation(s)
- Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Belgium.
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Yi CH, Lei WY, Hung JS, Liu TT, Orr WC, Chen CL. Sleep disturbance and enhanced esophageal capsaicin sensitivity in patients with gastroesophageal reflux disease. J Gastroenterol Hepatol 2016; 31:1940-1945. [PMID: 27131333 DOI: 10.1111/jgh.13428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIM Esophageal infusion of capsaicin-containing red pepper sauce induced heartburn symptoms in patients with gastroesophageal reflux disease (GERD). We aimed to test the hypothesis whether sleep disturbance modulates esophageal sensitivity to capsaicin infusion in patients with GERD. METHODS We enrolled 40 patients with their sleep quality measured by the Pittsburg Sleep Quality Index with > 5 indicating sleep disturbance. Esophageal sensation to capsaicin infusion was documented via measures of lag time to initial heartburn perception, heartburn intensity rating, and sensitivity score by esophageal infusion of capsaicin-containing red pepper sauce. Objective sleep measures were assessed by ambulatory actigraphy. RESULTS We found 22 patients with sleep disturbance. The patients with sleep disturbance had shorter lag time to initial heartburn perception (P = 0.03) and greater sensory intensity rating (P = 0.02). The sensitivity score for capsaicin infusion was greater in patients with sleep disturbance when compared with those without sleep disturbance (P = 0.04). Actigraphy measures revealed that patients with sleep disturbance also had poor sleep efficiency (P = 0.04), longer average awakening time (P = 0.03), and greater total activity account (P = 0.04). The lag time for perceiving capsaicin infusion was positively correlated with total sleep time (r = 0.43, P = 0.03). CONCLUSIONS We have shown that GERD patients with sleep disturbance have significantly enhanced heartburn perception to capsaicin infusion as compared with those with normal sleep. Our findings suggest that sleep disturbance is associated with esophageal hypersensitivity to capsaicin infusion in patients with GERD.
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Affiliation(s)
- Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - William C Orr
- Lynn Institute for Healthcare Research, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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18
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Mauritz FA, Rinsma NF, van Heurn ELW, Sloots CEJ, Siersema PD, Houwen RHJ, van der Zee DC, Masclee AAM, Conchillo JM, Van Herwaarden-Lindeboom MYA. Esophageal mucosal integrity improves after laparoscopic antireflux surgery in children with gastroesophageal reflux disease. Surg Endosc 2016; 31:2910-2917. [PMID: 27804042 PMCID: PMC5487897 DOI: 10.1007/s00464-016-5304-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 10/14/2016] [Indexed: 12/17/2022]
Abstract
Background Esophageal intraluminal baseline impedance reflects the conductivity of the esophageal mucosa and may be an instrument for in vivo evaluation of mucosal integrity in children with gastroesophageal reflux disease (GERD). Laparoscopic antireflux surgery (LARS) is a well-established treatment option for children with proton pump inhibitory (PPI) therapy resistant GERD. The effect of LARS in children on baseline impedance has not been studied in detail. The aim of this study was to evaluate the effect of LARS on baseline impedance in children with GERD. Methods This is a prospective, multicenter, nationwide cohort study (Dutch national trial registry: NTR2934) including 25 patients [12 males, median age 6 (range 2–18) years] with PPI-resistant GERD scheduled to undergo LARS. Twenty-four hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3 months after LARS. Baseline impedance was evaluated during consecutive 2-h intervals in the 24-h tracings. Results LARS reduced acid exposure time from 8.5 % (6.0–16.2 %) to 0.8 % (0.2–2.8 %), p < 0.001. Distal baseline impedance increased after LARS from 2445 Ω (1147–3277 Ω) to 3792 Ω (3087–4700 Ω), p < 0.001. Preoperative baseline impedance strongly correlated with acid exposure time (r −0.76, p < 0.001); however, no association between symptomatic outcome and baseline impedance was identified. Conclusions LARS significantly increased baseline impedance likely reflecting recovery of mucosal integrity. As the change in baseline impedance was not associated with the clinical outcome of LARS, other factors besides mucosal integrity may contribute to symptom perception in children with GERD.
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Affiliation(s)
- Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands. .,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Nicolaas F Rinsma
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ernest L W van Heurn
- Department of Pediatric Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roderick H J Houwen
- Department of Pediatric Gastroenterology and Hepatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
| | - Ad A M Masclee
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - José M Conchillo
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Maud Y A Van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
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19
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Ribolsi M, Balestrieri P, Holloway RH, Emerenziani S, Cicala M. Intra-bolus pressure and esophagogastric gradient, assessed with high-resolution manometry, are associated with acid exposure and proximal migration of refluxate. Dis Esophagus 2016; 29:1020-1026. [PMID: 26542165 DOI: 10.1111/dote.12434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Trans-sphincteric pressure gradient (TSPG) seems to play a relevant role in eliciting refluxes during transient lower esophageal sphincter relaxations (TLESRs). Intra-bolus pressure (IBP) is considered to be correlated to esophageal wall tone. We aimed to evaluate the relationship between IBP, TSPG during TLESRs and the dynamic properties of refluxate in gastroesophageal reflux disease. Sixteen non-erosive reflux disease (NERD), 10 erosive disease (ERD) patients and 12 healthy volunteers (HVs), underwent 24-hour impedance-pH monitoring and combined high-resolution manometry-impedance before and 60 minutes. After a meal, ERD patients presented a significantly lower mean IBP (4.7 ± 1.6 mmHg) respect to NERD patients (8.9 ± 2.8 mmHg) and HVs (9.2 ± 3.2 mmHg). NERD patients with physiological abnormal acid exposure time showed a mean IBP (10.4 ± 3.1 mmHg) significantly higher than that in NERD with pathological abnormal acid exposure time (5.1 ± 1.5 mmHg). The TSPG value was significantly higher during TLESRs accompanied by reflux than during TLESRs not associated with reflux, both in patients and in HVs. A significant direct correlation was found between IBP, TSPG and proximal spread of refluxes in patients and in HVs. Gastroesophageal reflux disease patients display different degrees of esophageal distension. An increased compliance of the distal esophagus may accommodate larger volumes of refluxate and likely facilitates the injuries development. Higher TSPG values appear to facilitate the occurrence of refluxes during TLESRs. In patients with NERD, higher TSPG and IBP values favor proximal spread of refluxate and hence may play a relevant role in symptom generation.
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Affiliation(s)
- M Ribolsi
- Gastroenterology, Campus Bio Medico University, Rome, Italy
| | - P Balestrieri
- Gastroenterology, Campus Bio Medico University, Rome, Italy
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - S Emerenziani
- Gastroenterology, Campus Bio Medico University, Rome, Italy
| | - M Cicala
- Gastroenterology, Campus Bio Medico University, Rome, Italy
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Abstract
PURPOSE OF REVIEW The traditional gold standard for measuring gastroesophageal acid reflux has been by placing a pH sensor 5 cm proximal to the lower esophageal sphincter. It is known that damage induced by reflux is maximal near to the gastroesophageal junction and this has stimulated interest in determining acid reflux at that site. RECENT FINDINGS The extent of esophageal exposure from refluxing gastric acid is inversely related to the distance proximal to the gastroesophageal junction. In addition, the pH transition point from gastric to esophageal pH can be displaced proximally within the lower esophageal sphincter without complete loss of sphincter tone. This intrasphincteric reflux is associated with proximal extension of cardia mucosa because of columnar metaplasia of the most distal esophageal squamous mucosa. SUMMARY The most distal esophageal mucosa is exposed to substantially greater gastric acid refluxate than that recorded at the traditional site 5 cm proximal to the lower esophageal sphincter.
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21
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van Hoeij FB, Weijenborg PW, van den Bergh Weerman MA, van den Wijngaard RMJGJ, Verheij J, Smout AJPM, Bredenoord AJ. Mucosal integrity and sensitivity to acid in the proximal esophagus in patients with gastroesophageal reflux disease. Am J Physiol Gastrointest Liver Physiol 2016; 311:G117-22. [PMID: 27198192 DOI: 10.1152/ajpgi.00134.2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 05/15/2016] [Indexed: 01/31/2023]
Abstract
Acid reflux episodes that extend to the proximal esophagus are more likely to be perceived. This suggests that the proximal esophagus is more sensitive to acid than the distal esophagus, which could be caused by impaired mucosal integrity in the proximal esophagus. Our aim was to explore sensitivity to acid and mucosal integrity in different segments of the esophagus. We used a prospective observational study, including 12 patients with gastroesophageal reflux disease (GERD). After stopping acid secretion-inhibiting medication, two procedures were performed: an acid perfusion test and an upper endoscopy with electrical tissue impedance spectroscopy and esophageal biopsies. Proximal and distal sensitivity to acid and tissue impedance were measured in vivo, and mucosal permeability and epithelial intercellular spaces at different esophageal levels were measured in vitro. Mean lag time to heartburn perception was much shorter after proximal acid perfusion (0.8 min) than after distal acid perfusion (3.9 min) (P = 0.02). Median in vivo tissue impedance was significantly lower in the distal esophagus (4,563 Ω·m) compared with the proximal esophagus (8,170 Ω·m) (P = 0.002). Transepithelial permeability, as measured by the median fluorescein flux was significantly higher in the distal (2,051 nmol·cm(-2)·h(-1)) than in the proximal segment (368 nmol·cm(-2)·h(-1)) (P = 0.033). Intercellular space ratio and maximum heartburn intensity were not significantly different between the proximal and distal esophagus. In GERD patients off acid secretion-inhibiting medication, acid exposure in the proximal segment of the esophagus provokes symptoms earlier than acid exposure in the distal esophagus, whereas mucosal integrity is impaired more in the distal esophagus. These findings indicate that the enhanced sensitivity to proximal reflux episodes is not explained by increased mucosal permeability.
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Affiliation(s)
- Froukje B van Hoeij
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and
| | - Pim W Weijenborg
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and
| | | | - René M J G J van den Wijngaard
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and
| | - J Verheij
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands;
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22
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Lee RH, Korsapati H, Bhalla V, Varki N, Mittal RK. Esophageal Submucosal Injection of Capsaicin but Not Acid Induces Symptoms in Normal Subjects. J Neurogastroenterol Motil 2016; 22:436-43. [PMID: 26932896 PMCID: PMC4930298 DOI: 10.5056/jnm15166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/14/2016] [Accepted: 01/27/2016] [Indexed: 12/17/2022] Open
Abstract
Background/Aims Transient receptor potential vanilloid-1 (TRPV1) is a candidate for mediating acid-induced symptoms in the esophagus. We conducted studies to determine if the presence of acid in the mucosa/submucosa and direct activation of TRPV1 by capsaicin elicited symptoms in normal healthy subjects. We also studied the presence of TRPV1 receptors in the esophagus. Methods Unsedated endoscopy was performed on healthy subjects with no symptoms. Using a sclerotherapy needle, normal saline (pH 2.0–7.5) was injected into the mucosa/submucosa, 5 cm above the Z line. In a separate group of healthy subjects, injection of capsaicin and vehicle was also studied. Quality of symptoms was reported using the McGill Pain Questionnaire, and symptom intensity using the visual analogue scale (VAS). Immunohistochemistry was performed on 8 surgical esophagus specimens using TRPV1 antibody. Results Acid injection either did not elicit or elicited mild symptoms in subjects at all pH solutions. Capsaicin but not the vehicle elicited severe heartburn/chest pain in all subjects. Mean VAS for capsaicin was 91 ± 3 and symptoms lasted for 25 ± 1 minutes. Immunohistochemistry revealed a linear TRPV1 staining pattern between the epithelial layer and the submucosa that extended into the papillae. Eighty-five percent of papillae stained positive for TRPV1 with a mean 1.1 positive papillae per high-powered field. Conclusions The mechanism of acid-induced heartburn and chest pain is not the simple interaction of hydrogen ions with afferents located in the esophageal mucosa and submucosa. TRPV1 receptors are present in the lamina propria and their activation induces heartburn and chest pain.
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Affiliation(s)
- Robert H Lee
- Division of Gastroenterology, University of California Irvine, Irvine, CA, USA
| | - Hariprasad Korsapati
- Division of Gastroenterology, University of California, San Diego, San Diego, CA, USA.,Gastroenterology Section, San Diego Veterans Administration Medical Center, La Jolla, CA, USA
| | - Vikas Bhalla
- Division of Gastroenterology, University of California, San Diego, San Diego, CA, USA.,Gastroenterology Section, San Diego Veterans Administration Medical Center, La Jolla, CA, USA
| | - Nissi Varki
- Department of Pathology, University of California San Diego, San Diego, CA, USA
| | - Ravinder K Mittal
- Division of Gastroenterology, University of California, San Diego, San Diego, CA, USA.,Gastroenterology Section, San Diego Veterans Administration Medical Center, La Jolla, CA, USA
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23
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de Bortoli N, Martinucci I, Savarino E, Franchi R, Bertani L, Russo S, Ceccarelli L, Costa F, Bellini M, Blandizzi C, Savarino V, Marchi S. Lower pH values of weakly acidic refluxes as determinants of heartburn perception in gastroesophageal reflux disease patients with normal esophageal acid exposure. Dis Esophagus 2016; 29:3-9. [PMID: 25212408 DOI: 10.1111/dote.12284] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Multichannel impedance pH monitoring has shown that weakly acidic refluxes are able to generate heartburn. However, data on the role of different pH values, ranging between 4 and 7, in the generation of them are lacking. The aim of this study was to evaluate whether different pH values of weakly acidic refluxes play a differential role in provoking reflux symptoms in endoscopy-negative patients with physiological esophageal acid exposure time and positive symptom index and symptom association probability for weakly acidic refluxes. One hundred and forty-three consecutive patients with gastroesophageal reflux disease, nonresponders to proton pump inhibitors (PPIs), were allowed a washout from PPIs before undergoing: upper endoscopy, esophageal manometry, and multichannel impedance pH monitoring. In patients with both symptom index and symptom association probability positive for weakly acidic reflux, each weakly acidic reflux was evaluated considering exact pH value, extension, physical characteristics, and correlation with heartburn. Forty-five patients with normal acid exposure time and positive symptom association probability for weakly acidic reflux were identified. The number of refluxes not heartburn related was higher than those heartburn related. In all distal and proximal liquid refluxes, as well as in distal mixed refluxes, the mean pH value of reflux events associated with heartburn was significantly lower than that not associated. This condition was not confirmed for proximal mixed refluxes. Overall, a low pH of weakly acidic reflux represents a determinant factor in provoking heartburn. This observation contributes to better understand the pathophysiology of symptoms generated by weakly acidic refluxes, paving the way toward the search for different therapeutic approaches to this peculiar condition of esophageal hypersensitivity.
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Affiliation(s)
- N de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - I Martinucci
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - E Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - R Franchi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - L Bertani
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - S Russo
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - L Ceccarelli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - F Costa
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - M Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - C Blandizzi
- Division of Pharmacology and Chemotherapy, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - V Savarino
- Division of Gastroenterology, Department of Internal Medicine DIMI, University of Genova, Genoa, Italy
| | - S Marchi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
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24
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Sano H, Iwakiri K, Kawami N, Tanaka Y, Sakamoto C. Mechanisms of acid reflux and how refluxed Acid extends proximally in patients with non-erosive reflux disease. Digestion 2015; 90:108-15. [PMID: 25196607 DOI: 10.1159/000365588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 06/27/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS The mechanisms that cause acid reflux in patients with non-erosive reflux disease (NERD), including those that determine how acid extends proximally, are not yet clear. METHODS Concurrent esophageal manometry and pH monitoring were performed for 3 h after a meal in 13 patients with NERD, 12 with mild reflux esophagitis (RE), and 13 healthy subjects (HS). RESULTS Transient lower esophageal sphincter (LES) relaxation (TLESR) was the major mechanism of acid reflux in all three groups. LES pressure did not differ between the groups. At 2 cm above the LES, there were no differences between the three groups in the number of TLESR-related acid reflux episodes, rate of TLESRs and rate of acid reflux during TLESR. However, at 7 cm above the LES, the rate of acid reflux during TLESRs was significantly higher in patients with NERD (mean ± SEM 42.3 ± 4.8) than in those with mild RE (28.0 ± 3.8) and HS (10.8 ± 2.5). CONCLUSIONS TLESRs are the sole motor events underlying acid reflux episodes in patients with NERD. Acid extends proximally more readily in patients with NERD than in HS and those with mild RE.
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Affiliation(s)
- Hirohito Sano
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
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25
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Miwa H, Haruma K, Sakamoto S, Sanada K, Hiroi S, Kinoshita Y. Demography and treatment response in patients with predominant non-erosive reflux disease or functional dyspepsia. J Gastroenterol Hepatol 2015; 30:834-41. [PMID: 25559435 DOI: 10.1111/jgh.12877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM Non-erosive reflux disease (NERD) and functional dyspepsia (FD) share some common features, and the appropriateness of managing these diseases independently has been questioned. A post-hoc subgroup analysis of the LEGEND study was performed to compare demographics and treatment response between patients with NERD and patients with FD. METHODS Patients with reflux and dyspepsia symptoms who had no endoscopic evidence of mucosal breaks and/or erosions were included and divided into groups with predominant NERD (n = 1546) or FD (n = 614). Patients received lansoprazole for 4 weeks, and their symptoms were evaluated using questionnaires. RESULTS FD patients were significantly younger than NERD patients (54 vs 60 years), more likely to have a body mass index < 25 kg/m(2) (72.4% vs 67.1%), less likely to have a hiatal hernia (24.0% vs 31.2%), and more likely to feel continuous stress (54.7% vs 48.0%). After 4 weeks of treatment, > 60% of both patients reported an improvement in reflux symptoms and in most dyspepsia symptoms. The improvement rate for reflux symptoms was lower in FD patients than in NERD patients (P < 0.05), whereas the improvement rate for dyspepsia symptoms did not differ between patient groups. CONCLUSION Although no clinically significant differences in pathophysiology exist between NERD and FD, there are some between-group differences in demographic characteristics and improvement rates for reflux symptoms after treatment with lansoprazole. It remains to be discussed whether it is necessary to make a strict differential diagnosis between these two conditions.
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Affiliation(s)
- Hiroto Miwa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Okayama, Japan
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26
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Rinsma NF, Farré R, Bouvy ND, Masclee AAM, Conchillo JM. The effect of endoscopic fundoplication and proton pump inhibitors on baseline impedance and heartburn severity in GERD patients. Neurogastroenterol Motil 2015; 27:220-8. [PMID: 25348594 DOI: 10.1111/nmo.12468] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 10/06/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antireflux therapy may lead to recovery of impaired mucosal integrity in gastro-esophageal reflux disease (GERD) patients as reflected by an increase in baseline impedance. The study objective was to evaluate the effect of endoscopic fundoplication and proton pump inhibitor (PPI) PPI therapy on baseline impedance and heartburn severity in GERD patients. METHODS Forty-seven GERD patients randomized to endoscopic fundoplication (n = 32) or PPI therapy (n = 15), and 29 healthy controls were included. Before randomization and 6 months after treatment, baseline impedance was obtained during 24-h pH-impedance monitoring. Heartburn severity was evaluated using the GERD-HRQL questionnaire. KEY RESULTS Before treatment, baseline impedance in GERD patients was lower than in healthy controls (p < 0.001). Antireflux therapy increased baseline impedance (from 1498 [IQR 951-2472] to 2393 [IQR 1353-3027] Ω, p = 0.001), however it only led to a partial recovery when compared to healthy controls (2393 [IQR 1353-3027] vs 2983 [2335-3810] Ω, p < 0.01). The effect of both treatment options was not significantly different (p = 0.13) despite the increased number of non-acid reflux events in the PPI group. No correlation was found between baseline impedance and GERD symptoms before or after treatment. CONCLUSIONS & INFERENCES Reduction in acid reflux by endoscopic fundoplication or PPI therapy leads to an increase in baseline impedance in GERD patients, likely to reflect recovery of mucosal integrity. The impact of non-acid reflux events on esophageal mucosal integrity may be limited as no difference in the increase in baseline impedance was observed after both treatment options. The lack of association between impedance baseline and heartburn severity indicates that other factors may contribute to heartburn perception in GERD.
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Affiliation(s)
- N F Rinsma
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
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27
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Abstract
Dramatic progress has been made over the past decade in the sophistication and availability of equipment to test esophageal motility and sensation. High-resolution esophageal manometry and impedance have moved from the research clinic into clinical practice. Some of the testing is costly and time consuming, and requires extensive experience to perform the testing and properly interpret the results. These sensory studies are valuable in the interpretation of clinical problems, and provide important research information. Clinicians should evaluate the research studies to advance their understanding of the pathophysiology of the esophagus.
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Affiliation(s)
- Salman Nusrat
- Section of Digestive Disease and Nutrition, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Philip B Miner
- Division of Gastroenterology, Department of Medicine, Oklahoma Foundation for Digestive Research, Oklahoma University School of Medicine, 525 Northwest 9th Street, Suite 325, Oklahoma City, OK 73102, USA.
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28
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Hoppo T, Rodríguez L, Soffer E, Crowell MD, Jobe BA. Long-term results of electrical stimulation of the lower esophageal sphincter for treatment of proximal GERD. Surg Endosc 2014; 28:3293-301. [PMID: 25047169 DOI: 10.1007/s00464-014-3603-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 05/03/2014] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Electrical stimulation of the lower esophageal sphincter (LES) in gastroesophageal reflux disease (GERD) patients, using EndoStim(®) LES stimulation system (EndoStim BV, the Hague, Netherlands), enhances LES pressure, decrease distal esophageal acid exposure, improves symptoms, and eliminates the need in many patients for daily GERD medications. AIM To evaluate, in a post hoc analysis, the effect of LES stimulation on proximal esophageal acid exposure in a subgroup of patients with abnormal proximal esophageal acid exposure. METHODS Nineteen patients (median age 54 years; IQR 47-64; men-10) with GERD partially responsive to proton pump inhibitors (PPI), hiatal hernia ≤ 3 cm, esophagitis ≤ LA grade C underwent laparoscopic implantation of the LES stimulator. LES stimulation at 20 Hz, 215 μs, 5-8 m Amp sessions was delivered in 6-12, 30 min sessions each day. Esophageal pH at baseline and after 12-months of LES stimulation was measured 5 and 23 cm above the manometric upper border of LES. RESULTS Total, upright and supine values of median (IQR) proximal esophageal pH at baseline were 0.4 (0.1-1.4), 0.6 (0.2-2.3), and 0 (0.0-0.2) %, respectively, and at 12 months on LES-EST were 0 (0-0) % (p = 0.001 total and upright; p = 0.043 supine comparisons). 24-hour distal esophageal acid exposure improved from 10.2 (7.6-11.7) to 3.4 (1.6-7.0) % (p = 0.001). Seven (37%) patients had abnormal (>1.1%) 24-hour proximal acid exposure at baseline; all normalized at 12 months (p = 0.008). In these 7 patients, total, upright, and supine median proximal acid exposure values at baseline were 1.7 (1.3-4.1), 2.9 (1.9-3.7), and 0.3 (0-4.9) %, respectively, and after 12 months of LES-EST were 0 (0-0.0), 0 (0-0.1), and 0 (0-0) % (p = 0.018 total and upright; p = 0.043 supine comparisons). Distal esophageal pH for this group improved from 9.3 (7.8-17.2) at baseline to 3.2 (1.1-3.7) % at 12-months (p = 0.043). There were no GI side effects such as dysphagia, gas-bloat or diarrhea or device or procedure related serious adverse events with LES-EST. There was also a significant improvement in their GERD-HRQL scores. CONCLUSION LES-EST is associated with normalization of proximal esophageal pH in patients with GERD and may be useful in treating those with proximal GERD. The LES-EST is safe without typical side effects associated with traditional antireflux surgery.
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Affiliation(s)
- Toshitaka Hoppo
- Institute for the Treatment of Esophageal & Thoracic Disease, The Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, PA, USA,
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29
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Huang L, Xu AM, Li TJ, Han WX, Xu J. Should peri-gastrectomy gastric acidity be our focus among gastric cancer patients? World J Gastroenterol 2014; 20:6981-6988. [PMID: 24944492 PMCID: PMC4051941 DOI: 10.3748/wjg.v20.i22.6981] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/19/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the necessity and correctness of acid suppression pre- and post-gastrectomy among gastric carcinoma (GC) patients.
METHODS: From June 2011 to April 2013, 99 patients who were diagnosed with GC or adenocarcinoma of the gastroesophageal junction (type II or III) and needed surgical management were enrolled. They all underwent gastrectomy by the same operators [35 undergoing total gastrectomy (TG) plus Roux-en-Y reconstruction, 34 distal gastrectomy (DG) plus Billroth I reconstruction, and 30 proximal gastrectomy (PG) plus gastroesophagostomy]. We collected and analyzed their gastrointestinal juice and tissues from the pre-operational day to the 5th day post-operation, and 6 mo post-surgery. Gastric pH was detected with a precise acidity meter. Gastric juice contents including potassium, sodium and bicarbonate ions, urea nitrogen, direct and indirect bilirubin, and bile acid were detected using Automatic Biochemical Analyzer. Data regarding tumor size, histological type, tumor penetration and tumor-node-metastasis (TNM) stage were obtained from the pathological records. Reflux symptoms pre- and 6 mo post-gastrectomy were evaluated by reflux disease questionnaire (RDQ) and gastroesophageal reflux disease questionnaire (GERD-Q). SPSS 16.0 was applied to analyze the data.
RESULTS: Before surgery, gastric pH was higher than the threshold of hypoacidity (4.25 ± 1.45 vs 3.5, P = 0.000), and significantly affected by age, tumor size and differentiation grade, and potassium and bicarbonate ions; advanced malignancies were accompanied with higher pH compared with early ones (4.49 ± 1.31 vs 3.66 ± 1.61, P = 0.008). After operation, gastric pH in all groups was of weak-acidity and significantly higher than that pre-gastrectomy; on days 3-5, comparisons of gastric pH were similar between the 3 groups. Six months later, gastric pH was comparable to that on days 3-5; older patients were accompanied with higher total bilirubin level, indicating more serious reflux (r = 0.238, P = 0.018); the TG and PG groups had higher RDQ (TG vs DG: 15.80 ± 5.06 vs 12.26 ± 2.14, P = 0.000; PG vs DG: 15.37 ± 3.49 vs 12.26 ± 2.14, P = 0.000) and GERD-Q scores (TG vs DG: 10.54 ± 3.16 vs 9.15 ± 2.27, P = 0.039; PG vs DG: 11.00 ± 2.07 vs 9.15 ± 2.27, P = 0.001) compared with the DG group; all gastric juice contents except potassium ion significantly rose; reflux symptom was significantly associated with patient’s body mass index, direct and indirect bilirubin, and total bile acid, while pH played no role.
CONCLUSION: Acidity is not an important factor causing unfitness among GC patients. There is no need to further alkalify gastrointestinal juice both pre- and post-gastrectomy.
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30
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Lee YY, McColl KEL. Disruption of the gastroesophageal junction by central obesity and waist belt: role of raised intra-abdominal pressure. Dis Esophagus 2014; 28:318-25. [PMID: 24575877 DOI: 10.1111/dote.12202] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Obesity is a major reason for the recent increase in incidence of reflux disease and cancers at the distal esophagus and gastroesophageal junction (GOJ) and is mediated through a rise in the intra-abdominal pressure (IAP) but the exact mechanisms are unclear. Raised IAP from obesity and with application of waist belt produces mechanical distortion of the GOJ through formation of partial hiatus hernia. Even though there is no trans-sphincteric acid reflux, there is increased ingress of acid into the lower sphincter (intra-sphincteric reflux) as a consequence of raised IAP. In addition, short segment acid reflux is more evident in obese subjects with a belt on. Acid pocket is also enlarged in hiatus hernia, and acts as a reservoir of acid available to reflux whenever the sphincter fails. Above mechanisms may explain the common occurrence of cardiac lengthening and inflammation found in asymptomatic obese subjects. The inflamed cardia is also immunohistochemically similar to non-intestinal Barrett's mucosa, which is of etiological importance for cancers at the GOJ. Interventions that can reduce the mechanical distortion and acid exposure at the GOJ, including diet, exercise, drugs, sphincter augmentation therapy, and surgery, are clinically relevant in the treatment of gastroesophageal reflux disease but more data are needed whether if these strategies are also effective in preventing cancer. As a conclusion, raised IAP produces silent mechanical disruption of the GOJ, which may explain the high occurrence of cancers in this region and it is potentially reversible with early interventions.
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Affiliation(s)
- Y Y Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bahru, Kelantan, Malaysia; Department of Medicine, Section of Gastroenterology and Hepatology, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA
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31
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Altomare A, Luca Guarino Sara Emerenziani MP, Cicala M, Drewes AM, Krarup AL, Brock C, Lottrup C, Frøkjaer JB, Souza RF, Nardone G, Compare D. Gastrointestinal sensitivity and gastroesophageal reflux disease. Ann N Y Acad Sci 2013; 1300:80-95. [PMID: 24117636 DOI: 10.1111/nyas.12236] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This paper reports on gastrointestinal sensitivity, including on the role of refluxate volume on the perception of reflux symptoms; experimental pain models that mimic mechanisms and symptoms of pain associated with esophageal diseases; the potential role of the acid receptor TRPV1 in the genesis of gastroesophageal reflux disease (GERD) symptoms; and roles for ATP and the purine and pyrimidine receptor subfamilies P1, P2X, and P2Y in the pathogenesis of GERD symptoms.
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Affiliation(s)
- Annamaria Altomare
- Department of Digestive Disease, Campus Bio-medico University, Rome, Italy
| | | | - Michele Cicala
- Department of Digestive Disease, Campus Bio-medico University, Rome, Italy
| | - Asbjørn Mohr Drewes
- Mech-Sense, Departments of Gastroenterology & Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Lund Krarup
- Mech-Sense, Departments of Gastroenterology & Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Departments of Gastroenterology & Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Lottrup
- Mech-Sense, Departments of Gastroenterology & Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjaer
- Mech-Sense, Departments of Gastroenterology & Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Rhonda F Souza
- Departments of Medicine, University of Texas Southwestern Medical Center and the VA North Texas Health Care System, Dallas, Texas
| | - Gerardo Nardone
- Department of Clinical and Experimental Medicine, Gastroenterology Unit, University "Federico II,", Naples, Italy
| | - Debora Compare
- Department of Clinical and Experimental Medicine, Gastroenterology Unit, University "Federico II,", Naples, Italy
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Ohara S, Furuta K, Adachi K, Fukazawa K, Aimi M, Miki M, Kinoshita Y. Generation of Gastroesophageal Reflux Disease Symptoms During Esophageal Acid Infusion With Concomitant Esophageal pH Monitoring in Healthy Adults. J Neurogastroenterol Motil 2013; 19:503-8. [PMID: 24199011 PMCID: PMC3816185 DOI: 10.5056/jnm.2013.19.4.503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/23/2013] [Accepted: 07/31/2013] [Indexed: 11/20/2022] Open
Abstract
Background/Aims The sensitivity of the upper and lower esophageal mucosa to acid is considered to differ. We investigated the relationship between pH changes in different sites of the esophagus and generation of gastroesophageal reflux symptoms during an acid infusion test. Methods An acid infusion catheter was placed at 5 or 15 cm above the lower esophageal sphincter (LES) in 18 healthy volunteers, while a 2-channel pH sensor catheter was also placed in each with the sensors set at 5 and 15 cm above the LES. Solutions containing water and hydrochloric acid at different concentrations were infused through the infusion catheter. Results Acid infusion in the upper esophagus caused a pH drop in both upper and lower esophageal sites, whereas that in the lower esophagus resulted in a significant pH drop only in the lower without a corresponding pH decline in the upper esophagus. Stronger heartburn, chest pain, and chest oppression symptoms were noted when acid was infused in the upper as compared to the lower esophagus, while increased intra-esophageal acidity strengthened each symptom. Regurgitations caused by upper and lower esophageal acid infusions were similar, and not worsened by a larger drop in intra-esophageal pH. Chest pain was caused only by lowered intra-esophageal pH, while heartburn, chest oppression, and regurgitation were induced by a less acidic solution. Conclusions Higher intra-esophageal acidity caused stronger heartburn, chest pain, and chest oppression symptoms. However, regurgitation was not significantly influenced by intra-esophageal acidity. The upper esophagus showed higher acid sensitivity than the lower esophagus.
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Affiliation(s)
- Shunji Ohara
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan. ; Division of Internal Medicine, Himeji Aiwa Hospital, Himeji, Japan
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Lim CH, Choi MG, Baeg MK, Moon SJ, Kim JS, Cho YK, Park JM, Lee IS, Kim SW, Choi KY. Symptom characteristics and psychosomatic profiles in different spectrum of gastroesophageal reflux disease. Gut Liver 2013; 8:165-9. [PMID: 24672658 PMCID: PMC3964267 DOI: 10.5009/gnl.2014.8.2.165] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 05/04/2013] [Accepted: 05/07/2013] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/AIMS Gastroesophageal reflux disease (GERD) is diagnosed based on symptoms of heartburn and regurgitation but is a heterogeneous condition which can be subclassified according to endoscopy and esophageal reflux monitoring. The aim of this study was to identify differences in demographic characteristics and reflux symptom patterns among patients with various spectrum of GERD. METHODS Patients having weekly heartburn or acid regurgitation were classified into four pathophysiological subgroups according to endoscopy and pH monitoring: reflux esophagitis (RE), endoscopy-negative reflux disease with pathological reflux (PR+), hypersensitive esophagus (HE), and normal acid exposure with negative symptom association (pH-). RESULTS A total of 195 patients were enrolled. The numbers of patients in the subgroups were: RE, 39.0%; PR+, 20.0%; HE, 10.3%; and pH-, 30.8%. Grossly, reflux symptom patterns and relieving/exacerbating factors did not differ between subgroups. Prevalence of extraesophageal syndrome was higher in patients with PR+ than in other groups. Overlapping functional dyspepsia was common in all groups. The SCL-90-R depression score was higher in PR+ patients than in RE patients (p<0.05). CONCLUSIONS Demographic characteristics and reflux symptom patterns cannot differentiate pH- group from GERD subtypes. Esophageal pH monitoring could be considered for the initial evaluation of GERD in the tertiary referral setting.
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Affiliation(s)
- Chul-Hyun Lim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Myung-Gyu Choi
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Myong Ki Baeg
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung Jin Moon
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jin Su Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yu Kyung Cho
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jae Myung Park
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - In Seok Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sang Woo Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyu Yong Choi
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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34
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Effect of transoral incisionless fundoplication on reflux mechanisms. Surg Endosc 2013; 28:941-9. [PMID: 24149854 DOI: 10.1007/s00464-013-3250-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 09/30/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Transoral incisionless fundoplication (TIF) is a new endoscopic treatment option for gastroesophageal reflux disease (GERD). The mechanisms underlying the anti-reflux effect of this new procedure have not been studied. We therefore conducted this explorative study to evaluate the effect of TIF on reflux mechanisms, focusing on transient lower esophageal sphincter relaxations (TLESRs) and esophagogastric junction (EGJ) distensibility. METHODS GERD patients (N = 15; 11 males, mean age 41 years, range 23-66), dissatisfied with medical treatment were studied before and 6 months after TIF. We performed 90-min postprandial combined high-resolution manometry and impedance-pH monitoring and an ambulatory 24-h pH-impedance monitoring. EGJ distensibility was evaluated using an endoscopic functional luminal imaging probe before and directly after the procedure. RESULTS TIF reduced the number of postprandial TLESRs (16.8 ± 1.5 vs. 9.2 ± 1.3; p < 0.01) and the number of postprandial TLESRs associated with reflux (11.1 ± 1.6 vs. 5.6 ± 0.6; p < 0.01), but the proportion of TLESRs associated with reflux was unaltered (67.6 ± 6.9 vs. 69.9 ± 6.3 %). TIF also led to a decrease in the number and proximal extent of reflux episodes and an improvement of acid exposure in the upright position; conversely, TIF had no effect on the number of gas reflux episodes. EGJ distensibility was reduced after the procedure (2.4 ± 0.3 vs. 1.6 ± 0.2 mm(2)/mmHg; p < 0.05). CONCLUSIONS TIF reduced the number of postprandial TLESRs, the number of TLESRs associated with reflux and EGJ distensibility. This resulted in a reduction of the number and proximal extent of reflux episodes and improvement of acid exposure in the upright position. The anti-reflux effect of TIF showed to be selective for liquid-containing reflux only, thereby preserving the ability of venting gastric air.
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Woodland P, Sifrim D, Krarup AL, Brock C, Frøkjaer JB, Lottrup C, Drewes AM, Swanstrom LL, Farmer AD. The neurophysiology of the esophagus. Ann N Y Acad Sci 2013; 1300:53-70. [DOI: 10.1111/nyas.12238] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Philip Woodland
- Neurogastroenterology Group, Barts and The London School of Medicine and Dentistry; Queen Mary University of London; London United Kingdom
| | - Daniel Sifrim
- Neurogastroenterology Group, Barts and The London School of Medicine and Dentistry; Queen Mary University of London; London United Kingdom
| | - Anne Lund Krarup
- Mech-Sense, Department of Gastroenterology; Aalborg Hospital; Aarhus University; Aarhus Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology; Aalborg Hospital; Aarhus University; Aarhus Denmark
| | - Jens Brøndum Frøkjaer
- Mech-Sense, Department of Gastroenterology; Aalborg Hospital; Aarhus University; Aarhus Denmark
| | - Christian Lottrup
- Mech-Sense, Department of Gastroenterology; Aalborg Hospital; Aarhus University; Aarhus Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology; Aalborg Hospital; Aarhus University; Aarhus Denmark
| | | | - Adam D. Farmer
- Department of Gastroenterology, Shrewsbury & Telford Hospitals NHS Trust; Princess Royal Hospital; Apley Castle Telford Shropshire United Kingdom
- Neurogastroenterology Group, Blizard Institute of Cell & Molecular Science; Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry; Queen Mary University of London; London United Kingdom
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Robertson EV, Derakhshan MH, Wirz AA, Lee YY, Seenan JP, Ballantyne SA, Hanvey SL, Kelman AW, Going JJ, McColl KEL. Central obesity in asymptomatic volunteers is associated with increased intrasphincteric acid reflux and lengthening of the cardiac mucosa. Gastroenterology 2013; 145:730-9. [PMID: 23796455 DOI: 10.1053/j.gastro.2013.06.038] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 06/07/2013] [Accepted: 06/18/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS In the West, a substantial proportion of subjects with adenocarcinoma of the gastric cardia and gastroesophageal junction have no history of reflux. We studied the gastroesophageal junction in asymptomatic volunteers with normal and large waist circumferences (WCs) to determine if central obesity is associated with abnormalities that might predispose individuals to adenocarcinoma. METHODS We performed a study of 24 healthy, Helicobacter pylori-negative volunteers with a small WC and 27 with a large WC. Abdominal fat was quantified by magnetic resonance imaging. Jumbo biopsy specimens were taken across the squamocolumnar junction (SCJ). High-resolution pH-metry (12 sensors) and manometry (36 sensors) were performed in upright and supine subjects before and after a meal; the SCJ was visualized fluoroscopically. RESULTS The cardiac mucosa was significantly longer in the large WC group (2.5 vs 1.75 mm; P = .008); its length correlated with intra-abdominal (R = 0.35; P = .045) and total abdominal (R = 0.37; P = .034) fat. The SCJ was closer to the upper border of the lower esophageal sphincter (LES) in subjects with a large WC (2.77 vs 3.54 cm; P = .02). There was no evidence of excessive reflux 5 cm above the LES in either group. Gastric acidity extended more proximally within the LES in the large WC group, compared with the upper border (2.65 vs 4.1 cm; P = .027) and peak LES pressure (0.1 cm proximal vs 2.1 cm distal; P = .007). The large WC group had shortening of the LES, attributable to loss of the distal component (total LES length, 3 vs 4.5 cm; P = .043). CONCLUSIONS Central obesity is associated with intrasphincteric extension of gastric acid and cardiac mucosal lengthening. The latter might arise through metaplasia of the most distal esophageal squamous epithelium and this process might predispose individuals to adenocarcinoma.
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Affiliation(s)
- Elaine V Robertson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
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Farré R. Pathophysiology of gastro-esophageal reflux disease: a role for mucosa integrity? Neurogastroenterol Motil 2013; 25:783-99. [PMID: 23937353 DOI: 10.1111/nmo.12201] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 07/16/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastro-esophageal reflux disease (GERD) is very prevalent and has a high burden on health security system costs. Nevertheless, pathophysiology is complex and not well-understood. Several mechanisms have been proposed: decreased salivation, impaired esophageal clearance, decreased lower esophageal sphincter pressure resting tone, presence of hiatal hernia, increased number of transient lower esophageal sphincter relaxations (TLESRs), increased acid, and pepsin secretion, pyloric incompetence provoking duodeno-gastro-esophageal reflux of bile acids and trypsin. Independent of the relevance of each mechanism, the ultimate phenomenon is that mucosal epithelium is exposed for a longer time to agents as acid and pepsin or is in contact to luminal agents not commonly present in gastric refluxate as trypsin or bile acids. This leads to a visible damage of the epithelium (erosive esophagitis -EE) or impairing mucosal integrity without any sign of macroscopic alteration as occurs in non-erosive reflux disease (NERD). Luminal factors are not the only responsible for such impairment; more recent data indicate that endogenous factors may also play a role. PURPOSE This review will update the most recent findings on the putative pathophysiological mechanisms and specially will focus on the role of esophageal mucosal integrity in GERD. Methodologies used for the evaluation of mucosal integrity, its relevance in EE and NERD, its involvement in symptoms perception and the effect of luminal and endogenous factors will be discussed.
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Affiliation(s)
- R Farré
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos II, Madrid, Spain
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Extra-Esophageal Manifestations of Gastroesophageal Reflux Disease: Diagnosis and Treatment. Drugs 2013; 73:1281-95. [DOI: 10.1007/s40265-013-0101-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Weijenborg PW, Bredenoord AJ. How reflux causes symptoms: reflux perception in gastroesophageal reflux disease. Best Pract Res Clin Gastroenterol 2013; 27:353-64. [PMID: 23998974 DOI: 10.1016/j.bpg.2013.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 06/11/2013] [Accepted: 06/23/2013] [Indexed: 02/07/2023]
Abstract
In gastroesophageal reflux disease (GERD) symptoms arise due to reflux of gastric content into the oesophagus. However, the relation between magnitude and onset of reflux and symptom generation in GERD patients is far from simple; gastroesophageal reflux occurs several times a day in everyone and the majority of reflux episodes remains asymptomatic. This review aims to address the question how reflux causes symptoms, focussing on factors leading to enhanced reflux perception. We will highlight esophageal sensitivity variance between subtypes of GERD, which is influenced by peripheral sensitization of primary afferents, central sensitization of spinal dorsal horn neurons, impaired mucosal barrier function and genetic factors. We will also discuss the contribution of specific refluxate characteristics to reflux perception, including acidity, and the role of bile, pepsin and gas and proximal extent. Further understanding of reflux perception might improve GERD treatment, especially in current partial responders to therapy.
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Affiliation(s)
- Pim W Weijenborg
- Dept. of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, Postbus 22660, 1100 DD Amsterdam, The Netherlands.
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Quigley EMM, Lacy BE. Overlap of functional dyspepsia and GERD--diagnostic and treatment implications. Nat Rev Gastroenterol Hepatol 2013; 10:175-86. [PMID: 23296247 DOI: 10.1038/nrgastro.2012.253] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
GERD and functional dyspepsia are the two most prevalent upper gastrointestinal disorders. Gastro-oesophageal reflux is most commonly diagnosed using the cardinal symptoms of heartburn and regurgitation. Patients might also be diagnosed using a questionnaire, after empiric treatment with an acid suppressant, after upper endoscopy or by pH testing. Functional dyspepsia is best diagnosed using symptoms outlined by the Rome committee in conjunction with a normal upper endoscopy. Theoretically, distinguishing these two populations should be easy for all health-care providers. In reality, however, carefully separating out these two populations can be quite difficult, as substantial overlap exists epidemiologically, symptomatically and even diagnostically. This overlap renders precise diagnosis a challenge; given the limited treatment options, the primary goal is to identify those patients who will respond to acid suppressive therapy. Despite the frequency with which functional dyspepsia and GERD overlap, remarkably few studies have investigated this overlap. Most recommendations are based on data derived from separate studies of functional dyspepsia and GERD. A further limitation of existing studies is their failure to differentiate between the various diagnostic categories into which the individual presenting with heartburn might belong.
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Abstract
This article discusses the current state of knowledge regarding the relationship between gastroesophageal reflux disease (GERD) and pulmonary and ear/nose/throat manifestations of reflux and outlines the recent developments in the diagnostic and treatment strategies for this difficult group of patients. Upper gastrointestinal endoscopy and pH monitoring are poorly sensitive for diagnosing reflux in this group of patients. Instead it is recommended that in those without warning symptoms, an empiric trial of proton-pump inhibitors be the initial approach to diagnosing and treating the potential underlying cause of these extraesophageal symptoms.
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Tokudome K, Funaki Y, Sasaki M, Izawa S, Tamura Y, Iida A, Ogasawara N, Konagaya T, Tokura Y, Kasugai K. Efficacy of endoluminal gastroplication in Japanese patients with proton pump inhibitor-resistant, non-erosive esophagitis. World J Gastroenterol 2012; 18:5940-7. [PMID: 23139611 PMCID: PMC3491602 DOI: 10.3748/wjg.v18.i41.5940] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 07/16/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy, safety, and long-term outcomes of endoluminal gastroplication (ELGP) in patients with proton pump inhibitor (PPI)-resistant, non-erosive reflux disease (NERD).
METHODS: The subjects were NERD patients, diagnosed by upper endoscopy before PPI use, who had symptoms such as heartburn or reflux sensations two or more times a week even after 8 wk of full-dose PPI treatment. Prior to ELGP, while continuing full-dose PPI medication, patients’ symptoms and quality of life (QOL) were assessed using the questionnaire for the diagnosis of reflux disease, the frequency scale for symptoms of gastro-esophageal reflux disease (FSSG), gastrointestinal symptoms rating scale, a 36-item short-form. In addition, 24-h esophageal pH monitoring or 24-h intraesophageal pH/impedance (MII-pH) monitoring was performed. The Bard EndoCinchTM was used for ELGP, and 2 or 3 plications were made. After ELGP, all acid reducers were temporarily discontinued, and medication was resumed depending on the development and severity of symptoms. Three mo after ELGP, symptoms, QOL, pH or MII-pH monitoring, number of plications, and PPI medication were evaluated. Further, symptoms, number of plications, and PPI medication were evaluated 12 mo after ELGP to investigate long-term effects.
RESULTS: The mean FSSG score decreased significantly from before ELGP to 3 and 12 mo after ELGP (19.1 ± 10.5 to 10.3 ± 7.4 and 9.3 ± 9.9, P < 0.05, respectively). The total number of plications decreased gradually at 3 and 12 mo after ELGP (2.4 ± 0.8 to 1.2 ± 0.8 and 0.8 ± 1.0, P < 0.05, respectively). The FSSG scores in cases with no remaining plications and in cases with one or more remaining plications were 4.4 and 2.7, respectively, after 3 mo, and 2.0 and 2.8, respectively, after 12 mo, showing no correlation to plication loss. On pH monitoring, there was no difference in the percent time pH < 4 from before ELGP to 3 mo after. Impedance monitoring revealed no changes in the number of reflux episodes or the symptom index for reflux events from before ELGP to 3 mo after, but the symptom sensitivity index decreased significantly 3 mo after ELGP (16.1 ± 12.9 to 3.9 ± 8.3, P < 0.01). At 3 mo after ELGP, 6 patients (31.6%) had reduced their PPI medication by 50% or more, and 11 patients (57.9%) were able to discontinue PPI medication altogether. After 12 mo, 3 patients (16.7%) were able to reduce the amount of PPI medication by 50% or more, and 12 patients (66.7%) were able to discontinue PPI medication altogether. A high percentage of cases with remaining plications had discontinued PPIs medication after 3 mo, but there was no difference after 12 mo. No serious complications were observed in this study.
CONCLUSION: ELGP was safe, resulted in significant improvement in subjective symptoms, and allowed less medication to be used over the long term in patients with PPI-refractory NERD.
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Abstract
BACKGROUND AND AIM Ineffective oesophageal motility (IOM) often occurs in patients with gastro-oesophageal reflux disease. We aimed to examine the hypothesis of whether the presence of IOM differs between patients with gastro-oesophageal reflux disease with different symptom profiles. METHODS Eligible patients were subclassified according to their predominant symptom of heartburn (HB) or acid regurgitation (AR). All patients underwent combined multichannel intraluminal impedance and oesophageal manometry. IOM was further graded according to the presence of oesophageal transit abnormalities. RESULTS Fourteen healthy individuals, 16 HB patients and 24 AR patients participated in this study. The percentage of swallows with complete bolus transit was lower in AR than in HB patients during liquid and viscous swallowing (P<0.05). Abnormal bolus transit occurred more frequently in AR patients than in HB patients with liquid swallows (P<0.001) and viscous swallows (P<0.05). IOM occurred more frequently in AR patients than in HB patients (42.7 vs. 12.5%, P=0.049). In patients with IOM, severe functional abnormality was more frequently found in AR patients than in HB patients (P<0.05). CONCLUSION This study suggests a potential link between oesophageal body dysfunction and individual reflux symptom. Patients with a predominant symptom of AR are characterized by greater IOM and defective bolus clearance.
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Yi CH, Liu TT, Chen CL. Atypical symptoms in patients with gastroesophageal reflux disease. J Neurogastroenterol Motil 2012; 18:278-83. [PMID: 22837875 PMCID: PMC3400815 DOI: 10.5056/jnm.2012.18.3.278] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Revised: 02/02/2012] [Accepted: 02/10/2012] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Atypical symptoms are common in gastroesophageal reflux disease (GERD). Patients with non-erosive reflux disease (NERD) and erosive reflux disease (ERD) exhibit different clinical characteristics and responses to acid suppression treatment. We aimed to compare atypical characteristics in patients with NERD and ERD. We also investigated the presence of histological esophagitis in patients with NERD and ERD. Methods Eligible patients completed a questionnaire regarding reflux symptoms and concomitant atypical symptoms. Endoscopic biopsies with histological examination were performed. Results Of the 210 patients with GERD, 90 patients with ERD and 120 patients with NERD were studied. ERD patients were characterized by higher prevalence of hiatal hernia (P = 0.001) and smoking (P = 0.047). The prevalence of GERD was greater in the age group between 41 and 60 years regardless of endoscopic finding. There was no difference in the prevalence of atypical symptoms or histological esophagitis between NERD and ERD. In all subjects, heartburn was associated with dysphagia (r = 0.16, P = 0.01), dyspepsia (r = 0.22, P = 0.008) and hiccup (r = 0.19, P = 0.003), whereas acid regurgitation was associated with dyspepsia (r = 0.21, P = 0.014), belching (r = 0.15, P = 0.018) and hiccup (r = 0.19, P = 0.002). Conclusions Atypical symptoms did not correlate with the presence of histological esophagitis. Atypical symptoms were equally prevalent in patients with NERD and ERD. The existence of atypical symptoms appears to be associated with the presence of typical reflux symptoms irrespective of endoscopic and histological reflux esophagitis.
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Affiliation(s)
- Chih-Hsun Yi
- Department of Medicine, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
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Increased frequency and enhanced perception of reflux in non-erosive reflux disease patients non-responders to proton pump inhibitors. Dig Liver Dis 2012; 44:549-54. [PMID: 22366345 DOI: 10.1016/j.dld.2012.01.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 01/07/2012] [Accepted: 01/11/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND The unsatisfactory response to medical treatment in non-erosive patients is becoming a real challenge for gastroenterologists. Non-responder patients, evaluated under treatment, present symptoms which are related to non-acidic, mixed and proximal reflux episodes. METHODS To elucidate the reflux pattern and mechanisms related to persistence of symptoms despite treatment, oesophageal pH-impedance was performed in 55 non-erosive responder and 24 non-responder patients, studied off therapy. Ten responder and 10 non-responder patients underwent a repeated study during proton pump inhibitor treatment. RESULTS Non-responders were characterised by a higher overall number and larger proportion of symptomatic reflux episodes. Non-responders were also characterised by an enhanced sensitivity to acidic, mixed and proximal refluxes. Weakly acidic reflux accounted for 29% of symptomatic refluxes in non-responders and 34% in responders. Proportions of acidic and weakly acidic reflux episodes were comparable both in responders and non-responders when analysed off and on treatment. CONCLUSIONS An increased overall number of reflux episodes and enhanced sensitivity to reflux are strongly associated with treatment failure. Treatment strategies aimed at decreasing transient lower oesophageal sphincter relaxations, pain modulators or anti-reflux surgery should be considered in non-responders in whom a significant relationship between symptoms and reflux has been confirmed.
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Shimatani T, Sugimoto M, Nishino M, Adachi K, Furuta K, Ito M, Kurosawa S, Manabe N, Mannen K, Hongo M, Chiba T, Kinoshita Y. Predicting the efficacy of proton pump inhibitors in patients with non-erosive reflux disease before therapy using dual-channel 24-h esophageal pH monitoring. J Gastroenterol Hepatol 2012; 27:899-906. [PMID: 22098590 DOI: 10.1111/j.1440-1746.2011.06975.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM We aimed to determine whether reflux- and symptom-related parameters can predict the efficacy of proton pump inhibitors (PPI) in non-erosive reflux disease (NERD). METHODS Twenty-seven NERD patients who had experienced heartburn more than once a week within the previous month were enrolled. Intraesophageal pH before therapy was measured simultaneously at 5 and 15 cm above the esophagogastric junction (EGJ) for 24 h. The PPI rabeprazole was administered at a dose of 10 mg once daily for 4 weeks. In the event that heartburn was not relieved, the dose was increased to 10 mg twice daily for an additional 2 weeks, and again to 20 mg twice daily for another 2 weeks. RESULTS Univariate analysis demonstrated no significant associations between any reflux- or symptom-related parameters at either site and complete heartburn relief after 4 weeks, or cumulative complete heartburn relief after 8 weeks. However, post-hoc analysis demonstrated more satisfactory heartburn relief after 4 weeks in patients with a high symptom index compared with those with a low symptom index, at 5 cm above the EGJ (P = 0.009). Cumulative satisfactory heartburn relief after 8 weeks was also greater in patients with a high total number of acid reflux episodes compared with those with a low total number of episodes, at 15 cm above the EGJ (P = 0.037). CONCLUSIONS Pre-therapeutic pH monitoring in the lower and mid-esophagus is useful for predicting the efficacy of PPI in NERD patients.
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Affiliation(s)
- Tomohiko Shimatani
- Division of Adult Nursing and Internal Medicine, Hiroshima International University, Kure, Japan.
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van Boxel OS, ter Linde JJM, Oors J, Otto B, Feinle-Bisset C, Smout AJPM, Siersema PD. Duodenal lipid-induced symptom generation in gastroesophageal reflux disease: role of apolipoprotein A-IV and cholecystokinin. Neurogastroenterol Motil 2012; 24:350-e168. [PMID: 22300015 DOI: 10.1111/j.1365-2982.2012.01880.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Duodenal lipid intensifies the perception of esophageal acid perfusion. Recently, we showed that genes implicated in lipid absorption were upregulated in the duodenum of fasting gastro-esophageal reflux disease (GERD) patients. This suggests that chylomicron production and secretion may be enhanced and, consequently, the release of apolipoprotein A-IV (apoA-IV), a chylomicron-derived signaling protein. ApoA-IV may stimulate release of cholecystokinin (CCK), an activator of vagal afferents. This study evaluated putative involvement of abnormal apoA-IV and CCK responses to lipid in GERD. METHODS Ten GERD patients and 10 healthy volunteers (HV) underwent duodenal perfusion with Intralipid 20%, 2 kcal min(-1) , for 60 min. Symptoms were scored, blood samples collected every 15 min during lipid perfusion and 15 min after discontinuation when duodenal biopsies were taken. Plasma and mucosal concentrations of apoA-IV and CCK and transcript levels of 21 genes implicated in lipid absorption, differentially expressed under fasting conditions, were quantified. KEY RESULTS Heartburn (P = 0.003), abdominal discomfort (P = 0.037) and nausea (P = 0.008) only increased significantly during lipid infusion in GERD patients. Following lipid infusion mean mucosal apoA-IV concentration was lower in GERD patients compared with HV (P = 0.023), whereas plasma concentration tended to be elevated (P = 0.068). Mean mucosal CCK concentration was also lower in GERD patients (P = 0.009). Two genes, HIBADH and JTB, were upregulated in GERD patients (P = 0.008 and P = 0.038, respectively). CONCLUSIONS & INFERENCES Our results suggest excessive duodenal lipid-induced release of apoA-IV and CCK in GERD. We postulate that the resulting heightened activation of duodenal vagal afferents may underlie central sensitization, thereby increasing the perception of reflux events.
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Affiliation(s)
- O S van Boxel
- Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, the Netherlands.
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Shapiro M, Simantov R, Yair M, Leitman M, Blatt A, Scapa E, Broide E. Comparison of central and intraesophageal factors between gastroesophageal reflux disease (GERD) patients and those with GERD-related noncardiac chest pain. Dis Esophagus 2012; 25:702-8. [PMID: 22309285 DOI: 10.1111/j.1442-2050.2011.01317.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux disease (GERD) causes a wide range of symptoms. Some patients present with typical symptoms such as heartburn and regurgitation and others with atypical symptoms such as chest pain. The mechanism responsible for the varying clinical presentation of GERD is still not fully elucidated. The aim of this study was to prospectively evaluate differences in central and local intraesophageal factors between patients with typical GERD symptoms and those with noncardiac chest pain (NCCP). Patients presenting with typical and atypical symptoms suspicious of GERD underwent upper endoscopy and 24-hour pH monitoring with four sensors, each positioned at a different esophageal level. All patients completed GERD symptom, Hospital Anxiety and Depression Scale, and Symptom Stress Rating questionnaires. From January 2006 to December 2009, 50 patients were recruited, 29 with typical symptoms, and 21 with NCCP. Patients with proven GERD and NCCP had higher proximal extension of acid during reflux episodes than patients with typical symptoms. They were found to be older, had a shorter history of symptom onset, worse anxiety scores, and more endoscopic findings compatible with gastritis. Proximal extension of acid during the reflux episodes in patients with GERD presenting with NCCP may play a role in symptom generation.
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Affiliation(s)
- M Shapiro
- Institute of Gastroenterology, Liver Diseases and Nutrition, Assaf Harofeh Medical Center, Zerifin, Israel.
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Arts J, Bisschops R, Blondeau K, Farré R, Vos R, Holvoet L, Caenepeel P, Lerut A, Tack J. A double-blind sham-controlled study of the effect of radiofrequency energy on symptoms and distensibility of the gastro-esophageal junction in GERD. Am J Gastroenterol 2012; 107:222-30. [PMID: 22108449 DOI: 10.1038/ajg.2011.395] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Several studies have reported symptom relief in gastro-esophageal reflux disease (GERD) patients treated with radiofrequency delivery (Stretta procedure) at the gastro-esophageal junction (GEJ), but the mechanism underlying this improvement is unclear. The objective of this study was to test the hypothesis that Stretta alters GEJ resistance. METHODS We conducted a double-blind randomized cross-over study of Stretta and sham treatment. Consecutive GERD patients were included in the study. The study was conducted in a tertiary care center. Patients underwent two upper gastrointestinal endoscopies with 3 months interval, during which active or sham Stretta treatment was performed in a randomized double-blind manner. Symptom assessment, endoscopy, manometry, 24-h esophageal pH monitoring, and a distensibility test of the GEJ were done before the start of the study and after 3 months. RESULTS Barostat distensibility test of the GEJ before and after administration of sildenafil was the main outcome measure. In all, 22 GERD patients (17 females, mean age 47±12 years) participated in the study; 11 in each group. Initial sham treatment did not affect any of the parameters studied. Three months after initial Stretta procedure, no changes were observed in esophageal acid exposure and lower esophageal sphincter (LES) pressure. In contrast, symptom score was significantly improved and GEJ compliance was significantly decreased. Administration of sildenafil, an esophageal smooth muscle relaxant, normalized GEJ compliance again to pre-Stretta level, arguing against GEJ fibrosis as the underlying mechanism. CONCLUSIONS The limitation of this study was reflux evaluation did not include impedance monitoring. In this sham-controlled study, Stretta improved GERD symptoms and decreased GEJ compliance. Decreased GEJ compliance, which reflects altered LES neuromuscular function, may contribute to symptomatic benefit by decreasing refluxate volume.
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Affiliation(s)
- J Arts
- Department of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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Abstract
Patients with reflux symptoms often do not have excessive esophageal acid exposure, and patients with severe gastroesophageal reflux often do not have reflux symptoms. Understanding why different types of reflux induce symptoms in different patients is vital for addressing therapeutic gaps in the treatment of gastroesophageal reflux disease (GERD). Here we review studies providing insight into how gastroesophageal reflux is perceived, with a focus on comparing reflux characteristics and esophageal sensitivity among subgroups of patients with GERD. The available studies indicate that patients with nonerosive reflux disease have fewer acid reflux episodes and thus less esophageal acid exposure than patients with reflux esophagitis but perceive less intense stimuli because of greater esophageal sensitivity. Reflux characteristics other than acidity, such as the presence of bile, pepsin, liquid, or gas in reflux, and the proximal extent or volume of reflux, may also contribute to symptom perception. Factors contributing to greater esophageal sensitivity may include impaired mucosal barrier function, peripherally mediated esophageal sensitivity (enhanced esophageal receptor signaling), and centrally mediated esophageal sensitivity (physiological stressors, sensitization of spinal sensory neurons). Further insight into mechanisms of reflux perception may require a shift toward studies aimed at understanding predisposing cellular, molecular, and genetic factors.
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Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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