The nonerosive reflux disease-gastroesophageal reflux disease controversy

Juice Test for Identification of Nonerosive Reflux Disease in Heartburn Patients

Background/Aims

Evaluation of esophageal clearance by orange juice swallowing could be useful to identify different categories of gastroesophageal reflux disease. We determined whether a juice test at the beginning of esophageal pH monitoring can identify nonerosive reflux disease (NERD) among heartburn patients.

Methods

Multiple swallows of orange juice (pH 3) were performed at the beginning of esophageal pH monitoring in 71 heartburn patients off acid-suppressive therapy. The area between pH drop below 5 and recovery to 5 was calculated from pH tracings and named Delta5 (mmol·L⁻¹·sec). Fifteen healthy subjects served to determine Delta5 cutoff (95th percentile). Patients were classified as NERD, non-NERD (a mix of reflux hypersensitivity, functional heartburn, and undetermined), and erosive disease depending on acid exposure, reflux symptom analysis, and upper endoscopy.

Results

Delta5 cutoff in healthy subjects was 251 mmol·L⁻¹·sec. Among 71 patients, 23 had NERD, 26 had non-NERD, and 22 had erosive disease. Compared to non-NERD, Delta5 was higher in both NERD (median [interquartile range]: 316 [213–472] vs 165 [105–225]; P < 0.01) and erosive disease (310 [169–625] vs 165 [105–225]; P < 0.01). An elevated Delta5 (> 251 mmol·L⁻¹·sec) showed sensitivity of 74% and specificity of 81% for identification of NERD. Positive and negative likelihood ratios were 3.84 and 0.32 respectively, whereas test accuracy was 78%.

Conclusions

A juice test with calculation of Delta5 helps in the identification of true NERD among heartburn patients with endoscopy-negative reflux disease. In these patients, an elevated Delta5 could make prolonged reflux testing unnecessary.

Comparison of oesophageal function tests between Chinese non-erosive reflux disease and reflux hypersensitivity patients

BACKGROUND

By means of 24 h multi-channel intraluminal impedance and pH recording (MII/pH), patients with heartburn and normal upper gastrointestinal endoscopy findings can be classified into those with non-erosive reflux disease (NERD) and those with reflux hypersensitivity (RH). Therefore, in this study, we investigated the difference in oesophageal function tests in Chinese patients with NERD and RH.

METHODS

NERD patients were selected from the digestive department, Beijing Anzhen Hospital and Beijing Chao-Yang Hospital, Capital Medical University, after upper gastrointestinal endoscope, high-resolution manometry and impedance (HRiM), and MII/pH examinations between 2014 and 2016.

RESULTS

In total, 111 NERD patients with abnormal acid exposure, and 92 RH patients were enrolled. Values for NERD and RH were as follows: lower oesophageal sphincter pressure, 15.3 ± 8.9 and 19.3 ± 23.3 mmHg (P = 0.122); integrated relaxation pressure, 7.5 ± 4.8 and 7.9 ± 5.2 mmHg (P = 0.485); distal contractile integral, 751.9 ± 856.2 and 661.9 ± 961.7 mmHg∙s∙cm (P = 0.482); ineffective oesophageal motility rate, 49.5% and 41.3% (P = 0.241); fragmented peristalsis rate, 5.4% and 9.8% (P = 0.235); hiatal hernia rate, 9.0% and 8.6% (P = 0.938); total bolus transit time, 6.3 ± 1.3 and 6.5 ± 1.3 s (P = 0.119); complete bolus transit rate, 76.1 ± 33.0% and 73.1 ± 32.0% (P = 0.224); total acid exposure time, 6.1 ± 3.7% and 0.8 ± 0.8% (P < 0.001); total bolus exposure time, 2.5 ± 2.1% and 1.5 ± 1.1% (P < 0.001); proximal acid reflux events, 13.2 ± 10.5 and 9.7 ± 8.9 (P = 0.011); distal acid reflux events, 25.3 ± 15.8 and 13.4 ± 11.2 (P < 0.001); post-reflux swallow-induced peristaltic wave index, 25.1 ± 9.5% and 32.6 ± 15.2% (P < 0.001); and mean nocturnal baseline impedance, 1,450.2 ± 750.8 and 2,503.6 ± 964.1 ohms (P < 0.001), respectively.

CONCLUSIONS

NERD and RH patients showed similar values on HRiM. NERD patients had greater acid exposure time, bolus exposure time, proximal and distal acid reflux events, and increased impairment of chemical clearance and mucosal integrity than RH patients. NERD and RH should be classified correctly by MII/pH to provide adequate relief from related symptoms.

The Effect of Diabetes and Hypertension on the Placental Permeation of the Hydrophilic Drug, Ranitidine

INTRODUCTION

Ranitidine is a hydrophilic weak base and an H₂-receptor antagonist which is commonly used for gastroesophageal reflux, including during pregnancy. It has limited placental permeation and can be used as a pre-anesthetic antacid to prevent aspiration of acidic stomach contents. Recent studies suggest that diabetes and hypertension may influence placental permeation of hydrophilic drugs. Thus, this study aimed to investigate the influence of diabetes and hypertension on ranitidine's placental permeation in pregnant women.

METHODS

Forty one pregnant women all scheduled for elective cesarean section entered the study: healthy control (n = 15), with hypertension (n = 16) and with gestational diabetes (n = 10). All women received 50 mg of ranitidine intravenously. Three samples of maternal plasma (after ranitidine application, at delivery and after delivery), and two umbilical cord samples (arterial and venous blood) were collected and analyzed for ranitidine concentrations. Maternal pharmacokinetic parameter were calculated as well as feto:maternal and umbilical cord arterial to venous concentration ratios.

RESULTS

Ranitidine maternal and umbilical cord (arterial and venous) concentrations were similar in all three groups and there were no difference between feto:maternal ratios nor volume of distribution, clearance and half life between the groups.

DISCUSSION

Fetal concentrations are dependent on maternal concentrations in healthy and hypertensive women but not in diabetic women. Hypertension and diabetes did not affect fetal handling of ranitidine. Though hypertension and diabetes did not influence ranitidine placental permeation, it appears they altered time needed to achieve unity between maternal and fetal plasma.

Wireless ambulatory esophageal pH monitoring in dogs with clinical signs interpreted as gastroesophageal reflux

Background

Although gastroesophageal reflux (GER) often is assumed to be causative for upper gastrointestinal and respiratory signs in dogs, no attempts have been made to verify this assumption.

Objectives

To monitor esophageal pH with the Bravo pH system in healthy dogs and client‐owned dogs displaying signs commonly attributed to GER.

Animals

Seven healthy and 22 client‐owned dogs.

Methods

After routine esophagogastroduodenoscopy, radiotelemetric pH capsules were placed in distal esophagus for continuous pH recording. Reflux was defined as single pH measurement <4. At discharge, owners were instructed to press individually predefined clinical sign‐buttons on the receiver whenever indicated. Results between groups were compared using Mann–Whitney U‐test.

Results

The median (range) number of refluxes in client‐owned and healthy dogs, respectively, was 17 (1–205) and 10 (1–65), the number of refluxes >5 minutes in duration was 1 (0–14), and 1 (0–4), duration of longest reflux (min) was 10 (0–65) and 8 (0–27), and fractional time pH <4 (%) was 0.76% (0.01–6.28), and 0.3% (0–3.1). No differences were found between groups. The median of 7 (1–35) clinical sign‐button pushes were recorded in 21 dogs. Median of 12.5% (2.8% [1/35]–50% [2/4]) reflux‐positive clinical sign‐button pushes was found in 10 dogs with reflux‐positive pushes. Five (22.7%) dogs had increased esophageal acid exposure, and mild esophagitis was noted in 1 dog.

Conclusion and Clinical Importance

Despite evidence of increased GER in some dogs, the clinical sign‐reflux association remained poor. Future investigation should focus on dogs with esophagitis.

Current advances in the diagnosis and treatment of nonerosive reflux disease

Nonerosive reflux disease (NERD) is a distinct pattern of gastroesophageal reflux disease (GERD). It is defined as a subcategory of GERD characterized by troublesome reflux-related symptoms in the absence of esophageal mucosal erosions/breaks at conventional endoscopy. In clinical practice, patients with reflux symptoms and negative endoscopic findings are markedly heterogeneous. The potential explanations for the symptom generation in NERD include microscopic inflammation, visceral hypersensitivity (stress and sleep), and sustained esophageal contractions. The use of 24-hour esophageal impedance and pH monitoring gives further insight into reflux characteristics and symptom association relevant to NERD. The treatment choice of NERD still relies on acid-suppression therapy. Initially, patients can be treated by a proton pump inhibitor (PPI; standard dose, once daily) for 2–4 weeks. If initial treatment fails to elicit adequate symptom control, increasing the PPI dose (standard dose PPI twice daily) is recommended. In patients with poor response to appropriate PPI treatment, 24-hour esophageal impedance and pH monitoring is indicated to differentiate acid-reflux-related NERD, weakly acid-reflux-related NERD (hypersensitive esophagus), nonacid-reflux-related NERD, and functional heartburn. The response is less effective in NERD as compared with erosive esophagitis.

Outcomes in patients with nonerosive reflux disease treated with a proton pump inhibitor and alginic acid ± glycyrrhetinic acid and anthocyanosides

Background

The purpose of this study was to compare the efficacy of alginic acid alone versus alginic acid combined with low doses of pure glycyrrhetinic acid and bilberry anthocyanosides as an addon to conventional proton pump inhibitor therapy in relieving symptoms associated with nonerosive reflux disease.

Methods

This prospective, randomized, 8-week, open-label trial was conducted at two centers. Sixty-three patients with persistent symptoms of gastroesophageal reflux disease and normal upper gastrointestinal endoscopy were eligible for the study. Patients in group A (n = 31) were treated with pantoprazole and a formula (Mirgeal^®) containing alginic acid and low doses of pure glycyrrhetinic acid + standardized Vaccinium myrtillus extract for 4 weeks, then crossed over to the multi-ingredient formula for a further 4 weeks. Patients in group B (n = 32) were treated pantoprazole and alginic acid alone twice daily, then crossed over to alginic acid twice daily for a further 4 weeks. Efficacy was assessed by medical evaluation of a symptom relief score, estimated using a visual analog scale (0–10). Side effects, tolerability, and compliance were also assessed.

Results

Of the 63 patients enrolled in the study, 58 (29 in group A and 29 in group B) completed the 8-week trial. The baseline characteristics were comparable between the two groups. During the study, significant differences were recorded in symptom scores for both groups. In group A, symptoms of chest pain, heartburn, and abdominal swelling were less serious than in group B. Treatment A was better tolerated, did not induce hypertension, and had fewer side effects than treatment B. No significant differences in compliance were found between the two groups.

Conclusion

Use of low doses of pure glycyrrhetinic acid + bilberry anthocyanosides, together with alginic acid as addon therapy, substantially improves symptoms in patients with nonerosive reflux disease without increasing side effects or worsening tolerability or compliance.

Role of tight junction proteins in gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is associated with impaired epithelial barrier function that is regulated by cell-cell contacts. The aim of the study was to investigate the expression pattern of selected components involved in the formation of tight junctions in relation to GERD.

METHODS

Eighty-four patients with GERD-related symptoms with endoscopic signs (erosive: n = 47) or without them (non-erosive: n = 37) as well as 26 patients lacking GERD-specific symptoms as controls were included. Endoscopic and histological characterization of esophagitis was performed according to the Los Angeles and adapted Ismeil-Beigi criteria, respectively. Mucosal biopsies from distal esophagus were taken for analysis by histopathology, immunohistochemistry and quantitative reverse-transcription polymerase chain reaction (RT-PCR) of five genes encoding tight junction components [Occludin, Claudin-1, -2, Zona occludens (ZO-1, -2)].

RESULTS

Histopathology confirmed GERD-specific alterations as dilated intercellular spaces in the esophageal mucosa of patients with GERD compared to controls (P < 0.05). Claudin-1 and -2 were 2- to 6-fold upregulation on transcript (P < 0.01) and in part on protein level (P < 0.015) in GERD, while subgroup analysis of revealed this upregulation for ERD only. In both erosive and non-erosive reflux disease, expression levels of Occludin and ZO-1,-2 were not significantly affected. Notably, the induced expression of both claudins did not correlate with histopathological parameters (basal cell hyperplasia, dilated intercellular spaces) in patients with GERD.

CONCLUSIONS

Taken together, the missing correlation between the expression of tight junction-related components and histomorphological GERD-specific alterations does not support a major role of the five proteins studied in the pathogenesis of GERD.

Randomised clinical trial: sustained response to PPI treatment of symptoms resembling functional dyspepsia and irritable bowel syndrome in patients suffering from an overlap with erosive gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease (GERD), functional dyspepsia (FD) and irritable bowel syndrome (IBS) are highly prevalent gastrointestinal conditions with accumulating evidence of overlap in patients. Despite availability of a vast body of research related to individual disorders, major pharmacological breakthrough in treatment of the overlap condition is still lacking.

AIM

To assess sustainability of GERD healing and whether known beneficial effects of proton pump inhibitor treatment on GERD also extend to symptoms suggestive of FD and IBS.

METHODS

A total of 626 patients with reflux oesophagitis were treated with pantoprazole for up to 16 weeks depending on healing of GERD, followed by an observational phase of up to 6 months without treatment. Rates of patients suffering from GERD, FD or IBS were assessed at baseline, and at last visits of treatment and observational phase.

RESULTS

Rates of patients with reflux oesophagitis and concomitantly with reflux symptoms, FD or IBS were each significantly lower after pantoprazole treatment (P < 0.0001). While rates of patients with reflux signs or symptoms increased again during observational phase, rates of FD and IBS were maintained at the low level after cessation of medication (P < 0.0001).

CONCLUSIONS

Pantoprazole is efficacious in the treatment of patients suffering from signs and symptoms suggesting an overlap of GERD, FD and/or IBS, providing a sustained response post-treatment in FD and IBS symptom categories. Mechanisms underlying the beneficial effects of improvement in reflux oesophagitis on symptoms suggestive of FD or IBS still need to be determined.

A randomized open-label trial of on-demand rabeprazole vs ranitidine for patients with non-erosive reflux disease

AIM: To compare the efficacy of the proton-pump inhibitor, rabeprazole, with that of the H₂-receptor antagonist, ranitidine, as on-demand therapy for relieving symptoms associated with non-erosive reflux disease (NERD).

METHODS: This is a single center, prospective, randomized, open-label trial of on-demand therapy with rabeprazole (group A) vs ranitidine (group B) for 4 wk. Eighty-three patients who presented to the American University of Beirut Medical Center with persistent gastroesophageal reflux disease (GERD) symptoms and a normal upper gastrointestinal endoscopy were eligible for the study. Patients in group A (n = 44) were allowed a maximum rabeprazole dose of 20 mg twice daily, while those in group B (n = 39) were allowed a maximum ranitidine dose of 300 mg twice daily. Efficacy was assessed by patient evaluation of global symptom relief, scores of the SF-36 quality of life (QoL) questionnaires, total number of pills used, and number of medication-free days.

RESULTS: Among the 83 patients who were enrolled in the study, 76 patients (40 in the rabeprazole group and 36 in the ranitidine group) completed the 4-wk trial. Baseline characteristics were comparable between both groups. After 4 wk, there was no significant difference in the subjective global symptom relief between the rabeprazole and the ranitidine groups (71.4% vs 65.4%, respectively; P = 0.9). There were no statistically significant differences between mean cumulative scores of the SF-36 QoL questionnaire for the two study groups (rabeprazole 22.40 ± 27.53 vs ranitidine 17.28 ± 37.06; P = 0.582). There was no significant difference in the mean number of pills used (rabeprazole 35.70 ± 29.75 vs ranitidine 32.86 ± 26.98; P = 0.66). There was also no statistically significant difference in the mean number of medication-free days between both groups.

CONCLUSION: Rabeprazole has a comparable efficacy compared to ranitidine when given on-demand for the treatment of NERD. Both medications were associated with improved quality of life.

Ranitidine is associated with infections, necrotizing enterocolitis, and fatal outcome in newborns

BACKGROUND AND OBJECTIVES

Gastric acidity is a major nonimmune defense mechanism against infections. The objective of this study was to investigate whether ranitidine treatment in very low birth weight (VLBW) infants is associated with an increased risk of infections, necrotizing enterocolitis (NEC), and fatal outcome.

METHODS

Newborns with birth weight between 401 and 1500 g or gestational age between 24 and 32 weeks, consecutively observed in neonatal intensive care units, were enrolled in a multicenter prospective observational study. The rates of infectious diseases, NEC, and death in enrolled subjects exposed or not to ranitidine were recorded.

RESULTS

We evaluated 274 VLBW infants: 91 had taken ranitidine and 183 had not. The main clinical and demographic characteristics did not differ between the 2 groups. Thirty-four (37.4%) of the 91 children exposed to ranitidine and 18 (9.8%) of the 183 not exposed to ranitidine had contracted infections (odds ratio 5.5, 95% confidence interval 2.9-10.4, P < .001). The risk of NEC was 6.6-fold higher in ranitidine-treated VLBW infants (95% confidence interval 1.7-25.0, P = .003) than in control subjects. Mortality rate was significantly higher in newborns receiving ranitidine (9.9% vs 1.6%, P = .003).

CONCLUSIONS

Ranitidine therapy is associated with an increased risk of infections, NEC, and fatal outcome in VLBW infants. Caution is advocated in the use of this drug in neonatal age.

Influence of irritable bowel syndrome on treatment outcome in gastroesophageal reflux disease

AIM: To investigate the influence of irritable bowel syndrome (IBS)-like symptoms on treatment outcomes with pantoprazole in gastroesophageal reflux disease (GERD) in a real life setting.

METHODS: For this prospective, open-label, multinational, multicentre study, 1888 patients assessed by the investigators as suffering from GERD were recruited. The patients were additionally classified as with or without IBS-like symptoms at baseline. They were treated with pantoprazole 40 mg once daily and completed the Reflux Questionnaire™ (ReQuest™) short version daily. Response rates and symptom scores were compared after 4 and 8 wk of treatment for subgroups defined by the subclasses of GERD [erosive (ERD) and non-erosive reflux disease (NERD)] and the presence of IBS-like symptoms.

RESULTS: IBS-like symptoms were more prevalent in NERD than in ERD (18.3% vs 12.7%, P = 0.0015). Response rates after 4 and/or 8 wk of treatment were lower in patients with IBS-like symptoms than in patients without IBS-like symptoms in both ERD (Week 4: P < 0.0001, Week 8: P < 0.0339) and NERD (Week 8: P = 0.0088). At baseline, ReQuest™“lower abdominal complaints” symptom scores were highest in NERD patients with IBS-like symptoms. Additionally, these patients had the strongest symptom improvement after treatment compared with all other subgroups.

CONCLUSION: IBS-like symptoms influence treatment outcome and symptom burden in GERD and should be considered in management. Proton pump inhibitors can improve IBS-like symptoms, particularly in NERD.

To Bravo or not? A comparison of wireless esophageal pH monitoring and conventional pH catheter to evaluate non-erosive gastroesophageal reflux disease in a multiracial Asian cohort

OBJECTIVE

Non-erosive reflux disease (NERD) constitutes the majority of patients with gastroesophageal reflux disease (GERD). Esophageal pH monitoring is useful in distinguishing patients with NERD from functional heartburn. The gastroenterologist often faces the dilemma of choosing the most appropriate investigative modality. The wireless Bravo capsule allows prolonged 48 hour monitoring with improved patient tolerance, but concerns regarding its reduced sensitivity compared to conventional pH catheter have been raised. We compared the prevalence of high esophageal acid exposure and positive symptom correlation profiles (using the symptom index [SI] and symptom association probability [SAP]) in patients who underwent Bravo compared to patients who underwent conventional pH catheter, and evaluated the efficacy of Bravo monitoring in a multiracial Asian cohort.

METHODS

Retrospective analysis of all pH studies performed between January 2004 and February 2009 for patients with persistent reflux symptoms and a normal gastroscopy.

RESULTS

66 (27 Male, 42.4 +/- 13.4 years) and 55 (24 Male, 47.1 +/- 13.3 years) patients underwent wireless and pH catheter evaluation respectively. "True NERD" (abnormal acid exposure) was diagnosed in 26 (39.4%) and 20 (36.4%) patients (pNS) while "acid-sensitive esophagus" (SI > or = 50% and/or SAP > or = 95%) occurred in 14 (21.2%) and 12 (21.8%) patients (pNS) using the wireless and pH catheter respectively. Extended recording time with Bravo led to an incremental diagnostic yield of 30%.

CONCLUSION

The wireless capsule was well tolerated. The diagnostic yield was similar using both modalities. With the increasing availability of impedance-pH technology, it is uncertain if devices that detect only acid-reflux events will be surpassed.

Evolving issues in the management of reflux disease?

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) is a common chronic disorder often successfully treated, although there are several evolving issues in management. We reviewed the issues related to unmet needs over the past 12 months.

RECENT FINDINGS

A substantial number of patients fail to respond adequately to once or even twice daily proton pump inhibitor (PPI). There is no standard definition of PPI failure in GERD; a universally accepted definition for treatment success is also not available. Differentiation between erosive esophagitis and nonerosive reflux disease can be made but requires endoscopy; but studies still confuse functional heartburn and nonerosive reflux disease, which impacts management. Acid reflux plays an important role in GERD pathogenesis and the precise role of acid requires more studies of differences between erosive esophagitis and nonerosive reflux disease symptom generation and the implication of nocturnal acidification. Several possible mechanisms may explain GERD refractory to PPIs.

SUMMARY

Management of PPI nonresponders remains a challenge. Objective and precise evaluation of symptoms and treatment response requires study in high-quality trials. New therapeutic approaches are under investigation to answer unmet needs and improve erosive esophagitis healing rates and symptom control.

Utility of non-endoscopic investigations in the practical management of oesophageal disorders

The current available methods for diagnosis of GORD are symptom questionnaires, catheter and wireless pH-metry, impedance-pH monitoring and Bilitec(@). Osophageal pH monitoring allows both quantitative analysis of acid reflux and assessment of reflux-symptom association. Impedance-pH monitoring detects all types of reflux (acid and non-acid) and allows assessment of proximal extent of reflux, a relevant parameter for understanding symptoms perception and extraoesophageal symptoms. Bilitec provides a quantitative assessment of duodeno-gastro-oesophageal reflux. Oesophageal motor abnormalities have been associated with GORD symptoms as well as chest pain and dysphagia. High-resolution manometry contributed to re-classify oesphageal motor disorders. However, barium swallows are still essential for evaluation of oesophageal anatomy and combined oesophageal manometry-impedance can assess oesophageal motility and bolus transit simultaneously in a non-radiological way. Still in experimental phase, high-frequency ultrasound allows monitoring of the oesophageal wall thickness and exaggerated longitudinal muscle contraction that might be associated to chest pain and dysphagia. This chapter provides a critical evaluation of the clinical application of these techniques.