Three- to 4.5-year prospective study of prognostic indicators in gastro-oesophageal reflux disease

Refractory Gastroesophageal Reflux Disease: A Management Update

Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.

Whole Genome Methylation Analysis of Nondysplastic Barrett Esophagus that Progresses to Invasive Cancer

OBJECTIVE

To investigate differences in methylation between patients with nondysplastic Barrett esophagus who progress to invasive adenocarcinoma and those who do not.

BACKGROUND

Identifying patients with nondysplastic Barrett esophagus who progress to invasive adenocarcinoma remains a challenge. Previous studies have demonstrated the potential utility of epigenetic markers for identifying this group.

METHODS

A whole genome methylation interrogation using the Illumina HumanMethylation 450 array of patients with nondysplastic Barrett esophagus who either develop adenocarcinoma or remain static, with validation of findings by bisulfite pyrosequencing.

RESULTS

In all, 12 patients with "progressive" versus 12 with "nonprogressive" nondysplastic Barrett esophagus were analyzed via methylation array. Forty-four methylation markers were identified that may be able to discriminate between nondysplastic Barrett esophagus that either progress to adenocarcinoma or remain static. Hypomethylation of the recently identified tumor suppressor OR3A4 (probe cg09890332) validated in a separate cohort of samples (median methylation in progressors 67.8% vs 96.7% in nonprogressors; P = 0.0001, z = 3.85, Wilcoxon rank-sum test) and was associated with the progression to adenocarcinoma. There were no differences in copy number between the 2 groups, but a global trend towards hypomethylation in the progressor group was observed.

CONCLUSION

Hypomethylation of OR3A4 has the ability to risk stratify the patient with nondysplastic Barrett esophagus and may form the basis of a future surveillance program.

The Troublesome Epidemiology of Barrett's Esophagus and Esophageal Adenocarcinoma

Barrett's esophagus and esophageal adenocarcinoma diagnoses have increased markedly in recent decades. Recent research with patients diagnosed with Barrett's esophagus (the only known precursor for esophageal adenocarcinoma) and esophageal adenocarcinoma has identified several modifiable and nonmodifiable potential risk factors. Consistent risk factors for both disorders include increasing age, male sex, white non-Hispanic race/ethnicity, gastroesophageal reflux disease, lack of infection with Helicobacter pylori, smoking, abdominal obesity, and a Western diet. The authors present detailed discussions of these risk factors along with possible explanations for some apparent discrepancies and ideas for future study.

Impact of obesity treatment on gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD.

A review of the epidemiology of Barrett's oesophagus and oesophageal adenocarcinoma

While the incidence rates of many cancers have decreased in past decades, the incidence of oesophageal adenocarcinoma continues to increase. The only known precursor for oesophageal adenocarcinoma is Barrett's oesophagus. Studies conducted have identified white race, male sex, GORD, cigarette smoking, obesity, and the absence of Helicobacter pylori status as risk factors for oesophageal adenocarcinoma. Other potential associations include dietary factors and the absence of non-steroidal anti-inflammatory drug use. Many individual studies have been limited by sample size and several meta-analyses have pooled data from studies to address this limitation. In this review we present a synthesis of these studies and summarize current knowledge of risk factors for both oesophageal adenocarcinoma and Barrett's oesophagus.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endotherapy for and tailored approaches to treating GERD, and refractory GERD

This paper presents commentaries on how endoluminal antireflux procedures compare to laparoscopic fundoplication; new endoscopic procedures being studied to treat refractory gastroesophageal reflux disease (GERD); the new Stretta; the relationship between obesity and proton pump inhibitor (PPI) resistance; data concerning acid hypersensitivity and sensory receptors (vallinoid, TRPV1) causing refractory GERD; whether microscopic esophagitis is relevant in determining symptoms of non-erosive reflux disease (NERD); how concomitant functional gastrointestinal disorders affect the PPI response in NERD; the evidence that a functional esophagus is associated with inflammatory bowel syndrome (IBS); the role of GABA agonists in the treatment of refractory GERD; the role of biofeedback and antidepressants in refractory GERD; and endoluminal fundoplication using the EsophyX device.

Comparison of Risk Factors and Disease Severity Between Old and Young Patients With Gastroesophageal Reflux Disease

Background

Gastroesophageal reflux disease (GERD) tends to relapse and develop complications. The aim of the study was to compare the risk factors and disease severity of GERD in young and old patients.

Methods

Data from patients with GERD were collected between January and November 2009. The enrolled cases were assigned to the younger group if they were below 65 years, or the elderly group if 65 years or older. The general demographic data, lifestyle characteristics and endoscopic findings of the two groups were compared.

Results

Among all enrolled 111 patients, 78 and 33 patients were classified in the younger and elderly groups, respectively. The elderly group had significantly more men than the younger group did (72.7% vs 39.7%, P = 0.001). Lower rates of smoking (3% vs 6.4%, P = 0.029) and tea drinking (21.3% vs 34.6%, P = 0.001) were noted in the elderly patients, but similar rates of alcohol and coffee drinking. There were more severe esophagitis, esophagocardiac junction (ECJ) ulcers (21.2% vs. 2.6%, P = 0.003) and hiatal hernia (36.4% vs 16.9%, P = 0.025) in the elderly group.

Conclusion

Elderly GERD patients were more likely to be male, and having severe esophagitis, but lower rates of cigarette smoking and tea drinking, than those of younger patients.

Epidemiology of reflux symptoms and GORD

Gastro-oesophageal reflux disease (GORD) occurs when reflux of gastric contents causes troublesome symptoms and/or complications (the Montreal definition). GORD is a common condition with a substantial economical burden to the community and it has a significant negative effect on health-related quality of life (HRQoL) while endoscopic findings like erosive oesophagitis per se seem to correlate badly with the experienced HRQoL. The prevalence of GORD varies over the world for unknown reasons, but genetic differences, difference in the Helicobacter pylori prevalence and life style factors like obesity might influence. The prevalence is lowest in East Asia (2.5-9.4%) and higher in Mid (7.6-19.4%) and Western Asia (12.5-27.6%). The highest population-based prevalence is reported from Europe (23.7%) and the US (28.8%). GORD seems to be fairly stable over time both in terms of symptoms and erosive oesophagitis, but the prevalence seems to be increasing both in Asia and in the West.

Barrett's esophagus: proton pump inhibitors and chemoprevention II

The following on proton pump inhibitors (PPIs) and chemoprevention in relation to Barrett's esophagus includes commentaries on 48-h pH monitoring, pH-impedence, bile acid testing, dyspepsia, long/short segment Barrett's esophagus, nonerosive reflux disease (NERD), functional heartburn, dual-release delivery PPIs, immediate-release PPIs, long-term PPI use, prokinetic agents, obesity, baclofen, nocturnal acid breakthrough, nonsteroidal anti-inflammatory drugs (NSAIDs), and new PPIs.

Comparison of presentation and impact on quality of life of gastroesophageal reflux disease between young and old adults in a Chinese population

AIM

To compare the presentation and impact on quality of life of gastroesophageal reflux disease (GERD) in old and young age groups.

METHODS

Data from adult patients with GERD diagnosed by endoscopic and symptomic characteristics were collected between January and November 2009. Exclusion criteria included combined peptic ulcers, malignancy, prior surgery, antacid medication for more than 2 mo, and pregnancy. Enrolled patients were assigned to the elderly group if they were 65 years or older, or the younger group if they were under 65 years. They had completed the GERD impact scale, the Chinese GERD questionnaire, and the SF-36 questionnaire. Data from other cases without endoscopic findings or symptoms were collected and these subjects comprised the control group in our study.

RESULTS

There were 111 patients with GERD and 44 normal cases: 78 (70.3%) and 33 patients (29.7%) were in the younger and elderly groups, respectively. There were more female patients (60.3%) in the younger group, and more males (72.7%) in the elderly group. The younger cases had more severe and frequent typical symptoms than the elderly patients. Significantly more impairment of daily activities was noted in the younger patients compared with the elderly group, except for physical functioning.

CONCLUSION

Elderly patients with GERD were predominantly male with rare presentation of typical symptoms, and had less impaired quality of life compared with younger patients in a Chinese population.

Does BMI affect the clinical efficacy of proton pump inhibitor therapy in GERD? The case for rabeprazole

BACKGROUND

Increased BMI is associated with a higher risk of gastroesophageal reflux disease.

AIMS

To investigate whether overweight/obesity (BMI≥25 kg/m(2)) affects rabeprazole clinical efficacy versus omeprazole in patients with erosive esophagitis (EE).

PATIENTS AND METHODS

Post-hoc analysis of EE healing rate and symptom response stratified by patient BMI was performed on data from a multicenter, double-blind, randomized, 4-to-8-week trial comparing EE healing with rabeprazole (20 mg daily) and omeprazole (20 mg daily). Analysis of variance, two-sample t-test, Blackwelder's test for equivalence, log-rank, and Cochran-Mantel-Haenszel tests were used to analyze comparisons.

RESULTS

In the two BMI groups (<25 kg/m(2) and ≥25 kg/m(2) respectively), rabeprazole and omeprazole were equally effective for mucosal healing regardless of patient's BMI (N=542, P>0.05). However, in overweight/obese patients, rabeprazole was significantly faster than omeprazole in inducing heartburn relief during the first treatment week (P<0.0001).

CONCLUSIONS

Results of this study show that the clinical efficacy of rabeprazole is maintained in overweight/obese patients with gastroesophageal reflux disease and suggest that this subgroup of patients may derive, from rabeprazole, even greater benefit than lean patients.

Age and body mass index: significant predictive factors for successful laparoscopic antireflux surgery

PURPOSE

Laparoscopic antireflux surgery (LARS) is a feasible treatment for gastroesophageal reflux disease (GERD) patients, but it is unclear who will benefit from the surgery. This study investigated patients' GERDspecific quality of life (GsQOL) and analyzed the factors leading to the performance of successful LARS.

METHODS

Twenty-six (57.8%) of 45 consecutive patients who underwent LARS for GERD during the last decade were enrolled. All patients were evaluated by 24-h pH monitoring, esophageal manometry, esophagogastro-duodenoscopy and physical examinations. GsQOL was assessed by a visual analog scale, and the difference between the pre- and postoperative scores was defined as the visual analog scale improvement score (VASIS). The patients were classified into three groups based on the VASIS, and their clinical factors and surgical outcomes were compared.

RESULTS

The high VASIS group patients (>70 VASIS; Excellent group) patients were significantly younger and obese in comparison to low the VASIS group (<30 VASIS; Poor group) consisting of older nonobese patients (P < 0.05). A multiple regression analysis revealed that age <60 years and body mass index (BMI) >25 kg/m(2) were significant factors that affected postoperative GsQOL. No other clinical or surgical factors had any influence on the postoperative GsQOL.

CONCLUSION

These results suggest that age and BMI can be predictive factors for the performance of successful LARS.

Disease progression in non-erosive reflux disease (NERD): impact of initial esophageal acid exposure

We investigated the 5-year clinical course in a cohort of patients with typical reflux symptoms and negative endoscopy. Prospective follow-up was conducted in patients with non-erosive reflux disease (NERD) for at least 5 years after initial evaluation with esophageal pH monitoring and upper gastrointestinal endoscopy. Within the last year of follow-up, reflux symptoms occurred in 27 of the 30 patients (90%). Twenty-five of twenty-seven symptomatic patients (93%) were on acid suppression therapy. The majority of our patients (70%) remained unchanged regarding their endoscopic status over 5 years. Progression to erosive esophagitis occurred in four patients with Los Angeles (LA) A (13%), three patients with LA B (10%), and two patients with LA C (7%). The presence of pathological acid exposure did not alter the presence of reflux symptoms over 5 years. Disease progression to erosive esophagitis occurred more frequently in patients with pathological acid exposure than those without pathological acid exposure (P= 0.025). Most NERD patients have symptoms and require acid suppression therapy 5 years after their initial diagnosis. Initial pathological acid exposure does not influence the use of acid suppression; however, it does influence the progression of NERD within 5 years of follow-up.

Is the course of gastroesophageal reflux disease progressive? A 21-year follow-up

OBJECTIVE. We re-evaluated a cohort of patients referred for reflux symptoms and objectively diagnosed with pathological reflux, with the purpose of clarifying the course of conservatively treated gastroesophageal reflux disease (GERD). MATERIAL AND METHODS. All consecutive patients with GERD diagnosed between 1984 and 1988 showing pathologic 24-h pH-metry in the interval 3.8-10% and without any previous surgery in the gastroesophageal tract were assessed for further follow-up. A total of 40 evaluable patients were followed in the years 2007-08 with endoscopy, manometry, 24-h pH-metry, Helicobacter pylori assessment and the self-administered questionnaires the GERD Impact Scale, the Reflux Disease Questionnaire, the Quality of Life in Reflux and Dyspepsia and the Medical Outcome Study Short Form-36 Health Survey. Baseline data from the 1980s were retrieved and compared with the evaluations conducted at follow-up. RESULTS. At follow-up 20.7 years (range 18.8-23.5 years) after referral, the study population showed more use of acid suppressants (p = 0.007) and increasing prevalences of esophagitis (p = 0.001) and Barrett's esophagus (p = 0.002). Esophagitis was seen in 16/40 patients (40%) at baseline and in 29/40 (72.5%) at follow-up. No significant deterioration was seen at follow-up in manometry data and in most pH data. Patients with esophagitis (ERD) were less likely to have a positive H. pylori test (hazard ratio 0.054; p = 0.002) than non-erosive (NERD) patients. Symptom evaluations showed significantly lower quality of life in the ERD group. CONCLUSIONS. After 20 years a considerable part of the cohort still experienced symptoms of reflux and showed endoscopic progression, although no significant deteriorations were seen in manometry data and in most pH-metry data. H. pylori infection was inversely associated with erosive esophagitis and this supports the hypothesis that H. pylori colonization is a protective factor against GERD.

Outcome of nonerosive gastro-esophageal reflux disease patients with pathological acid exposure

AIM: To assess the management and outcome of nonerosive gastro-esophageal reflux disease (NERD) patients who were identified retrospectively, after a 5-year follow-up.

METHODS: We included patients with gastro-esophageal reflux disease (GERD) symptoms who had a negative endoscopy result and pathological 24-h esophageal pH-monitoring while off therapy. We interviewed them after an average period of 5 years (range 3.5-7 years) by means of a structured questionnaire to assess presence of GERD symptoms, related therapy, updated endoscopic data and other features. We assessed predictors of esophagitis development by means of univariate and multivariate statistical analysis.

RESULTS: 260 patients (137 women) were included. Predominant GERD symptoms were heartburn and regurgitation in 103/260 (40%). 70% received a maintenance treatment, which was proton pump inhibitor (PPI) in 55% of cases. An average number of 1.5 symptomatic relapses per patient/year of follow-up were observed. A progression to erosive gastro-esophageal reflux disease (ERD) was found in 58/193 (30.0%) of patients undergoing repeat endoscopy; 72% of these were Los Angeles grade A-B.

CONCLUSION: This study shows that progression to ERD occurs in about 5% of NERD cases per year, despite therapy. Only two factors consistently and independently influence progression: smoking and absence of PPI therapy.

The Italian validation of the Montreal Global definition and classification of gastroesophageal reflux disease

BACKGROUND AND AIMS

Recently, a Global definition and a classification of gastroesophageal reflux disease (GERD) were developed by Montreal Consensus Group, composed of international expert gastroenterologists. Guidelines and consensus documents are, however, infrequently accepted and adopted at a local level. The aim of this study was to measure the acceptance of Montreal Global definition of GERD consensus document by specialists in a single country (Italy) and to measure the linguistic, scientific, and practical differences between the international consensus document and the Italian version.

METHODS

A 2-day meeting was held in June 2007 in Rome, Italy, attended by 147 Italian physicians who were experts in gastroenterology. They reviewed the individual original statements in their Italian translation and then voted on the statement using the scoring system used by the Montreal Consensus Group (6-point Likert scale). Voting was performed at baseline and after an analytical discussion on each statement, led by six internationally renowned experts. Consensus was defined as an agreement with a statement by at least two-thirds of the group. Results were compared with the Montreal statements.

RESULTS AND DISCUSSION

The level of consensus was already extremely high at the first vote (>90% with the two-thirds threshold). The level of agreement at the second vote increased slightly. The maximum variation between two votes was 33% (of increase from first to second round, 59-92%). The high level of agreement could be because of both the general acceptance of Montreal Consensus by scientific community, and the new scientific evidences published after the Montreal report, which fit with the original statements.

CONCLUSION

This study is the first national linguistic validation of the Montreal Global definition of GERD and is also proof of its scientific validity, based on the same methodology used to create the Montreal statements. It also suggests that evidence-based International disease classification systems can be applied to local settings after validation by local experts.

Heterogeneity of endoscopy negative heartburn: Epidemiology and natural history

It has now become clear that only about 40% or less of patients with heartburn and/or regurgitation have esophagitis, and that the majority of them lack visible distal esophageal mucosa breaks. These subjects are referred to as non-erosive gastroesophageal reflux disease (NERD) patients. It has been estimated that in the Western world at least one tenth of the general population has at least weekly heartburn. This proportion seems to be lower in Asia, while prevalence is rapidly increasing. Although it would be extremely useful to have prospective information regarding the fate of such patients, the natural history of NERD is largely unknown, and very few studies in the literature have addressed this issue. These studies are for the greater part old, not well conducted, and suffer from methodological drawbacks including ill-defined entry criteria. However, a review of these studies indicates that a consistent minority of NERD patients may develop erosive disease at an approximate rate of about 10% per year.

Body mass index and the efficacy of acid-mediating agents for GERD

In studies of the association between obesity and gastroesophageal reflux, one subject that has received very little attention is the effect excess body mass may have on the effectiveness of acid-mediating agents. The lack of systematic research may reflect the perceived high clinical efficacy of drugs like proton pump inhibitors. Both proton pump inhibitors and histamine type 2 receptor antagonists have low rates of significant adverse events; if there are differences in the side effect profiles based on BMI, it is unlikely such associations would be detected. Also, while the metabolism of many drugs can be affected by body mass, it is not clear that such a relationship exists with acid-mediating agents. Nevertheless, there is evidence that body mass index may indeed be associated with the efficacy of proton pump inhibitors and histamine type 2 receptor antagonists. This review will examine that evidence and consider some of the possible pharmacokinetic effects that might relate to body mass index.

The role of GABA(A) receptors in the control of transient lower oesophageal sphincter relaxations in the dog

BACKGROUND AND PURPOSE

Transient lower oesophageal sphincter relaxations (TLESRs) are triggered by activation of mechanosensitive gastric vagal afferents and are the major cause of gastroesophageal reflux and therefore an important target for therapeutic intervention in gastroesophageal reflux disease (GERD). Activation of the metabotropic GABA(B) receptor has shown to inhibit TLESRs. The aim of the present study was to assess the role of the ionotropic GABA(A) receptor in the regulation of TLESRs.

EXPERIMENTAL APPROACH

TLESRs were quantified using Dentsleeve manometry in dogs, and GABA(A) agonists were given i.v. prior to gastric distension. Immunohistochemistry and RT-PCR were used to localize GABA(A) receptors in the dog nodose ganglion, the source of vagal afferents which initiate TLESRs.

KEY RESULTS

The prototypical GABA(A) agonist muscimol produced a dose-dependent inhibition of TLESRs ranging from 19 to 56%. The two other GABA(A) agonists evaluated, isoguvacine and 4,5,6,7-tetrahydroisoxazolo-[5,4-c]pyridin-3-ol (THIP), as well as the GABA(A) positive allosteric modulator diazepam, had no major effects on TLESRs. Evaluation of higher doses was limited by emesis (THIP and isoguvacine) or restlessness/sedation (diazepam). Of the predominant GABA(A) receptor subunits (alpha, beta and gamma components), alpha and beta but not gamma were detected in the dog nodose ganglion by RT-PCR, while immunohistochemistry in addition demonstrated nerve fibres expressing the gamma subunit.

CONCLUSIONS AND IMPLICATIONS

The present observations demonstrate that GABA(A) receptors exert an inhibitory control of TLESRs. These results warrant further studies using GABA(A) isoform-selective agonists to define the identity of receptors involved.

Prospective Acid Reflux Study of Iran (PARSI): methodology and study design

Background

Gastroesophageal reflux disease is a common and chronic disorder but long term, prospective studies of the fate of patients seeking medical advice are scarce. This is especially prominent when looking at non-erosive reflux disease (NERD) patients.

Methods

We designed a prospective cohort to assess the long term outcome of GERD patients referring to gastroenterologists. Consecutive consenting patients, 15 years of age and older, presenting with symptoms suggestive of GERD referring to our outpatient clinics undergo a 30 minute interview. Upper gastrointestinal endoscopy is performed for them with protocol biopsies and blood samples are drawn. Patients are then treated according to a set protocol and followed regularly either in person or by telephone for at least 10 years.

Discussion

Our data show that such a study is feasible and follow-ups, which are the main concern, can be done in a fairly reliable way to collect data. The results of this study will help to clarify the course of various subgroups of GERD patients after coming to medical attention and their response to treatment considering different variables. In addition, the basic symptoms and biological database will fuel further molecular epidemiologic studies.

Gastroesophageal reflux disease is a progressive disease

It is controversial whether gastrooesophageal reflux disease represents a spectrum disease from a nonerosive to a complicated one, or whether it is a categorial disease, i.e. it can be divided into three categories, such as nonerosive gastrooesophageal reflux disease, erosive gastrooesophageal reflux disease and Barrett's esophagus (BE) with little or no transition from one category to the other. This controversy might be of general interest, because it has some implications in the management of the patient. However, literature data concerning the natural history of gastrooesophageal reflux disease are very limited, and in particular very few papers have dealt with the issue of describing the natural history of patients with nonerosive gastrooesophageal reflux disease. Aim of the present review is to reassess these scanty data, and to try to demonstrate that progression from milder to more severe forms of gastrooesophageal reflux disease is possible and documented.

Optimization of outcome after laparoscopic antireflux surgery

Laparoscopic fundoplication has emerged as an effective treatment for gastro-oesophageal reflux disease. The majority of patients who have undergone antireflux surgery report an improvement in reflux symptoms and in quality of life. However, some patients are dissatisfied with the outcome of antireflux surgery, and attempts have been made by surgeons to improve the results of this surgery. Careful case selection based on objective evidence of acid reflux, refinement of the surgical technique and 'tailoring' the wrap to suit the patient by selective use of a partial fundoplication may help to optimize the outcome from laparoscopic antireflux surgery.

The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus

OBJECTIVES

A globally acceptable definition and classification of gastroesophageal reflux disease (GERD) is desirable for research and clinical practice. The aim of this initiative was to develop a consensus definition and classification that would be useful for patients, physicians, and regulatory agencies.

METHODS

A modified Delphi process was employed to reach consensus using repeated iterative voting. A series of statements was developed by a working group of five experts after a systematic review of the literature in three databases (Embase, Cochrane trials register, Medline). Over a period of 2 yr, the statements were developed, modified, and approved through four rounds of voting. The voting group consisted of 44 experts from 18 countries. The final vote was conducted on a 6-point scale and consensus was defined a priori as agreement by two-thirds of the participants.

RESULTS

The level of agreement strengthened throughout the process with two-thirds of the participants agreeing with 86%, 88%, 94%, and 100% of statements at each vote, respectively. At the final vote, 94% of the final 51 statements were approved by 90% of the Consensus Group, and 90% of statements were accepted with strong agreement or minor reservation. GERD was defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The disease was subclassified into esophageal and extraesophageal syndromes. Novel aspects of the new definition include a patient-centered approach that is independent of endoscopic findings, subclassification of the disease into discrete syndromes, and the recognition of laryngitis, cough, asthma, and dental erosions as possible GERD syndromes. It also proposes a new definition for suspected and proven Barrett's esophagus.

CONCLUSIONS

Evidence-based global consensus definitions are possible despite differences in terminology and language, prevalence, and manifestations of the disease in different countries. A global consensus definition for GERD may simplify disease management, allow collaborative research, and make studies more generalizable, assisting patients, physicians, and regulatory agencies.

Esophagitis: incidence and risk of esophageal adenocarcinoma--a population-based cohort study

OBJECTIVES

Although symptoms of reflux are common, our knowledge of the epidemiology and natural history of gastroesophageal reflux disease is sparse. The risk of esophageal adenocarcinoma is increased among patients with acid reflux, but the contribution of Barrett's lesions is unknown.

METHODS

With the aim to estimate the incidence of diagnosed endoscopic esophagitis lesions and the risk of esophageal adenocarcinoma among patients with previously diagnosed esophagitis, we extracted data on endoscopies, esophagitis diagnoses, and gastroesophageal cancer diagnoses from five population-based databases covering the period from 1974 to 2002, and covering all citizens in Funen County (population 470,000).

RESULTS

In 2002, the incidence of esophagitis lesions was 2.4 per 1,000 person-years (95% confidence interval 2.3-2.6), 18.3 per 1,000 persons (17.9-18.7) had previously diagnosed esophagitis. Incidence increased by calendar year and age, was higher among males than among females, and was closely related to rate of endoscopy. Among 11,129 patients with previously diagnosed esophagitis, 15 had esophageal adenocarcinoma during 58,322 person-years of follow-up (26 per 100,000 person-years). The expected number was 2.79 and the standardized incidence ratio was 5.38 (3.01-8.87). Ten of the 15 patients with esophageal adenocarcinoma had previously diagnosed Barrett's esophagus.

CONCLUSION

The risk of esophageal adenocarcinoma is increased fivefold in patients with previously diagnosed esophagitis, but most of the adenocarcinomas occurred among patients with Barrett's esophagus.

CagA-positive Helicobacter pylori infection is not associated with decreased risk of Barrett's esophagus in a population with high H. pylori infection rate

BACKGROUND & AIM

The role that H. pylori infection plays in the development of and Barrett's esophagus (BE) is uncertain. We tested the hypothesis that infection with cagA+ Helicobacter pylori strains protects against the development of BE.

METHODS

We studied 104 consecutive patients, residents in an area with a high prevalence of H. pylori infection, with BE and 213 sex- and age-matched controls. H. pylori infection and CagA antibody status were determined by western blot serology.

RESULTS

H. pylori prevalence was higher in patients with BE than in controls (87.5% vs. 74.6%; OR. 2.3; 95% CI: 1.23-4.59). Increasing age was associated with a higher prevalence of H. pylori (p < 0.05). The prevalence of CagA+ H. pylori serology was similar in patients with BE and controls (64.4% vs. 54.5%; NS). Type I H. pylori infection (CagA+ and VacA+) was similar in patients with BE and controls (44.2% vs. 41.3%; NS). Logistic regression analysis identified alcohol (O.R. 7.09; 95% CI 2.23-22.51), and H. pylori infection (OR: 2.41; 95%CI: 1.20-4.84) but not CagA+ serology as independent factors.

CONCLUSION

Neither H. pylori infection nor H. pylori infection by CagA+ strains reduce the risk of BE in a population with high prevalence of H. pylori infection.

A systematic review and meta-analysis of the sex ratio for Barrett's esophagus, erosive reflux disease, and nonerosive reflux disease

Barrett's esophagus is associated with reflux disease and substantially increases the risk of esophageal adenocarcinoma. The authors undertook a systematic review and meta-analysis of the sex ratio for Barrett's esophagus, erosive reflux disease (ERD), and nonerosive reflux disease (non-ERD) to compare these results with the sex ratio for esophageal adenocarcinoma. MEDLINE (US National Library of Medicine, Bethesda, Maryland) (1966-2004) and EMBASE (Reed Elsevier PLC, Amsterdam, Netherlands) (1980-2004) were searched for relevant citations with a highly sensitive search strategy. Studies to be included required a sample size of 50 or more patients and consecutive recruitment at an institute accessible by all. Stata, version 8.2, software (StataCorp LP, College Station, Texas) was used to conduct random effects meta-analyses. Excess heterogeneity was investigated by meta-regression. The Barrett's esophagus meta-analysis gave an overall pooled male/female sex ratio of 1.96/1 (95% confidence interval (CI): 1.77, 2.17/1). For ERD, the pooled male/female sex ratio was 1.57/1 (95% CI: 1.40, 1.76/1) and, for non-ERD, 0.72/1 (95% CI: 0.62, 0.84/1). All of these estimates were associated with substantial heterogeneity (I2 = 81.1%, 92.7%, and 88.8%, respectively). The meta-analysis estimates for ERD and Barrett's esophagus, while showing an excess of males, are substantially lower than similar estimates for esophageal adenocarcinoma. It is important to establish why male Barrett's esophagus and ERD patients are at increased risk of malignancy compared with females.

Review article: prevalence and epidemiology of gastro-oesophageal reflux disease

There are considerable uncertainties around the definition and the appropriate clinical diagnostic criteria for gastro-oesophageal reflux disease (GERD), a common condition that appears to be increasing in prevalence in the Western world. Prevalence studies of GERD are hampered by whether any heartburn symptom is included, or just predominant or even 'sole' heartburn, and also by the time frame over which the symptoms have been evaluated. A systematic search of Medline using the keywords 'GERD' 'prevalence' and 'community' yielded three papers, two original articles and one systematic review of studies that surveyed symptoms in unselected subjects. Heartburn is a common symptom in Europe ranging from a prevalence of 38% in Northern Europe to 9% in Italy. Comparable 6-month data from the USA suggest an even higher prevalence with a rate of 42%. GERD is also a long-term, relapsing disorder. A population survey in Sweden found GERD symptoms over time at 18% of the population surveyed. In summary, although symptoms and quality of life improve with acid suppression therapy, costs are high and the potential benefit of long-term treatment is rare, but serious complications of GERD are unknown.

Functional dyspepsia (FD) and non-erosive reflux disease (NERD): overlapping or discrete entities?

As the incidence of both gastric cancer and peptic ulcer disease have declined, that of gastro-oesophageal reflux disease (GORD) and non-ulcer, or functional dyspepsia (FD) have reached virtually epidemic proportions. As we come to appreciate the expression of these disorders in the community, the real spectrum of each disease has become evident. FD and non-erosive reflux disease (NERD), the most prevalent manifestation of GORD, frequently overlap. Where then does GORD end and FD begin? Is it realistic, or even clinically relevant, to attempt a clear separation between these entities? These are more than issues of mere semantics; therapeutic options may be dictated by the classification of the patient as one or the other. Recent work indicates clearly that NERD is a heterogeneous disorder incorporating some patients who may well harbour subtle manifestations of oesophagitis and others who have entirely normal 24-hour pH studies. These differences may be crucial to the concept of NERD/FD overlap. While evidence in support of this concept is far from complete, it would appear that this overlap is most relevant to those NERD patients who do not exhibit abnormal esophageal acid exposure. These patients truly belong in the spectrum of functional gastrointestinal disorders rather than in GORD; attempts to shoe-horn these individuals into the spectrum of GORD will result in therapeutic disappointment and surgical disaster.

Risk factors of gastroesophageal reflux disease: methodology and first epidemiological results of the ProGERD study

OBJECTIVE

We describe the design and report the first results of the Progression of Gastroesophageal Reflux Disease (ProGERD) study, to our knowledge the largest prospective study of GERD patients.

STUDY DESIGN AND SETTING

Patients were recruited at 1,253 centers in Germany, Austria, and Switzerland. Following an assessment of medical history, all patients were endoscoped and received esomeprazole for 2 to 8 weeks before entering the 5-year observational phase.

RESULTS

A total of 6,215 patients (53% male, age 54+/-14) were included. Of these patients, 46% reported at least daily symptoms, 15% were unable to work at least once during the prior year, and 71% had visited a physician due to reflux symptoms. Barrett's esophagus (BE) was found in 11% of our GERD patients. In polychotomous regression analysis, the main factors related to the occurrence of the three GERD subgroups (nonerosive, erosive disease, and BE) were age, gender, duration of GERD, body mass index (BMI), smoking, and previous PPI use. Factors associated with longer disease duration were increasing age, male gender, BMI, increasing symptom severity, presence of erosive GERD or BE, positive family history, and smoking.

CONCLUSION

The findings indicate that GERD is a great burden for patients, and has significant socioeconomic implications. The long-term follow-up period with further endoscopic and histologic evaluations, will help further our understanding of the natural course of the disease.

Gastroesophageal reflux disease: a typical spectrum disease (a new conceptual framework is not needed)

Gastroesophageal reflux disease (GERD) is a common GI disorder, particularly frequent in the primary care setting, with a high direct and indirect economic burden on society. Despite the high prevalence and costs of the disease, the epidemiology and natural history of GERD have not been fully elucidated. It has recently been suggested to abandon the current model of GERD as a "spectrum" disease and to adopt a new conceptual framework, e.g., categorizing GERD into three unique groups of patients: nonerosive reflux disease, erosive esophagitis, and Barrett's esophagus. In the present review we present arguments against this proposal, and argue that the concept of a single disease, potentially progressing from mild nonerosive forms toward metaplasia and neoplasia (adenocarcinoma), still holds true and may in fact help us in planning the diagnostic and therapeutic approach as well as in allocating financial resources much better than the proposed model of a "tripartited" disease. Independently from the conceptual model adopted, however, more data on the natural history of patients with GERD are eagerly needed.

Natural history of gastro-oesophageal reflux disease without oesophagitis (NERD)--a reappraisal 10 years on

BACKGROUND AND AIM

Ten years ago we published a study describing the 6-month outcome of 33 outpatients with typical gastro-oesophageal reflux disease symptoms and pH-metry proven excess gastro-oesophageal reflux but without endoscopical evidence of oesophagitis, currently referred to as patients with gastro-oesophageal reflux disease without oesophagitis. We now present an update of that report concerning morbidity, drug consumption and quality of life of the original patients 10 years after the initial diagnosis.

METHODS

The study consisted of the retrieval and revision of all clinical and instrumental records concerning the cohort of 33 above-mentioned patients. Data are available regarding annual intervals within the first 5 years from original diagnosis and, subsequently, with a follow-up ranging from 7 to 14 years (median 10 years). The records of these 33 patients were reviewed, including the results of clinical visits at the outpatients department, of oesophagogastroduodenoscopies and pH- metries. Finally, a telephonic interview was conducted by means of a structured questionnaire, aiming at evaluating present symptoms, actual therapy if any, health-related quality of life and other information regarding any gastro-oesophageal reflux disease symptoms.

RESULTS

Of the original 33 patients, 31 are still alive and 2 were lost to follow-up. Of the 29 remaining, only 1 is definitively not complaining of any gastro-oesophageal reflux disease-related symptoms. Within 5 years of the first diagnosis, oesophagitis was found in all but one of the 18 subjects who underwent repeated endoscopy. At the latest follow-up check, after a median of 10 years, out of the 28 still complaining of gastro-oesophageal reflux disease symptoms, 21 (75%) were presently taking antisecretory drugs (proton pump inhibitors and H-2 receptor antagonists) because of gastro-oesophageal reflux disease symptoms/lesions, 12 of whom intermittently or on demand and the remaining 9 continuously. Two patients (2/28) underwent antireflux surgery, but despite this were still taking antisecretory drugs (in one case H2-RA; in the other proton pump inhibitor). The health-related quality of life, self-evaluated by the patient by means of a VAS scoring from 0 (worst possible) to 10 (best possible) increased significantly from 3.2 to 6.5 from baseline (before therapy) to present time, possibly due to the positive effect of present therapy.

CONCLUSIONS

Our study conducted on a cohort of endoscopy-negative patients with pH-metry-confirmed reflux disease has shown that after a median time of 10 years following the original diagnosis, the majority of patients have, in fact, developed reflux oesophagitis and are on prolonged antisecretory therapy because of recurrent gastro-oesophageal reflux disease symptoms/lesions. The study confirms that gastro-oesophageal reflux disease without oesophagitis, as well as gastro-oesophageal reflux disease at large, is a chronic disease characterised by increasing severity with time, which requires protracted medical therapy in a vast proportion of patients. Absence of endoscopic oesophagitis at presentation does not represent a positive prognostic factor.

The epidemiology of gastroesophageal reflux disease

Symptoms of gastroesophageal reflux disease (GERD) are among the most common encountered in primary practice. Reported symptoms certainly under-represent the true prevalence of this disease in the population, because many patients do not seek care for symptoms of GERD and many physicians do not specifically ask about such symptoms when performing the review of systems. We describe the epidemiology of GERD. We begin by considering the prevalence of GERD as a function of the disease definition used. We then discuss the epidemiology of nonerosive reflux disease. After that, we consider the population risk factors for GERD. Next, we briefly touch on the epidemiology of GERD complications, including erosive esophagitis, strictures, and Barrett esophagus. We will end with a brief discussion of population screening of those with GERD for Barrett esophagus.

New developments in the pathophysiology of gastro-oesophageal reflux disease (GERD): implications for patient management

The spectrum of gastro-oesophageal reflux disease (GERD) has expanded; indeed the majority of individuals with symptomatic GERD do not have erosive reflux disease (ERD); this group has been referred to as nonerosive or negative-endoscopy reflux disease (NERD). There may be important differences between NERD and ERD in terms of pathophysiology and management. Thus, NERD patients appear relatively resistant to proton pump inhibitors and may not be good surgical candidates. The clinician caring for patients with GERD must therefore be aware of the full spectrum of GERD and of the pathophysiological and therapeutic implications of NERD. Recent twin studies have revealed that genetic factors play a role in GERD and form the basis for future studies on the role of inheritance in the various manifestations of GERD. Several recent investigations have reaffirmed the primacy of acid reflux in the pathogenesis of GERD and have also provided insights into the pathophysiology of postprandial heartburn. Transient lower oesophageal sphincter relaxations and hiatal hernias have emerged as major and interacting factors in the genesis of reflux events and in the potentiation of acid exposure; the former are attracting considerable attention as a potential therapeutic target. Nocturnal acid breakthrough, which has been implicated in the failure of some patients to respond to high doses of proton pump inhibitors, appears, on further examination, to be a gastric rather than an oesophageal phenomenon, and may not be of clinical or therapeutic importance.

Factors that influence therapeutic outcomes in symptomatic gastroesophageal reflux disease

The term "symptomatic gastroesophageal reflux disease" (GERD) refers to those patients who present with the typical GERD symptoms of heartburn and regurgitation, yet do not have endoscopic evidence of esophagitis. The primary goals of managing symptomatic GERD are to control symptoms and improve quality of life. A clinical assessment of the GERD patient can identify important clinical features, such as atypical and extraesophageal symptoms for which acid-suppressive agents tend to be less effective. Performing an endoscopy can further identify the patient as having nonerosive reflux disease, erosive esophagitis, or Barrett's esophagus-diagnoses which can help determine treatment but may not prove predictive of therapeutic response. Determining acid exposure through pH testing can predict therapeutic response, with those revealing an abnormal acid exposure time being more responsive to acid-suppressive therapy. However, the performance of an endoscopy and pH testing on each patient is clearly not practical. Whereas the natural history of symptomatic GERD is still largely undefined, acid-suppressive therapy appears to be the best approach available for both the short-term and long-term management of this disease.

Long-term clinical outcome of elderly patients with reflux esophagitis: a six-month to three-year follow-up study

Although the prevalence of reflux esophagitis is known to increase with age, data on the long-term outcome of esophagitis in elderly patients are scarce. We sought to evaluate the clinical outcome of elderly patients with esophagitis 6 months to 3 years after diagnosis and to identify specific prognostic indicators of a poor outcome. This was a long-term (6 months to 3 years) follow-up study. Patients older than 65 years of age diagnosed as having reflux esophagitis healed after acute treatment (2 to 4 months) were included in the study. Clinical examinations and upper gastrointestinal endoscopy were performed every 6 months for the first year and annually thereafter. After healing, no therapy was prescribed; in the event of symptom recurrence, a maintenance therapy consisting either of H2 blockers or proton pump inhibitors (PPI) was prescribed. At baseline and during follow-up, the following clinical parameters were recorded: gender, age, the presence of symptoms (heartburn, acid regurgitation, epigastric/chest pain), type and dose of the maintenance therapy, nonsteroidal antiinflammatory drug use; gastric Helicobacter pylori infection, diagnosis of hiatal hernia, and/or Barrett's esophagus. The chi-square test, the Kaplan-Meier test, and Cox's proportional hazards regression analysis were used for statistical analyses. Included in the final analysis were 138 patients (M/F, 81/57; mean age, 79.7 years; range, 66-97). The numbers of patients in need of maintenance therapy were 47 of 69 (68.1%) after 6 months, 29 of 58 (50%) after 12 months, 17 of 39 (43.6%) after 24 months, and 12 of 26 (46.1%) after 36 months of follow-up. A significantly higher esophagitis relapse rate was found in patients not treated compared with subjects who were in maintenance therapy: 59% versus 8.5% (P <.0001) at 6 months, 65.5% versus 20.7% at 12 months (P <.002), 63.6% versus 11.7% at 24 months (P =.003), and 57.1% versus 8.3% at 36 months (P =.02). No significant difference in relapse rate was found in patients treated with H2 blockers versus PPIs (21.7% versus 10%). The Cox model demonstrated that no maintenance treatment (P =.00001), the presence of typical symptoms (P =.00001), the presence of hiatal hernia (P =.03), and a high severity grade of esophagitis at baseline (P =.009) were risk factors for relapse of esophagitis. In elderly subjects, esophagitis relapse occurs in a high percentage of cases, particularly in patients not treated with antisecretory drugs. The presence of typical symptoms, hiatal hernia, and a severe grade of esophagitis are risk factors for relapse. The most effective measure for minimizing the occurrence of relapse is a maintenance therapy with antisecretory drugs.

Corpus gastritis in patients with endoscopic diagnosis of reflux oesophagitis and Barrett's oesophagus

BACKGROUND

A high level of gastric acid secretion is considered to be a risk factor for reflux oesophagitis or Barrett's oesophagus. Corpus gastritis may have a protective effect on the oesophagus, because of decreased gastric acid output.

AIM

To determine if corpus gastritis is associated with reflux oesophagitis or Barrett's oesophagus.

METHODS

Three antral and two corpus biopsies were taken from consecutive patients in whom Helicobacter pylori testing was requested during endoscopy at a single centre between January 1995 and May 1997. Antral and corpus gastritis was studied by histology; H. pylori was studied by histology, culture and CLO test. A regression model was used to test for correlation between reflux oesophagitis, Barrett's oesophagus and risk factors.

RESULTS

During the study period, 676 patients had biopsies taken during upper gastrointestinal endoscopy. Endoscopic signs of reflux oesophagitis and Barrett's oesophagus were observed in 125 and 23 patients, respectively. Corpus gastritis was found in 59% of patients without reflux oesophagitis or Barrett's oesophagus, 45% of patients with reflux oesophagitis and 30% of patients with Barrett's oesophagus. Two hundred and fifty-seven patients underwent follow-up endoscopy after H. pylori therapy. During a mean follow-up of 3 months, the incidence of reflux oesophagitis was not statistically different for patients with healing of corpus gastritis (10/98; 10%) and patients with persistent gastritis (8/97; 8%).

CONCLUSIONS

Corpus gastritis was less common in patients with an endoscopic diagnosis of reflux oesophagitis or Barrett's oesophagus.

Analysis of medical compliance in gastro-oesophageal reflux disease patients referred to pre-surgical examination

BACKGROUND

Despite potential of modern pharmacotherapy to control gastro-oesophageal reflux disease and also to improve patients' quality of life, an efficient long-term management always depends on patients compliance with medication.

AIMS

To evaluate and analyse potential aspects of compliance or non-compliance with medical and clinical prescriptions in a selected group of gastro-oesophageal reflux disease patients referred to pre-surgical examination because of persistent or recurrent symptoms.

PATIENTS

A total of 182 gastro-oesophageal reflux disease patients have been divided by patient rating to 3 different subgroups: group 1/TC consisted of patients who subjectively stated to be totally compliant (n=71; 39%); group 2/PC of patients with partial compliance (n=65; 36%), and group 3/NC consisted of patients with non-compliance (n=46; 25%) in relation to the prescriptions of their doctor taking care of their treatment.

METHODS

All patients have been asked for potential aspects of compliance or non-compliance. The following aspects have been analysed: understandable medical prescription, information about gastro-oesophageal reflux disease, subjective severity of gastro-oesophageal reflux disease-related symptoms, severity of disease, side-effects of medication, general rejection of medication, multi-medication, patient age and sex, quality of life, and a specific construct of personality (health locus of control).

RESULTS

Significant differences could be calculated between patients' age and gender showing that female and elderly patients are more compliant with medication. Group 1/TC patients suffered from a significantly longer period of symptoms and received medication for a longer period when compared to the other groups. Quality of life was impaired in all patients but patients in group 3/NC had a significantly better quality of life than patients in group 1/TC. The leading aspects for total compliance were: an understandable medical prescription (95%), high severity of perceived symptoms (76%) and of disease (88%). The major factors in group 2/PC patients have been unclear information about gastro-oesophageal reflux disease (41%), mild severity of perceived symptoms (59%), low severity of disease (30%), and a general rejection of medical treatment (21%). General rejection of drug treatment has been the major factor in group 3/NC patients (80%) which can be viewed in relation to patients' personality

CONCLUSION

Compliance or non-compliance in this selected group of patients depended on several factors such as information, subjective severity of symptoms, severity of disease but, in addition, on patients' personality Therefore, new strategies for compliance with long-term treatment in gastro-oesophageal reflux disease patients should be discussed.

Transient lower oesophageal sphincter relaxations--a pharmacological target for gastro-oesophageal reflux disease?

The oesophago-gastric junction functions as an anti-reflux barrier preventing increased exposure of the oesophageal mucosa to gastric contents. Failure of this anti-reflux barrier results in gastro-oesophageal reflux disease, and may lead to complications such as oesophagitis, Barrett's oesophagus and eventually oesophageal carcinoma. Recent studies have suggested that transient lower oesophageal sphincter relaxation is the main mechanism underlying gastro-oesophageal reflux. It involves a prolonged relaxation of the lower oesophageal sphincter, mediated by a vago-vagal neural pathway, synapsing in the brainstem. Several drugs, such as atropine, baclofen and loxiglumide, have been shown to reduce the rate of transient lower oesophageal sphincter relaxations and concomitantly the number of reflux episodes. These findings illustrate that transient lower oesophageal sphincter relaxations may represent a potential new target for the pharmacological treatment of gastro-oesophageal reflux disease. It is possible that the reduction in the number of transient lower oesophageal sphincter relaxations may also contribute to the beneficial effect of fundoplication and new endoscopic anti-reflux procedures. It should be emphasized, however, that other factors, such as low lower oesophageal sphincter pressure, the presence of a hiatal hernia and impaired oesophageal peristalsis, are also of great importance. Therefore, whether the targeting of transient lower oesophageal sphincter relaxations is the 'golden bullet' in anti-reflux therapy remains to be proven, as evidence of an effective control of gastro-oesophageal reflux in reflux patients is still lacking.

Duodenal erosions after eradication of Helicobacter pylori infection

BACKGROUND

There is interest in the development of GERD after Helicobacter pylori eradication. In contrast, the development of duodenal erosions after therapy has received scant attention. Patients were examined after eradication of H pylori infection to determine the frequency of post-therapy duodenal erosions (primary outcome) and whether there was a relation between development of duodenal and esophageal erosions. Additionally, factors were searched for that would identify patients at increased risk for duodenal erosions.

METHODS

A single-center, endoscopist-blinded, observational study was conducted of 196 patients in whom H pylori was eradicated. The presence of esophageal or duodenal erosions was evaluated 4 weeks and 6 months after eradication. Serum gastrin and pepsinogen I (PG I) and II (PG II) levels were also determined for 83 patients entering the study during its final year.

RESULTS

Multiple small duodenal erosions developed in 8.6% of patients after H pylori eradication and were more common in patients with pre-eradication duodenal ulcer (27.8%) compared with those with gastric ulcer (6.7%) or atrophic gastritis (1.4%) (p < 0.05). Duodenal erosions were associated with high levels of PG I before and after eradication. The frequency of duodenal erosions decreased over time (3.1% by 6 months).

CONCLUSION

Duodenal erosions occur after H pylori eradication and appear to be related to duodenal ulcer and increased PG I levels, both of which are associated with increased acid secretion. Measurement of PG I may help to identify patients who have duodenal erosions develop after H pylori therapy for studies of the pathogenesis of these lesions.