Acid sensitization of esophageal mucosal afferents: implication for symptom perception in patients across the gastroesophageal reflux disease spectrum. Clin J Pain. 2013;29:70-77. [PMID: 22330131 DOI: 10.1097/AJP.0b013e3182478826]

Developments in Gastroesophageal Reflux Disease over the Last 40 Years

BACKGROUND

The last 40 years have seen a remarkable change in our understanding of reflux disease.

SUMMARY

These changes encompass disease definition and impact, pathophysiology, diagnostic testing, regulatory oversight of clinical trials, pharmacotherapy, endoscopic, and surgical treatment. We have also seen a number of promising therapies fail.

KEY MESSAGES

The future holds the promise of further advances. Adaptive artificial intelligence will take over diagnostics in manometry and pH impedance testing and patient-driven outcomes may be changed by interactions with artificial intelligence rather than humans. Changes in chip technology will allow higher resolution chips to be carried on smaller devices making extra-esophageal areas where reflux may play a role more accessible to prolonged observation and testing.

[Analysis of esophageal manometry results and the inflection point of age in 41 volunteers without laryngopharyngeal symptoms]

Objective:This study aimed to explore the differences in esophageal pressure at different ages, and to analyze the possible age inflection points of the physiological degeneration of esophageal motility, and to further evaluate whether the degeneration of esophageal kinetics with age is the only risk factor for the occurrence of throat reflux disease （LPRD）. Methods:A solid-state high-resolution esophageal pressure measurement was performed on 41 volunteers without throat symptoms. The Chicago classification data were compared with the manometry results of all volunteers. In addition, the esophageal manometry results were compared among groups with pre-set age inflection point. Results:Most of the volunteers' esophageal pressure measurements were in line with Chicago standards. When the inflection point of age was 55 years, no significant difference was found between the two groups. However, when the inflection point of age was 65 years, a significant difference in the length of the upper esophageal sphincter and the contractile front velocity was found between the two groups（P=0.021 and 0.046 respectively）. Conclusion:Esophageal dynamics was weakened with increasing age in the volunteers without laryngopharyngeal symptoms, which was more obvious after the age of 65, but still within the normal range. The degeneration of esophageal motility is not the only risk factor for LPRD.

The Characteristics of Postprandial Proximal Gastric Acid Pocket in Gastroesophageal Reflux Disease

Background

Postprandial proximal gastric acid pocket (PPGAP) plays important roles in gastroesophageal reflux disease (GERD). In this study, we analyzed the characteristics of PPGAP in GERD.

Material/Methods

There were 17 normal participants and 20 GERD patients who completed a gastroesophageal reflux disease questionnaire (GerdQ) and underwent a gastroscopy, a high-resolution manometry, an esophageal 24-hour pH monitoring, and a station pull-through pH monitoring to assess their symptomatic degree, endoscopic change, acid exposure, and PPGAP.

Results

PPGAP was present in all participants. Compared with normal participants, the PPGAP in GERD patients was significantly different, thus the disappearing time was significantly later (p<0.001), the lasting time was significantly longer (p<0.001), the length was significantly longer (p<0.001), and the lowest pH and the mean pH were significantly lower (p<0.001). The length of PPGAP in GERD patients was positively correlated with GerdQ score (p<0.05). The disappearing time, the lasting time, and the length of PPGAP in GERD patients was positively correlated with the DeMeester score (p<0.01). The lowest pH and the mean pH of PPGAP in GERD patients was negatively correlated with the DeMeester score (p<0.001).

Conclusions

PPGAP was generally present. PPGAP in GERD patients had characteristics of long time period, long length, and high acidity. Its length was positively correlated with subjective symptomatic degree. Its period, length, and acidity were positively correlated with the objective acid exposure. PPGAP seems to be the originator of acid reflux events and plays important roles in GERD.

The Relationship of the Post-reflux Swallow-induced Peristaltic Wave Index and Esophageal Baseline Impedance with Gastroesophageal Reflux Disease Symptoms

Background/Aims

The post-reflux swallow-induced peristaltic wave (PSPW) index and esophageal baseline impedance (BI) are novel impedance parameters used to evaluate esophageal chemical clearance and mucosal integrity. However, their relationship with reflux symptoms is not known. We aim to evaluate the correlations of PSPW index and esophageal BI with gastroesophageal reflux disease (GERD) symptoms.

Methods

We performed a retrospective review of multichannel intraluminal impedance and pH (MII-pH) tracings in patients with suspected GERD. Reflux symptoms were also analyzed from checklists using ordinal scales. The PSPW index and esophageal BIs in 6 spots (z1–z6) were measured. Bivariate (Spearman) correlation was used to analyze the relationship between the PSPW index or esophageal BI, and the degree of GERD symptoms measured.

Results

The MII-pH records of 143 patients were analyzed. The PSPW index was significantly lower in patients who had heartburn and negatively correlated with the degree of heartburn (r = −0.186, P < 0.05). On the contrary, the PSPW index was not significantly correlated with the degree of dysphagia (r = −0.013, P = 0.874). Distal esophageal BI was not significantly correlated with heartburn, but negatively correlated with the degree of dysphagia (z3: r = −0.328, z4: r = −0.361, z5: r = −0.316, z6: r = −0.273; P < 0.05).

Conclusions

These findings suggest that delayed chemical clearance of the esophagus may induce heartburn, but that it is not related to dysphagia. However, a lack of esophageal mucosal integrity may be related to dysphagia.

Development and validation of the brief esophageal dysphagia questionnaire

BACKGROUND

Esophageal dysphagia is common in gastroenterology practice and has multiple etiologies. A complication for some patients with dysphagia is food impaction. A valid and reliable questionnaire to rapidly evaluate esophageal dysphagia and impaction symptoms can aid the gastroenterologist in gathering information to inform treatment approach and further evaluation, including endoscopy.

METHODS

1638 patients participated over two study phases. 744 participants completed the Brief Esophageal Dysphagia Questionnaire (BEDQ) for phase 1; 869 completed the BEDQ, Visceral Sensitivity Index, Gastroesophageal Reflux Disease Questionnaire, and Hospital Anxiety and Depression Scale for phase 2. Demographic and clinical data were obtained via the electronic medical record. The BEDQ was evaluated for internal consistency, split-half reliability, ceiling and floor effects, and construct validity.

KEY RESULTS

The BEDQ demonstrated excellent internal consistency, reliability, and construct validity. The symptom frequency and severity scales scored above the standard acceptable cutoffs for reliability while the impaction subscale yielded poor internal consistency and split-half reliability; thus the impaction items were deemed qualifiers only and removed from the total score. No significant ceiling or floor effects were found with the exception of 1 item, and inter-item correlations fell within accepted ranges. Construct validity was supported by moderate yet significant correlations with other measures. The predictive ability of the BEDQ was small but significant.

CONCLUSIONS & INFERENCES

The BEDQ represents a rapid, reliable, and valid assessment tool for esophageal dysphagia with food impaction for clinical practice that differentiates between patients with major motor dysfunction and mechanical obstruction.

Diabetes-induced mechanophysiological changes in the esophagus

Esophageal disorders are common in diabetes mellitus (DM) patients. DM induces mechanostructural remodeling in the esophagus of humans and animal models. The remodeling is related to esophageal sensorimotor abnormalities and to symptoms frequently encountered by DM patients. For example, gastroesophageal reflux disease (GERD) is a common disorder associated with DM. This review addresses diabetic remodeling of esophageal properties and function in light of the Esophagiome, a scientifically based modeling effort to describe the physiological dynamics of the normal, intact esophagus built upon interdisciplinary approaches with applications for esophageal disease. Unraveling the structural, biomechanical, and sensory remodeling of the esophagus in DM must be based on a multidisciplinary approach that can bridge the knowledge from a variety of scientific disciplines. The first focus of this review is DM-induced morphodynamic and biomechanical remodeling in the esophagus. Second, we review the sensorimotor dysfunction in DM and how it relates to esophageal remodeling. Finally, we discuss the clinical consequences of DM-induced esophageal remodeling, especially in relation to GERD. The ultimate aim is to increase the understanding of DM-induced remodeling of esophageal structure and sensorimotor function in order to assist clinicians to better understand the esophageal disorders induced by DM and to develop better treatments for those patients.

Generation of Gastroesophageal Reflux Disease Symptoms During Esophageal Acid Infusion With Concomitant Esophageal pH Monitoring in Healthy Adults

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.

Recent progress in research of gastroesophageal reflux disease: Pathogenesis, diagnosis and treatment

The incidence of gastroesophageal reflux disease has been increasing annually in China. The emergence of new techniques in recent years has not only facilitated the diagnosis of this complex disease but also improved the understanding of the pathogenesis of this disease. Nowadays much attention is paid to adverse reactions of drugs such as proton pump inhibitors and prokinetic agents for gastroesophageal reflux disease, which has promoted the development of new treatments for gastroesophageal reflux disease. In this review, we will summarize recent progress in research of gastroesophageal reflux disease in terms of its pathogenesis, diagnosis and treatment.