Natural history of gastro-oesophageal reflux disease diagnosed in general practice

Real-world evidence of safety and effectiveness of Barrett's endoscopic therapy

BACKGROUND AND AIMS

Real-world data on the adverse events and the survival benefit of Barrett's endoscopic therapy (BET) are limited. The aim of this study was to examine the safety and effectiveness (survival benefit) of BET in patients with neoplastic Barrett's esophagus (BE).

METHODS

An electronic health record-based database (TriNetX) was used to select patients with BE with dysplasia and esophageal adenocarcinoma (EAC) from 2016 to 2020. Primary outcome was 3-year mortality among patients with high-grade dysplasia (HGD) or EAC who underwent BET versus 2 comparison cohorts: patients with HGD or EAC who had not undergone BET and patients with GERD but no BE/EAC. Secondary outcome was adverse events (esophageal perforation, upper GI bleeding, chest pain, and esophageal stricture) after BET. To control for confounding variables, 1:1 propensity score matching was performed.

RESULTS

We identified 27,556 patients with BE and dysplasia, of whom 5295 underwent BET. After propensity score matching, patients with HGD and EAC who underwent BET had significantly lower 3-year mortality (HGD risk ratio [RR], .59; 95% CI, .49-.71; EAC RR, .53; 95% CI, .44-.65) compared with corresponding cohorts who did not undergo BET (P < .001). There was no difference in median 3-year mortality between control subjects (GERD without BE/EAC) compared with patients with HGD (RR, 1.04; 95% CI, .84-1.27) who underwent BET. Finally, there was no difference in median 3-year mortality between patients who underwent BET compared with patients who underwent esophagectomy among both HGD (RR, .67; 95% CI, .39-1.14; P =.14) and EAC (RR, .73; 95% CI, .47-1.13; P = .14). Esophageal stricture was the most common adverse event (6.5%) after BET.

CONCLUSIONS

Real-world, population-based evidence from this large database shows that endoscopic therapy is safe and effective for patients with BE. Endoscopic therapy is associated with a significantly lower 3-year mortality; however, it leads to esophageal strictures in 6.5% of treated patients.

Heartburn relief with bicarbonate-rich mineral water: results of the randomised, placebo-controlled phase-III trial STOMACH STILL

OBJECTIVE

We assessed whether the bicarbonate-rich mineral water Staatl. Fachingen STILL is superior over conventional mineral water in relieving heartburn.

DESIGN

Multicentre, double-blind, randomised, placebo-controlled trial STOMACH STILL in adult patients with frequent heartburn episodes since ≥6 months and without moderate/severe reflux oesophagitis. Patients drank 1.5 L/day verum or placebo over the course of the day for 6 weeks. Primary endpoint was the percentage of patients with reduction of ≥5 points in the Reflux Disease Questionnaire (RDQ) score for 'heartburn'. Secondary endpoints included symptom reduction (RDQ), health-related quality of life (HRQOL, Quality of Life in Reflux and Dyspepsia (QOLRAD)), intake of rescue medication and safety/tolerability.

RESULTS

Of 148 randomised patients (verum: n=73, placebo: n=75), 143 completed the trial. Responder rates were 84.72% in the verum and 63.51% in the placebo group (p=0.0035, number needed to treat=5). Symptoms improved under verum compared with placebo for the dimension 'heartburn' (p=0.0003) and the RDQ total score (p=0.0050). HRQOL improvements under verum compared with placebo were reported for 3 of 5 QOLRAD domains, that is, 'food/drink problems' (p=0.0125), 'emotional distress' (p=0.0147) and 'vitality' (p=0.0393). Mean intake of rescue medication decreased from 0.73 tablets/day at baseline to 0.47 tablets/day in week 6 in the verum group, whereas in the placebo group it remained constant during the trial. Only three patients had treatment-related adverse events (verum: n=1, placebo: n=2).

CONCLUSION

STOMACH STILL is the first controlled clinical trial demonstrating superiority of a mineral water over placebo in relieving heartburn, accompanied by an improved HRQOL.

TRIAL REGISTRATION NUMBER

EudraCT 2017-001100-30.

Erosive and ulcerative lesions of the digestive tract: optimization of diagnosis and management tactics

Erosive and ulcerative lesions of the digestive tract are one of the most pressing problems in the clinic of internal diseases due to the extremely widespread prevalence, the presence of severe complications, often fatal, diagnostic difficulties due to the presence of a large number of asymptomatic pathologies and difficulties in the rational choice of therapy. Particularly noteworthy is the data that during the global pandemic of Covid-19 infection, it is capable, quite often, of causing the development of erosive and ulcerative lesions of the gastrointestinal tract. In this regard, it seems important to use drugs that can not only prevent the occurrence of erosive and ulcerative lesions and strictures throughout the gastrointestinal tract, but also effectively achieve epithelialization of injuries to the mucous membrane of the oral cavity, esophagus, stomach, small and large intestine. One of them is Rebamipid-CZ, which has a fairly high safety and efficacy profile. It seems important to consider the issues of optimizing the prevention and treatment of erosive and ulcerative lesions of various parts of the gastrointestinal tract of various etiologies, taking into account the possibility of using rebamipide both as part of complex therapy and in isolation.

Demographic and lifestyle risk factors for gastroesophageal reflux disease and Barrett's esophagus in Australia

We examined demographic and lifestyle risk factors for incidence of gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE) in an Australian cohort of 20,975 participants aged 40-63 at recruitment (1990-1994). Information on GERD and BE was collected between 2007 and 2010. GERD symptoms were defined as self-reported heartburn or acid regurgitation. BE was defined as endoscopically confirmed columnar-lined esophagus. Risk factors for developing GERD symptoms, BE diagnosis, age at symptom onset, and age at BE diagnosis were quantified using regression. During a mean follow-up of 15.8 years, risk of GERD symptoms was 7.5% (n = 1,318) for daily, 7.5% (n = 1,333) for 2-6 days/week, and 4.3% (n = 751) for 1 day/week. There were 210 (1.0%) endoscopically diagnosed BE cases, of whom 141 had histologically confirmed esophageal intestinal metaplasia. Female sex, younger age, lower socioeconomic position (SEP) and educational attainment, and former smoking were associated with higher GERD risk. Male sex and smoking were associated with earlier GERD symptom onset. Men, older participants, those with higher SEP, and former smokers were at higher BE risk. There was some evidence higher SEP was associated with earlier BE diagnosis. GERD and BE had different demographic risk factors but shared similar lifestyle factors. Earlier GERD symptom onset for men and smokers might have contributed to higher BE risk. The SEP patterns observed for GERD and BE suggest potential inequity in access to care. These findings would be important in the development of clinical risk prediction models for early detection of BE.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.

Extra-esophageal symptoms in individuals with and without erosive esophagitis: a case-control study in Albania

INTRODUCTION

Erosive reflux esophagitis caused a large clinical spectrum of symptoms. Our aim was to assess the prevalence of extra-esophageal symptoms in individuals with and those without erosive esophagitis in Albania.

METHODS

A case-control study was conducted at the Regional Hospital of Durres, the second main district in Albania, a transitional country in South Eastern Europe, including 248 patients with erosive esophagitis (aged 46.5 ± 16.3 years) and 273 controls (aged 46.4 ± 16.0 years; response rate: 70%) enrolled during the period January 2013-June 2014. Both cases and controls underwent upper endoscopy. Information on socio-demographic characteristics and lifestyle factors was also collected. Binary logistic regression was used to assess the association of erosive esophagitis and extra-esophageal symptoms.

RESULTS

Patients with erosive esophagitis had a higher prevalence of excessive alcohol consumption, smoking, sedentarity, non-Mediterranean diet and obesity compared to their control counterparts (9% vs. 5%, 70% vs. 49%, 31% vs. 17%, 61% vs. 49% and 22% vs. 9%, respectively). Upon adjustment for all socio-demographic characteristics and lifestyle/behavioral factors, there was evidence of a strong association of erosive esophagitis with chronic cough (OR = 3.2, 95% CI = 1.7-5.8), and even more so with laryngeal disorders (OR = 4.4, 95% CI = 2.6-7.5). In all models, the association of erosive esophagitis with any extra-esophageal symptoms was strong and mainly consistent with each of the symptoms separately (fully-adjusted model: OR = 4.6, 95% CI = 2.9-7.3).

CONCLUSION

Our findings indicate that the prevalence of extra-esophageal symptoms is higher among patients with erosive esophagitis in a transitional country characterized conventionally by employment of a Mediterranean diet.

Computational modelling suggests that Barrett's oesophagus may be the precursor of all oesophageal adenocarcinomas

OBJECTIVE

Barrett's oesophagus (BE) is a known precursor to oesophageal adenocarcinoma (OAC) but current clinical data have not been consolidated to address whether BE is the origin of all incident OAC, which would reinforce evidence for BE screening efforts. We aimed to answer whether all expected prevalent BE, diagnosed and undiagnosed, could account for all incident OACs in the US cancer registry data.

DESIGN

We used a multiscale computational model of OAC that includes the evolutionary process from normal oesophagus through BE in individuals from the US population. The model was previously calibrated to fit Surveillance, Epidemiology and End Results cancer incidence curves. Here, we also utilised age-specific and sex-specific US census data for numbers at-risk. The primary outcome for model validation was the expected number of OAC cases for a given calendar year. Secondary outcomes included the comparisons of resulting model-predicted prevalence of BE and BE-to-OAC progression to the observed prevalence and progression rates.

RESULTS

The model estimated the total number of OAC cases from BE in 2010 was 9970 (95% CI: 9140 to 11 980), which recapitulates nearly all OAC cases from population data. The model simultaneously predicted 8%-9% BE prevalence in high-risk males age 45-55, and 0.1%-0.2% non-dysplastic BE-to-OAC annual progression in males, consistent with clinical studies.

CONCLUSION

There are likely few additional OAC cases arising in the US population outside those expected from individuals with BE. Effective screening of high-risk patients could capture the majority of population destined for OAC progression and potentially decrease mortality through early detection and curative removal of small (pre)cancers during surveillance.

The Impact of Laryngopharyngeal Reflux on Patient-reported Measures of Chronic Rhinosinusitis

OBJECTIVE

This study explored the impact of laryngopharyngeal reflux (LPR) on quality-of-life outcomes captured by Sino-Nasal Outcome Test (SNOT-22) and Reflux Symptom Index (RSI) in patients with chronic rhinosinusitis (CRS) and patients with symptoms of LPR.

METHODS

In a retrospective chart review, SNOT-22 and RSI scores were analyzed in patients seen at a tertiary care center with CRS, LPR, or both CRS and LPR. SNOT-22 items were grouped into sleep, nasal, otologic, and emotional symptom subdomains.

RESULTS

A total of 138 patients (36 with CRS alone, 60 with LPR alone, and 42 with both CRS and LPR) were included. Compared to patients with CRS alone, those with CRS and LPR (CRS+LPR) had higher SNOT-22 total (50.54 ± 19.53 vs 35.31 ± 20.20, P < .001), sleep (19.61 ± 9.31 vs 14.42 ± 10.34, P < .022), nasal (17.38 ± 7.49 vs 11.11 ± 8.52, P < .001), otologic subdomains (9.17 ± 5.07 vs 5.53 ± 5.14, P < .002), and RSI (22.06 ± 9.42 vs 10.75 ± 8.43, P < .003). Patients with LPR alone had higher RSI compared to those with CRS (18.48 ± 9.77 vs 10.75 ± 8.43, P < .037). RSI and SNOT-22 scores were positively correlated irrespective of patient group (R = 0.289, P = .003).

CONCLUSION

Compared to patients with CRS or LPR alone, those with CRS+LPR demonstrated higher RSI and total and subdomain SNOT-22 scores. Patients with LPR alone had elevated SNOT-22 despite absent endoscopic evidence of sinusitis.

Proton Pump Inhibitors in the Elderly, Balancing Risk and Benefit: an Age-Old Problem

PURPOSE OF REVIEW

Proton pump inhibitors (PPIs) are one of the most prescribed drugs in the developed world and elderly patients are particularly likely to be prescribed acid suppression. There have been reports of many diseases being associated with PPI therapy and the elderly would be particular at risk of any harms these drugs may cause. This review therefore reviews the evidence of the risks and benefits of these drugs.

RECENT FINDINGS

PPIs are very effective at treating acid-related disorders. Recent randomized trials have suggested that the associations between PPI and various diseases are likely to be related to bias and residual confounding and these drugs appear to be safe apart from a possible increase risk of enteric infections. PPIs should be used at the lowest dose and for the shortest duration possible. They are still relatively safe drugs but should only be prescribed for proven indications.

Gastroesophageal reflux disease and esophagitis associated with the use of drugs: the modern state of the problem

From the standpoint of evidence - based medicine, the ability of various drugs to induce the development of gastroesophageal reflux disease and esophagitis is considered. Thus, all known drugs can be divided into 3 groups: drugs that have the ability to reduce pressure in the lower esophageal sphincter, for example, β-adrenoreceptor agonists, α-adrenoreceptor antagonists, anticholinergics, calcium channel blockers, nitrates, benzodiazepines (diazepam), estrogen, progesterone, aminophylline (theophylline), tricyclic antidepressants, selective serotonin reuptake inhibitors, glucocorticosteroids; means providing a direct damaging effect on the esophageal mucosa, as well as lowering its resistance reflyuktatu, e.g., bisphosphonates, acetylsalicylic acid / non - steroidal anti - inflammatory agents, anticoagulants, antiplatelet drugs, iron preparations, ascorbic acid, potassium chloride, quinidine, phenytoin, calcium dobesilate, 131I sodium iodide, antibiotics (tetracycline, doxycycline, clindamycin, ciprofloxacin, ornidazole, clindamycin, rifampicin), antitumor agents; drugs that impede gastric emptying: calcium channel blockers, anticholinergics. These data can be used in practice in the choice of treatment tactics, especially in individuals with a diagnosis of gastroesophageal reflux disease or heartburn.

Prevalence of Gastroesophageal Reflux Disease Symptoms in Infants and Children: A Systematic Review

OBJECTIVES

Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux causing troublesome symptoms or complications. In this study we reviewed the literature regarding the prevalence of GERD symptoms in infants and children.

METHODS

Databases of PubMed, EMBASE, and Cochrane were systematically searched from inception to June 26, 2018. English-written studies based on birth cohort, school-based, or general population samples of ≥50 children aged 0 to 21 years were included. Convenience samples were excluded.

RESULTS

In total, 3581 unique studies were found, of which 25 studies (11 in infants and 14 in children) were included with data on the prevalence of GERD symptoms comprising a total population of 487,969 children. In infants (0-18 months), GERD symptoms are present in more than a quarter of infants on a daily basis and show a steady decline in frequency with almost complete disappearance of symptoms at the age of 12 months. In children older than 18 months, GERD symptoms show large variation in prevalence between studies (range 0%-38% of study population) and overall, are present in >10% and in 25% on respectively a weekly and monthly basis. Of the risk factors assessed, higher body mass index and the use of alcohol and tobacco were associated with higher GERD symptom prevalence.

CONCLUSIONS

This systematic review demonstrates that the reported prevalence of GERD symptoms varies considerably, depending on method of data collection and criteria used to define symptoms. Nevertheless, the high reported prevalence rates support better investment of resources and educational campaigns focused on prevention.

Physical Activity Protects Against the Risk of Erosive Esophagitis on the Basis of Body Mass Index

GOAL

To determine whether physical activity lowers the risk for erosive esophagitis on the basis of body mass index (BMI).

BACKGROUND

Although previous studies have shown that physical activity is closely associated with erosive esophagitis, these data may be confounded by obesity.

STUDY

In this retrospective study, we included 182,409 patients who underwent an upper endoscopy and were diagnosed with erosive esophagitis. The impact of the amount and intensity of physical activity on the risk for erosive esophagitis was analyzed based on BMI groups. Subjects were classified into three BMI groups with equal numbers in each group.

RESULTS

Overall, 10.3% (n=18,859) of patients were diagnosed with erosive esophagitis. After adjusting for confounding factors, a greater amount of exercise [lower tertile: odd ratio (OR), 0.86; 95% confidence interval (CI), 0.77-0.96; middle tertile: OR, 0.91; 95%, CI 0.84-1.00; upper tertile: OR, 0.79; 95% CI, 0.73-0.85) and increased exercise intensity (lower tertile, moderate: OR, 0.61; 95% CI, 0.52-0.71; vigorous: OR, 0.51; 95% CI, 0.44-0.58; middle tertile, moderate: OR, 0.62; 95% CI, 0.55-0.70; vigorous: OR, 0.58; 95% CI, 0.51-0.65; upper tertile, moderate: OR, 0.58; 95% CI, 0.53-0.65; vigorous: OR, 0.58; 95% CI, 0.53-0.64) was associated with a decreased risk for erosive esophagitis in all 3 BMI groups. In addition, we observed that increased physical activity intensity notably decreased the risk for erosive esophagitis in subjects performing lesser physical activity, but slightly decreased the risk for erosive esophagitis in subjects performing more physical activity.

CONCLUSION

Physical activity is inversely associated with erosive esophagitis.

The association between waterpipe smoking and gastroesophageal reflux disease

Background

Unlike cigarettes, there is little information about the association between other tobacco products and the risk of gastroesophageal reflux disease (GERD) and esophageal adenocarcinoma.

Methods

We used the baseline data from the Pars Cohort Study conducted in southern Iran. In 2012, 9264 local residents between 40 and 75 years old were enrolled, with detailed information about lifestyle, including duration and frequency of tobacco use. GERD was defined based on questions assessing heartburn and regurgitation in the past 12 months, frequency and severity. Associations were calculated by logistic regression models adjusted for age, sex, education, cigarettes and body mass index.

Results

In the study, 25.4% of the participants had severe GERD (interfering with participants' routines), 25.1% had frequent GERD (at least once a week) and 11.2% had both severe and frequent GERD, all more common among women (p < 0.001); 45.6% of women and 28.3% of men smoked waterpipes. Among people not using medications against reflux symptoms, there was an association between waterpipe smoking and severe [odds ratio (OR) = 1.18; 95% confidence interval (CI):1.04-1.35], frequent (OR = 1.16; 95% CI: 1.02-1.32) and severe and frequent reflux (OR = 1.30; 95% CI: 1.08-1.56). The associations increased with the duration of use, intensity and cumulative waterpipe-years, reaching an OR of 1.44 (95% CI: 1.12-1.86) for severe and frequent reflux in those who had smoked more than 48 waterpipe-years. There was effect modification by sex, and all the associations were only seen among women.

Conclusion

The increasing trend in the association between cumulative waterpipe use and reflux disease among women is particularly important given the growing waterpipe tobacco epidemic in many populations.

Screening for Barrett's Esophagus: Are New High-Volume Methods Feasible?

New improved methods are required for the early detection of esophageal adenocarcinoma in order to reduce mortality from this aggressive cancer. In this review we discuss different screening methods which are currently under evaluation ranging from image-based methods to cell collection devices coupled with biomarkers. As Barrett's esophagus is a low prevalence disease, potential screening tests must be applied to an enriched population to reduce the false-positive rate and improve the cost-effectiveness of the program.

Risk of GERD-Related Disorders in Obese Patients on PPI Therapy: a Population Analysis

BACKGROUND

Increasing prevalence of obesity has shown an associated increase in gastroesophageal reflux disease (GERD)-related diseases. Proton pump inhibitor (PPI) therapy has been demonstrated to reduce the incidence of such diseases. The study's aim was to analyze the Clinical Practice Research Datalink (CPRD) to determine factors that increase the propensity of obese patients on PPIs to develop Barrett's esophagus (BE) and esophageal carcinoma.

METHOD

A case-control population study was carried out, including patients from the CPRD. Clinicopathological factors were extracted for each patient alongside clinical endpoints of GERD, BE, and esophageal carcinoma. Multivariate analysis was utilized to identify factors that increase the propensity to develop BE and esophageal carcinoma. Statistical significance was p < 0.050.

RESULTS

One hundred sixty five thousand nine hundred twenty nine obese patients on PPI treatment were identified up until July 2017. Median follow-up time was 119.0 months (range 11.3-1397.9 months). In patients with GERD, the following were associated with increased BE risk: age ≥ 60 years (OR = 1.197; p = 0.039), male (OR = 2.209; p < 0.001), H2 antagonists (OR = 1.377; p < 0.001), D2 antagonists (OR = 1.241; p = 0.008), and hiatus hernias (OR = 6.772; p = 0.017). The following were associated with increased risk of esophageal carcinoma: age (OR = 2.831; p = 0.031), male sex (OR = 3.954; p = 0.003), and hiatus hernias (OR = 12.170; p < 0.001). Only D2 antagonists (OR = 2.588; p = 0.002) were associated with increased risk of developing esophageal carcinoma in BE patients.

CONCLUSIONS

In obese patients on PPI therapy for reflux, higher BMIs were not associated with increased risk of BE or esophageal carcinoma. Males, older patients, and those with hiatus hernias are at increased risk of developing BE and carcinoma. Failure of PPI monotherapy is predictive of future metaplasia and dysplasia.

Predictive Biomarkers of Gastroesophageal Reflux Disease and Barrett's Esophagus in World Trade Center Exposed Firefighters: a 15 Year Longitudinal Study

Gastroesophageal reflux disease (GERD) and Barrett’s Esophagus (BE), which are prevalent in the World Trade Center (WTC) exposed and general populations, negatively impact quality of life and cost of healthcare. GERD, a risk factor of BE, is linked to obstructive airways disease (OAD). We aim to identify serum biomarkers of GERD/BE, and assess the respiratory and clinical phenotype of a longitudinal cohort of never-smoking, male, WTC-exposed rescue workers presenting with pulmonary symptoms. Biomarkers collected soon after WTC-exposure were evaluated in optimized predictive models of GERD/BE. In the WTC-exposed cohort, the prevalence of BE is at least 6 times higher than in the general population. GERD/BE cases had similar lung function, D_LCO, bronchodilator response and long-acting β-agonist use compared to controls. In confounder-adjusted regression models, TNF-α ≥ 6 pg/mL predicted both GERD and BE. GERD was also predicted by C-peptide ≥ 360 pg/mL, while BE was predicted by fractalkine ≥ 250 pg/mL and IP-10 ≥ 290 pg/mL. Finally, participants with GERD had significantly increased use of short-acting β-agonist compared to controls. Overall, biomarkers sampled prior to GERD/BE presentation showed strong predictive abilities of disease development. This study frames future investigations to further our understanding of aerodigestive pathology due to particulate matter exposure.

All-cause and cancer-specific mortality in GORD in a population-based cohort study (the HUNT study)

OBJECTIVE

Gastro-oesophageal reflux is a public health concern which could have associated oesophageal complications, including adenocarcinoma, and possibly also head-and-neck and lung cancers. The aim of this study was to test the hypothesis that reflux increases all-cause and cancer-specific mortalities in an unselected cohort.

DESIGN

The Nord-Trøndelag health study (HUNT), a Norwegian population-based cohort study, was used to identify individuals with and without reflux in 1995-1997 and 2006-2008, with follow-up until 2014. All-cause mortality and cancer-specific mortality were assessed from the Norwegian Cause of Death Registry and Cancer Registry. Multivariable Cox regression was used to calculate HRs with 95% CIs for mortality with adjustments for potential confounders.

RESULTS

We included 4758 participants with severe reflux symptoms and 51 381 participants without reflux symptoms, contributing 60 323 and 747 239 person-years at risk, respectively. Severe reflux was not associated with all-cause mortality, overall cancer-specific mortality or mortality in cancer of the head-and-neck or lung. However, for men with severe reflux a sixfold increase in oesophageal adenocarcinoma-specific mortality was found (HR 6.09, 95% CI 2.33 to 15.93) and the mortality rate was 0.27 per 1000 person-years. For women, the corresponding mortality was not significantly increased (HR 3.68, 95% CI 0.88 to 15.27) and the mortality rate was 0.05 per 1000 person-years.

CONCLUSIONS

Individuals with severe reflux symptoms do not seem to have increased all-cause mortality or overall cancer-specific mortality. Although the absolute risk is small, individuals with severe reflux symptoms have a clearly increased oesophageal adenocarcinoma-specific mortality.

Tobacco smoking, alcohol consumption and gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) develops when reflux of gastric content causes troublesome symptoms or complications. The main symptoms are heartburn and acid regurgitation and complications include oesophagitis, strictures, Barrett's oesophagus and oesophageal adenocarcinoma. In addition to hereditary influence, GORD is associated with lifestyle factors, mainly obesity. Tobacco smoking is regarded as an aetiological factor of GORD, while alcohol consumption is considered a triggering factor of reflux episodes and not a causal factor. Yet, both tobacco smoking and alcohol consumption can reduce the lower oesophageal sphincter pressure, facilitating reflux. In addition, tobacco smoking reduces the production of saliva rich in bicarbonate, which is important for buffering and clearance of acid in the oesophagus. Alcohol also has a direct noxious effect on the oesophageal mucosa, which predisposes to acidic injury. Tobacco smoking cessation reduces the risk of GORD symptoms and avoidance of alcohol is encouraged in individuals where alcohol consumption triggers reflux.

The association between gastroesophageal reflux disease with sleep quality, depression, and anxiety in a cohort study of Australian men

BACKGROUND AND AIM

Previous clinical studies have demonstrated a relationship between gastroesophageal reflux disease (GERD) with anxiety and depression; however, few population-based studies have controlled for sleep disorders. The current study aimed to assess the relationship between GERD and anxiety, depression, and sleep disorders in a community-based sample of Australian men.

METHODS

Participants comprised a subset of 1612 men (mean age: 60.7 years, range: 35-80) who participated in the Men Androgen Inflammation Lifestyle Environment and Stress Study during the years 2001-2012, who had complete GERD measures (Gastresophageal Reflux Disease Questionnaire), and were not taking medications known to impact gastrointestinal function (excluding drugs taken for acid-related disorders). Current depression and anxiety were defined by (i) physician diagnosis, (ii) symptoms of depression (Beck Depression Inventory and Centre for Epidemiological Studies Depression Scale) or anxiety (Generalized Anxiety Disorder-7), and/or current depressive or anxiolytic medication use. Previous depression was indicated by past depressive diagnoses/medication use. Data on sleep quality, daytime sleepiness, and obstructive sleep apnea were collected along with several health, lifestyle, and medical factors, and these were systematically evaluated in both univariate and multivariable analyses.

RESULTS

Overall, 13.7% (n = 221) men had clinically significant GERD symptoms. In the adjusted models, an association between GERD and anxiety (odds ratio [OR] 2.7; 95% confidence interval [CI] 1.0-6.8) and poor sleep quality (OR 1.8; 95% CI 1.2-2.9) was observed; however, no effect was observed for current depression (OR 1.5; 95% CI 0.8-2.7). After removing poor sleep quality from the model, an independent association between current depression (OR 2.6; 95% CI 1.7-3.8) and current anxiety (OR 3.2; 95% CI 1.8-6.0) and GERD was observed, but not for previous depression (OR 1.4; 95% CI 0.7-2.8).

CONCLUSION

In this sample of urban-dwelling men, we observed a strong independent association between GERD, anxiety, and current depression, the latter appearing to be partly mediated by poor sleep quality. Patients presenting with GERD should have concurrent mental health assessments in order to identify potential confounders to the successful management of their symptoms.

Risk of acute myocardial infarction in patients with gastroesophageal reflux disease: A nationwide population-based study

Objective

Gastroesophageal reflux disease (GERD) is a common disease which can cause troublesome symptoms and affect quality of life. In addition to esophageal complications, GERD may also be a risk factor for extra-esophageal complications. Both GERD and coronary artery disease (CAD) can cause chest pain and frequently co-exist. However, the association between GERD and acute myocardial infarction (AMI) remain unclear. The purpose of the study was to compare the incidence of acute myocardial infarction in GERD patients with an age-, gender-, and comorbidity matched population free of GERD. We also examine the association of the risk of AMI and the use of acid suppressing agents in GERD patients.

Methods

We identified patients with GERD from the Taiwan National Health Insurance Research Database. The study cohort comprised 54,422 newly diagnosed GERD patients; 269,572 randomly selected age-, gender-, comorbidity-matched subjects comprised the comparison cohort. Patients with any prior CAD, AMI or peripheral arterial disease were excluded. Incidence of new AMI was studied in both groups.

Results

A total 1,236 (0.5%) of the patients from the control group and 371 (0.7%) patients from the GERD group experienced AMI during a mean follow-up period of 3.3 years. Based on Cox proportional-hazard model analysis, GERD was independently associated with increased risk of developing AMI (hazard ratio (HR) = 1.48; 95% confidence interval (CI): 1.31–1.66, P < 0.001). Within the GERD group, patients who were prescribed proton pump inhibitors (PPIs) for more than one year had slightly decreased the risk of developing AMI, compared with those without taking PPIs (HR = 0.57; 95% CI: 0.31–1.04, P = 0.066).

Conclusions

This large population-based study demonstrates an association between GERD and future development of AMI, however, PPIs use only achieved marginal significance in reducing the occurrence of AMI in GERD patients. Further prospective studies are needed to evaluate whether anti-reflux medication may reduce the occurrence of acute ischemic event in GERD patients.

Current status of surgical management of gastroesophageal reflux in children

PURPOSE OF REVIEW

Surgical therapy for gastroesophageal reflux disease (GERD) is controversial with considerable debate ranging from the indications for antireflux surgery to surgical technique. This article will attempt to clarify these issues with the most up-to-date information available on the prevalence, pathophysiology, diagnosis, and surgical treatment of GERD in children. Although laparoscopic Nissen fundoplication (LNF) has become the most popular operation performed for pathologic reflux, its superiority over both open surgery and other types of fundoplication is not well established.

RECENT FINDINGS

Large retrospective studies suggest LNF has a lower complication rate than open surgery. However, three prospective randomized controlled trials have been published recently which cast doubt on the superiority of LNF and suggest that LNF may have a higher failure rate compared to open fundoplication. Antireflux surgery has higher morbidity and failure rates in infants and in children with neurologic impairment.

SUMMARY

Based on the best available evidence, LNF may be less morbid, but have a higher rate of failure than open surgery. Pediatric surgeons should be mindful of the risks and benefits of both approaches to best counsel their patients. Larger prospective randomized controlled trials are needed to determine the best treatments for pediatric GERD.

Proton pump inhibitors utilisation in older people in New Zealand from 2005 to 2013

BACKGROUND

The prescriptions for proton pump inhibitors (PPI) to treat acid-related disorders continue to rise internationally and in New Zealand. Concerns have been raised regarding its widespread use, costs and potential adverse effects in older people.

AIMS

This study aimed to characterise the utilisation of PPI by older people (aged 65 years and older) in New Zealand from 2005 to 2013.

METHODS

Repeated cross-sectional analysis of population-level dispensing data was conducted from 1 January 2005 to 31 December 2013. Dispensing data for all PPI prescriptions from 2005 to 2013 were obtained from the Ministry of Health, New Zealand. Utilisation was measured in defined daily doses (DDD) per 1000 older people per day using the World Health Organization Collaborating Centre for Drug Statistics Methodology anatomic, therapeutic and chemical classification system. Utilisation was standardised by sex, age, ethnicity and district health board.

RESULTS

Overall PPI utilisation showed a 26.7% increase from 2005 to 2013, from 273.41 to 346.53 DDD/1000/day. The greatest utilisation was observed in individuals aged between 80 and 84 years. Middle Eastern/Latin American/African utilised more PPI compared with other ethnic groups.

CONCLUSIONS

Utilisation of PPI among older people in New Zealand increased by a fifth from 2005 to 2013. Given the concerns surrounding the long-term PPI use in older people, the appropriateness of the increased utilisation needs to be continuously re-evaluated by prescribers and health policy makers.

Laryngopharyngeal reflux disease in the Greek general population, prevalence and risk factors

Background

To assess the prevalence of laryngopharyngeal reflux (LPR) in the Greek general population and its risk factors.

Methods

Questionnaire based epidemiological, adult participants’ survey. The Reflux Symptom Index (RSI) was used for the assessment of LPR prevalence. The RSI questionnaire was completed by 340 (183 male and 157 female) randomly selected subjects. Subjects with RSI score ≥13 were considered as LPR patients and those with RSI score <13 were considered as non LPR subjects.

Results

The prevalence of LPR in the general Greek population was found to be 18.8 % with no statistically significant difference between the two genders (p > 0.05). The age group of 50–64 years showed the higher prevalence rate. Tobacco smoking and alcohol consumption were found to be related with LPR. No reported concomitant disease or medication was found to be related with LPR.

Conclusions

LPR prevalence in the Greek general population was found to be 18.8 %. Tobacco smoking and alcohol consumption were found to be related with LPR.

Prevalence of severe esophagitis in Spain. Results of the PRESS study (Prevalence and Risk factors for Esophagitis in Spain: A cross-sectional study)

BACKGROUND

*N.P. and M.P. contributed equally to this study.The current prevalence of esophagitis in southern Europe is unknown. In addition, the risk factors for reflux esophagitis are not fully understood.

OBJECTIVE

The objective of this article is to assess the prevalence and risk factors for esophagitis in Spain.

METHODS

A prospective, observational, cross-sectional, multicenter study (PRESS study) was conducted among 31 gastrointestinal endoscopy units throughout Spain. A total of 1361 patients undergoing upper gastrointestinal endoscopy were enrolled. Sociodemographic, clinical and treatment data were recorded.

RESULTS

A total of 95% of patients were Caucasian and 52% were male (mean age: 53 ± 17 years). The most frequent symptoms prompting endoscopy were heartburn (40%), regurgitation (26%) and dysphagia (15%). Fifty-four percent of patients undergoing endoscopy were receiving proton pump inhibitor (PPI) treatment. Esophagitis (mainly mild-moderate) was present in 154 (12.4%) patients. The severe form was recorded in only 11 (0.8%) patients. Multivariate analysis results indicated that the likelihood of esophagitis was higher in men (OR = 1.91, 95% CI = 1.31-2.78), in patients with high GERD-Q scores (OR = 1.256, 95% CI = 1.176-1.343), weight increase (OR = 1.014, 95% CI = 1.003-1.025) and high alcohol consumption (OR = 2.49, 95% CI = 1.16-5.36).

CONCLUSION

Severe esophagitis is a rare finding in the Spanish population. Male gender, high GERD-Q score, weight increase and high alcohol consumption are main risk factors for its appearance.

Gastroesophageal reflux disease and non-digestive tract diseases

Over the past decade, incidence of gastroesophageal reflux disease (GERD) showed an increasing trend resulting from factors, including lifestyle and dietary habits; however, both etiology and pathological mechanisms remain controversial. GERD occurs as a result of a variety of mechanisms and there is no single factor. Symptoms of GERD are often non-typical, with a likelihood of being overlooked by non-gastroenterology professionals. Therefore, improving GERD awareness in non-gastroenterology practitioners, along with early diagnosis and treatment, provide potential benefit to clinicians and patients alike. Increasing evidence suggests GERD has specific connections with a variety of non-digestive tract conditions, may contribute an aggravating compounding effect on other diseases, prolong hospitalization, and increase subsequent medical costs. This review considers and emphasizes the association between GERD and non-digestive tract conditions, including atrial fibrillation, chronic obstructive pulmonary disease, primary pulmonary fibrosis and energy metabolism related to diet.

The Role of Gastroesophageal Reflux and Other Factors during Progression to Esophageal Adenocarcinoma

BACKGROUND

U.S. esophageal adenocarcinoma (EAC) incidence increased over 5-fold between 1975 and 2009. Symptomatic gastroesophageal reflux disease (sGERD) elevates the risk for EAC. However, a simple calculation suggests that changes in sGERD prevalence can explain at most approximately 16% of this trend. Importantly, a mechanistic understanding of the influence of sGERD and other factors (OF) on EAC is lacking.

METHODS

A multiscale model was developed to estimate temporal trends for sGERD and OF, and their mechanistic role during carcinogenesis. Model calibration was to Surveillance, Epidemiology, and End Results (SEER) incidence and age-dependent sGERD data using maximum likelihood and Markov chain Monte Carlo (MCMC) methods.

RESULTS

Among men, 77.8% [95% credibility interval (CI), 64.9%-85.6%] of the incidence trend is attributable to OF, 13.4% (95% CI, 11.4%-17.3%) to sGERD, and 8.8% (95% CI, 4.2%-13.7%) to sGERD-OF interactions. Among women, 32.6% (95% CI, 27.0%-39.9%) of the trend is attributable to OF, 13.6% (95% CI, 12.5%-15.9%) to sGERD, and 47.4% (95% CI, 30.7%-64.6%) to interactions. The predicted trends were compared with historical trends for obesity, smoking, and proton pump inhibitor use. Interestingly, predicted OF cohort trends correlated most highly with median body mass index (BMI) at age 50 (r = 0.988 for men; r = 0.998 for women).

CONCLUSIONS

sGERD and OF mechanistically increase premalignant cell promotion, which increases EAC risk exponentially with exposure duration.

IMPACT

Surveillance should target individuals with long-duration sGERD and OF exposures.

Precision prevention of oesophageal adenocarcinoma

The incidence of oesophageal adenocarcinoma has risen rapidly over the past four decades. Unfortunately, treatments have not kept pace; unless their cancer is identified at a very early stage, most patients will not survive a year after diagnosis. The beginnings of this widespread problem were first recognized over 25 years ago, yet rates have continued to rise against a backdrop of much improved understanding and management of oesophageal adenocarcinoma. We estimate that only ∼7% of the 10,000 cases of oesophageal adenocarcinoma diagnosed annually in the USA are identified through current approaches to cancer control, and trace pathways by which the remaining 93% are 'lost'. On the basis of emerging data on aetiology and predictive factors, together with new diagnostic tools, we suggest a five-tier strategy for prevention and control that begins with a wide population base and triages individuals into progressively higher risk strata, each with risk-appropriate prevention, screening and treatment options.

Smoking as an independent determinant of Barrett's esophagus and, to a lesser degree, of reflux esophagitis

PURPOSE

To evaluate the role of smoking in Barrett's esophagus (BE) and erosive esophagitis (E) compared to endoscopic controls with no BE or E. Smoking is considered a cause of both BE and E, but results on this topic are quite controversial.

METHODS

Patients with BE (339), E (462) and controls (619: 280 with GERD (gastroesophageal reflux disease)-negative and 339 with GERD-positive anamnesis) were recruited in 12 Italian endoscopy units. Data were obtained from structured questionnaires.

RESULTS

Among former smokers, a remarkable upward linear trend was found in BE for all smoking-related predictors. In particular, having smoked for more than 32 years increased the risk more than two times (OR 2.44, 95 % CL 1.33-4.45). When the analysis was performed in the subgroup of subjects with GERD-negative anamnesis, the risk of late quitters (<9 years) passed from OR 2.11 (95 % CL 1.19-3.72) to OR 4.42 (95 % CL 1.52-12.8). A noticeably positive dose-response relationship with duration was seen also among current smokers. As regards E, no straightforward evidence of association was detected, but for an increased risk of late quitters (OR 1.84, 95 % CL 1.14-2.98) in former smokers and for early age at starting (OR 3.63, 95 % CL 1.19-11.1) in GERD-negative current smokers.

CONCLUSIONS

Smoking seems to be an independent determinant of BE and, to a lesser degree, of E. The elevation in risk is independent from GERD and is already present in light cigarette smokers. Smoking cessation may reduce, but not remove this risk.

Risk factors on the development of new-onset gastroesophageal reflux symptoms. A population-based prospective cohort study: the HUNT study

OBJECTIVES

Gastroesophageal reflux disease (GERD) is a highly prevalent disorder. This study assessed the risk factors of new-onset gastroesophageal reflux symptoms (GERS).

METHODS

The study was based on the HUNT study, a prospective population-based cohort study conducted in 1995-1997 and 2006-2009 in Nord-Trøndelag County, Norway. All inhabitants from 20 years of age were invited. Risk factors of new-onset heartburn or acid regurgitation were examined using logistic regression, providing odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

A total of 29,610 individuals were included (61% response rate). Participants reporting no GERS at baseline and severe GERS at follow-up (new-onset GERS; n=510) were compared with participants reporting no complaints at both times (n=14,406). Increasing age (OR 1.01 per year, 95% CI 1.00-1.02) was positively associated, whereas male sex (OR 0.81, 95% CI 0.66-0.98) and higher education (OR 0.69, 95% CI 0.56-0.86) were negatively associated with new-onset GERS. Gain in body mass index (BMI) was dose-dependently associated with new-onset GERS (OR 1.30 per unit increase in BMI, 95% CI 1.25-1.35), irrespective of baseline BMI. Previous and current tobacco smoking were associated with new-onset GERS (OR 1.37, 95% CI 1.07-1.76 and OR 1.29, 95% CI 1.00-1.67, respectively). Tobacco smoking cessation was associated with new-onset GERS among those with gain in BMI upon quitting (OR 2.03, 95% CI 1.31-3.16, with >3.5 BMI units increase).

CONCLUSIONS

New-onset GERS were associated with increasing age, female sex, lower education, gain in BMI, and ever tobacco smoking. Tobacco smoking cessation was associated with new-onset GERS among those who gained weight upon quitting.

Modeling the clinical and economic implications of obesity using microsimulation

OBJECTIVES

The obesity epidemic has raised considerable public health concerns, but there are few validated longitudinal simulation models examining the human and economic cost of obesity. This paper describes a microsimulation model as a comprehensive tool to understand the relationship between body weight, health, and economic outcomes.

METHODS

Patient health and economic outcomes were simulated annually over 10 years using a Markov-based microsimulation model. The obese population examined is nationally representative of obese adults in the US from the 2005-2012 National Health and Nutrition Examination Surveys, while a matched normal weight population was constructed to have similar demographics as the obese population during the same period. Prediction equations for onset of obesity-related comorbidities, medical expenditures, economic outcomes, mortality, and quality-of-life came from published trials and studies supplemented with original research. Model validation followed International Society for Pharmacoeconomics and Outcomes Research practice guidelines.

RESULTS

Among surviving adults, relative to a matched normal weight population, obese adults averaged $3900 higher medical expenditures in the initial year, growing to $4600 higher expenditures in year 10. Obese adults had higher initial prevalence and higher simulated onset of comorbidities as they aged. Over 10 years, excess medical expenditures attributed to obesity averaged $4280 annually-ranging from $2820 for obese category I to $5100 for obese category II, and $8710 for obese category III. Each excess kilogram of weight contributed to $140 higher annual costs, on average, ranging from $136 (obese I) to $152 (obese III). Poor health associated with obesity increased work absenteeism and mortality, and lowered employment probability, personal income, and quality-of-life.

CONCLUSIONS

This validated model helps illustrate why obese adults have higher medical and indirect costs relative to normal weight adults, and shows that medical costs for obese adults rise more rapidly with aging relative to normal weight adults.

Epidemiology of upper gastrointestinal symptoms in Brazil (EpiGastro): A population-based study according to sex and age group

AIM: To determine the prevalences of symptoms consistent with gastroesophageal reflux disease (GERD) and dyspepsia in South America.

METHODS: A telephone survey was conducted among adult owners of land-based telephones in São Paulo, Brazil, using previously validated computer-assisted sampling and survey protocols. The Portuguese-language survey included (1) sociodemographic characteristics (e.g., weight, height, smoking) and comorbidities; (2) dietary habits; (3) presence of symptoms consistent with GERD or dyspepsia within the prior 3 mo; and (4) use of medications and other therapies to manage symptoms. Data were stratified post-hoc into three homogeneous geographical regions of São Paulo according to the Social Exclusion Indices of the districts and postal codes. Survey response data from each respondent were weighted by the numbers of adults and landline telephones in each household. The analyses were weighted to account for sampling design and to be representative of the São Paulo population according to city census data.

RESULTS: Among 4570 households contacted, an adult from 3050 (66.7%) agreed to participate. The nonresponse rate was 33.3%. The mean (SE) respondent age was 42.6 (16.0) years. More than half of all respondents were women (53.1%), aged 18 through 49 years (66.7%), married or cohabitating (52.5%), and/or above normal-weight standards (i.e., 35.3% overweight and 16.3% obese). A total of 26.5% of women were perimenopausal. More than 20% of respondents reported highly frequent symptoms consistent with GERD (e.g., gastric burning sensation = 20.8%) or dyspepsia (e.g., abdominal swelling/distension = 20.9%) at least once per month. Prevalences of these symptoms were significantly (approximately 1.5- to 2.0-fold) higher among women than men but did not vary significantly as a function of advancing age. For instance, 14.1% of women reported that they experienced stomach burning (symptom of GERD) at least twice per week, compared to 8.4% of men (P = 0.012 by χ² test). A total of 15.7% of women reported that they experienced abdominal swelling (symptom of dyspepsia) at least twice per week, compared to 6.4% of men (P < 0.001 by χ² test). Despite frequent manifestations of GERD or dyspepsia, most (≥ 90%) respondents reported that they neither received prescription medications from physicians, nor took behavioral measures (e.g., dietary modifications), to manage symptoms.

CONCLUSION: Symptoms consistent with dyspepsia and GERD are prevalent in Brazil and represent major public-health and clinical challenges.

The prevalence of gastroesophageal reflux disease among hospital employees

Quantitative estimate of the actual prevalence of the gastroesophageal reflux disease (GERD) is difficult to obtain because most of the patients with heartburn have intermittent symptoms. The aim of this study was to assess the frequency of typical and atypical symptoms suggesting GERD to investigate the association of habits and social conditions reported to lead to reflux in the employees of hospital. A total of 2037 collected forms were assessed. The prevalence of GERD was found to be 21.7% (442). The prevalence of symptoms other than heartburn in employees with and without GERD symptoms were 6.6% versus 3.4% (P < 0.05) for asthma, 27.6% versus 8.3% (P < 0.001) for night cough, 50% versus 19.5% (P < 0.001) for noncardiac chest pain. Dyspeptic complaints were found to be significantly higher among GERD patients (P < 0.001). By multiple logistic regression analysis, female gender (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.03-1.60, P = 0.027), non-steroidal anti-inflammatory drug medication (OR 1.29, 95% CI 1.03-1.60, P = 0.021) and body mass index over 30 (OR 2.26, 95% CI 1.60-3.18, P < 0.001) were independent risk factors associated with GERD symptoms. GERD is a common health problem in Turkey, and its prevalence is similar to that of Western populations with different symptom profiles. Female gender, non-steroidal anti-inflammatory drug, and body mass index >30 kg/m(2) were independent risk factors associated with GERD symptoms. Age, alcohol, coffee, tea, and tobacco smoking do not seem to be risk factors for reflux.

Prevalence and risk factors for reflux esophagitis in patients with chronic obstructive pulmonary disease

BACKGROUND/AIMS

Gastroesophageal reflux disease is one of the most common causes of chronic cough and is a potential risk factor for the exacerbation of chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the prevalence and risk factors for reflux esophagitis (RE) in COPD patients.

METHODS

From our hospital database, between September 2006 and April 2010, we searched for subjects who were 40 years old or older and had undergone both postbronchodilator spirometry and esophagogastroduodenoscopy (EGD). COPD was defined as having a ratio of forced expiratory volume in 1 second to forced vital capacity < 0.7 in postbronchodilator spirometry and no abnormality causing airway obstruction, except emphysematous changes, on a chest X-ray. The diagnosis of RE was based on a mucosal break surrounding the distal esophageal sphincter through EGD.

RESULTS

In total, 253 patients with COPD were enrolled. The prevalence of RE in COPD was 30% (76/253). Multiple logistic regression analyses revealed that age (odds ratio [OR], 0.950; 95% confidence interval [CI], 0.918 to 0.983; p = 0.003), smoking pack-years (OR, 1.015; 95% CI, 1.004 to 1.025; p = 0.006), and inhaled anticholinergics (OR, 0.516; 95% CI, 0.271 to 0.982; p = 0.044) were independently associated with RE in COPD patients.

CONCLUSIONS

The prevalence of RE in our COPD patients was higher than that reported previously in the Korean general population. In COPD, smoking increased the risk of RE, whereas inhaled anticholinergics may be associated with a reduced risk of RE.

Treatment of GORD: Three decades of progress and disappointments

The treatment of GORD has been revolutionized by the introduction, in the 1980s, of proton-pump inhibitors as the mainstay of medical therapy and by the development of laparoscopic antireflux surgery which has definitively replaced open surgery. However, despite these major advances, many unmet therapeutic needs still persist and justify novel therapeutic approaches. The aim of this historical review is to recall the main discoveries in the treatment of GORD that have occurred during the last three decades and to discuss why some initially promising drugs or techniques have not translated into clinical applications. A careful analysis of these previous disappointing experiences should help to identify high priorities and better research programmes on the management of GORD.

Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review

OBJECTIVE

To update the findings of the 2005 systematic review of population-based studies assessing the epidemiology of gastro-oesophageal reflux disease (GERD).

DESIGN

PubMed and Embase were screened for new references using the original search strings. Studies were required to be population-based, to include ≥ 200 individuals, to have response rates ≥ 50% and recall periods <12 months. GERD was defined as heartburn and/or regurgitation on at least 1 day a week, or according to the Montreal definition, or diagnosed by a clinician. Temporal and geographic trends in disease prevalence were examined using a Poisson regression model.

RESULTS

16 studies of GERD epidemiology published since the original review were found to be suitable for inclusion (15 reporting prevalence and one reporting incidence), and were added to the 13 prevalence and two incidence studies found previously. The range of GERD prevalence estimates was 18.1%-27.8% in North America, 8.8%-25.9% in Europe, 2.5%-7.8% in East Asia, 8.7%-33.1% in the Middle East, 11.6% in Australia and 23.0% in South America. Incidence per 1000 person-years was approximately 5 in the overall UK and US populations, and 0.84 in paediatric patients aged 1-17 years in the UK. Evidence suggests an increase in GERD prevalence since 1995 (p<0.0001), particularly in North America and East Asia.

CONCLUSIONS

GERD is prevalent worldwide, and disease burden may be increasing. Prevalence estimates show considerable geographic variation, but only East Asia shows estimates consistently lower than 10%.

Exploring the recent trend in esophageal adenocarcinoma incidence and mortality using comparative simulation modeling

BACKGROUND

The incidence of esophageal adenocarcinoma (EAC) has increased five-fold in the United States since 1975. The aim of our study was to estimate future U.S. EAC incidence and mortality and to shed light on the potential drivers in the disease process that are conduits for the dramatic increase in EAC incidence.

METHODS

A consortium of three research groups calibrated independent mathematical models to clinical and epidemiologic data including EAC incidence from the Surveillance, Epidemiology, and End Results (SEER 9) registry from 1975 to 2010. We then used a comparative modeling approach to project EAC incidence and mortality to year 2030.

RESULTS

Importantly, all three models identified birth cohort trends affecting cancer progression as a major driver of the observed increases in EAC incidence and mortality. All models predict that incidence and mortality rates will continue to increase until 2030 but with a plateauing trend for recent male cohorts. The predicted ranges of incidence and mortality rates (cases per 100,000 person years) in 2030 are 8.4 to 10.1 and 5.4 to 7.4, respectively, for males, and 1.3 to 1.8 and 0.9 to 1.2 for females. Estimates of cumulative cause-specific EAC deaths between both sexes for years 2011 to 2030 range between 142,300 and 186,298, almost double the number of deaths in the past 20 years.

CONCLUSIONS

Through comparative modeling, the projected increases in EAC cases and deaths represent a critical public health concern that warrants attention from cancer control planners to prepare potential interventions.

IMPACT

Quantifying this burden of disease will aid health policy makers to plan appropriate cancer control measures. Cancer Epidemiol Biomarkers Prev; 23(6); 997-1006. ©2014 AACR.

EAES recommendations for the management of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux.

METHODS

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

RESULTS

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

CONCLUSIONS

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Prevalence and characteristics of dyspepsia among college students in Zhejiang Province

AIM: To investigate the prevalence and characteristics of uninvestigated dyspepsia among college students in Zhejiang Province.

METHODS: Young adult students attending undergraduate (within the 4-year program) and graduate (only first-year students) colleges in Zhejiang Province were recruited between November 2010 and March 2011 to participate in the self-report survey study. The questionnaire was designed to collect data regarding demographics (sex and age), general health [weight and height, to calculate body mass index (BMI)], and physical episodes related to gastrointestinal disorders. Diagnosis of dyspepsia and irritable bowel syndrome (IBS) was made according to the Rome III criteria. Gastroesophageal reflux disease (GERD) was defined by episodes of heartburn and/or acid reflux that occurred at least once a week, according to the Montreal definition.

RESULTS: Of 2520 students recruited for survey participation, only 1870 (males: 967; age range: 17-32 years, mean age: 21.3 years) returned a completed questionnaire. One hundred and eight (5.67%) of the student participants fit the criteria for dyspepsia diagnosis. Stratification analysis of dyspepsia and non-dyspepsia cases showed no statistically significant differences in age or BMI; however, the prevalence of dyspepsia was significantly higher in women than in men (7.53% vs 4.14%, P < 0.05). Stratification analysis of dyspepsia by grade level showed that year 4 undergraduate students had a significantly higher prevalence of dyspepsia (10.00% vs undergraduate year 1: 5.87%, year 2: 3.53% and year 3: 7.24%, and graduate year 1: 3.32%). Nearly all (95.37%) students with dyspepsia reported symptoms of postprandial distress syndrome, but only a small portion (4.63%) reported symptoms suggestive of abdominal pain syndrome. The students with dyspepsia also showed significantly higher rates of IBS (16.67% vs non-dyspepsia students: 6.30%, P < 0.05) and GERD (11.11% vs 0.28%, P < 0.05).

CONCLUSION: Although the prevalence of dyspepsia among Zhejiang college students is low, the significantly higher rates of concomitant IBS and GERD suggest common pathophysiological disturbances.

Antiplatelet drugs are a risk factor for esophageal mucosal injury

BACKGROUND

In esophagus whether antiplatelet drugs, such as low-dose aspirin (LDA) and clopidogrel, induce mucosal injury by pH changes or by acid reflux is unclear. We designed to clarify which mechanism was responsible.

METHODS

In study 1, 80 patients taking LDA and 80 age- and sex-matched subjects who underwent endoscopy for dyspeptic symptoms or for a health check-up were evaluated the endoscopic incidence of esophageal mucosal injury and severity. In study 2, 35 healthy subjects were treated with LDA 100 mg (regimen A), and then 20 randomly selected subjects were dosed clopidogrel 75 mg (regimen C), LDA/clopidogrel (regimen AC), or LDA/clopidogrel/rabeprazole 10 mg for 7 days. Subjects underwent endoscopy and 24-hour pH measurements on day 7.

RESULTS

In study 1, the prevalence of esophageal injury in LDA patients was 40.0%, significantly higher than in non-LDA subjects (25.0%, p = 0.042). In study 2, significant increases in incidence of injury were observed with regimens A (45.8%) and AC (50.0%), but not with C (20.0%), on day 7. Among subjects in whom pH was >5.0 and <4.0 for less than 40% of time, none developed esophageal injury.

CONCLUSIONS

LDA caused esophageal injury in half of patients and volunteers. Acid-inhibitory drugs effectively prevented the development of LDA-induced, not clopidogrel, esophageal injury.

Prevalence and determinants of gastroesophageal reflux symptoms in adolescents

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is common in adults, and there are increasing secular trends in adult GERD morbidity in many countries. However, population-based study on adolescent GERD was very limited. The specific aims of the study were to explore the prevalence and determinant of GERD symptoms in adolescents.

METHODS

A population-based association study was performed on 1828 students aged 13-16 years from four public junior high schools in Taiwan. The presences of symptoms of GERD, asthma and food allergy, demographic characteristics, and health behaviors were obtained by structured questionnaires.

RESULTS

Complete information of symptoms of GERD and asthma were available for 1745 (95.5%) students. The cumulative and 3-month prevalence rates of GERD symptoms were 20.5% and 8.9%, respectively. Multivariate-adjusted odds ratio of having experienced GERD symptoms were 1.53 (95% confidence interval [CI]: 1.18-1.98) for ever smoking, 1.52 (95% CI: 1.12-2.26) for bi-ethnicity, 1.70 (95% CI: 1.26-2.29) for food allergy, and 3.59 (95% CI: 2.69-4.82) and 2.43 (95% CI: 1.67-3.53) for having asthma attacks within or more than 1 year before, respectively. Similar results were found for 3-month prevalence.

CONCLUSIONS

The study showed that GERD symptoms were frequent in junior high school students in Taiwan. Food allergy, asthma, and cigarette smoking were independently correlated with the prevalence of GERD symptoms. Psychosocial factors associated with bi-ethnic family may contribute to its development.

Zero inflated statistical count models for analysing the costs imposed by GERD and dyspepsia

BACKGROUND AND STUDY AIMS

Recent studies have shown that the high prevalence and the various clinical presentations of gastro-oesophageal reflux disease (GERD) and dyspepsia impose an enormous economic burden on society. Economic cost data have unique characteristics: they are counts, and they have zero inflation. Therefore, these data require special models. Poisson regression (PR), negative binomial regression (NB), zero inflated Poisson (ZIP) and zero inflated negative binomial (ZINB) regression are the models used for analysing cost data in this paper.

PATIENTS AND METHODS

In this study, a cross-sectional household survey was distributed to a random sample of individuals between May 2006 and December 2007 in the Tehran province of Iran to determine the prevalence of gastrointestinal symptoms and disorders and their related factors. The cost associated with each item was calculated. PR, NB, ZIP and ZINB models were used to analyse the data. The likelihood ratio test and the Voung test were used to conduct pairwise comparisons of the models. The log likelihood, the Akaike information criterion (AIC) and the Bayesian information criterion (BIC) were used to compare the performances of the models.

RESULTS

According to the likelihood ratio test and the Voung test and all three criteria used to compare the performance of the models, ZINB regression was identified as the best model for analysing the cost data. Sex, age, smoking status, BMI, insurance status and education were significant predictors.

CONCLUSION

Because the NB model demonstrated a better fit than the PR and ZIP models, over-dispersion was clearly only due to unobserved heterogeneity. In contrast, according to the likelihood ratio test, the ZINB model was more appropriate than the ZIP model. The ZINB model for the cost data was more appropriate than the other models.

Binge eating, body mass index, and gastrointestinal symptoms

OBJECTIVE

Symptoms of both gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) are frequently reported by individuals who binge eat. Higher body mass index (BMI) has also been associated with these disorders and with binge eating (BE). However, it is unknown whether BE influences GERD/IBS and how BMI might affect these associations. Thus, we examined the potential associations among BE, GERD, IBS, and BMI.

METHODS

Participants were from the Swedish Twin study of Adults: Genes and Environment (STAGE) and provided information on disordered eating behavior, BMI, gastrointestinal (GI) disorders, and commonly comorbid psychiatric and somatic illnesses. Key features of GERD and IBS were identified to create modified definitions of both disorders that were used as primary outcome variables. Logistic regression models were applied to determine the association between BE and each GERD/IBS both independently and in the context of BMI and other commonly comorbid psychiatric and somatic morbidities.

RESULTS

Prevalence estimates for GERD and IBS were higher among women than men (all p-values<.001). Only the association between BE and IBS was significant in both men and women after adjustment for BMI and the psychiatric/somatic morbidities.

CONCLUSION

BE appears to be an important consideration in the presence of IBS symptoms in both men and women, even when considering the impact of BMI and other commonly comorbid conditions. This association underscores the importance of routine assessment of BE in patients presenting with IBS to effectively manage the concurrent presentation of these problems.

Optimal treatment of laryngopharyngeal reflux disease

Laryngopharyngeal reflux is defined as the reflux of gastric content into larynx and pharynx. A large number of data suggest the growing prevalence of laryngopharyngeal symptoms in patients with gastroesophageal reflux disease. However, laryngopharyngeal reflux is a multifactorial syndrome and gastroesophageal reflux disease is not the only cause involved in its pathogenesis. Current critical issues in diagnosing laryngopharyngeal reflux are many nonspecific laryngeal symptoms and signs, and poor sensitivity and specificity of all currently available diagnostic tests. Although it is a pragmatic clinical strategy to start with empiric trials of proton pump inhibitors, many patients with suspected laryngopharyngeal reflux have persistent symptoms despite maximal acid suppression therapy. Overall, there are scant conflicting results to assess the effect of reflux treatments (including dietary and lifestyle modification, medical treatment, antireflux surgery) on laryngopharyngeal reflux. The present review is aimed at critically discussing the current treatment options in patients with laryngopharyngeal reflux, and provides a perspective on the development of new therapies.

Patterns of diet-related practices and prevalence of gastro-esophageal reflux disease

BACKGROUND

No studies have evaluated associations between patterns of diet-related practices as determined by latent class analysis (LCA) and gastro-esophageal reflux disease (GERD). We aimed to assess this relationship in a large sample of Iranian adults.

METHODS

In a cross-sectional study in 4763 adults, diet-related practices were assessed in four domains, 'meal pattern', 'eating rate', 'intra-meal fluid intake', and 'meal-to-sleep interval', using a pretested questionnaire. LCA was applied to identify classes of diet-related practices. We defined GERD as the presence of heartburn sometimes, often or always.

KEY RESULTS

The prevalence of GERD in the study population was 23.5% (n = 1120). We identified two distinct classes of meal patterns: 'regular' and 'irregular', three classes of eating rates: 'moderate', 'moderate-to-slow', and 'moderate-to-fast', two major classes of fluid ingestion with meals: 'moderate' and 'much intra-meal drinking', and two classes regarding the interval between meals and sleeping: 'short' and 'long meal-to-sleep' interval. After adjustment for potential confounders, subjects with 'irregular meal pattern' had higher odds of GERD compared with subjects with 'regular meal pattern' (OR: 1.21; 1.00-1.46). However, when taking into account BMI, the association disappeared. 'Long meal-to-sleep interval' was inversely associated with GERD compared with 'short meal-to-sleep interval' (OR: 0.73; 95% CI: 0.57-0.95). 'Eating rate' and 'intra-meal fluid intake' were not significantly associated with GERD.

CONCLUSIONS & INFERENCES

Our data suggest certain associations between dietary patterns and GERD. These findings warrant evaluation in prospective studies to establish the potential value of modifications in dietary behaviors for the management of GERD.

Evidence-based recommendations for GERD treatment

Gastroesophageal reflux disease (GERD) is a common presentation in primary care. New research findings have implications for the diagnosis and management of GERD. The purpose of this article is to synthesize current research related to the diagnosis and management of GERD in adults and to make practice recommendations.

Review on novel concepts of columnar lined esophagus

BACKGROUND

Columnar lined esophagus (CLE) is a marker for gastroesophageal reflux and associates with an increased cancer risk among those with Barrett's esophagus. Recent studies fostered the development of integrated CLE concepts.

METHODS

Using PubMed, we conducted a review of studies on novel histopathological concepts of nondysplastic CLE.

RESULTS

Two histopathological concepts-the squamo-oxyntic gap (SOG) and the dilated distal esophagus (DDE), currently model our novel understanding of CLE. As a consequence of reflux, SOG interposes between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. Thus the SOG describes the histopathology of CLE within the tubular esophagus and the DDE, which is known to develop at the cost of a shortened lower esophageal sphincter and foster increased acid gastric reflux. Histopathological studies of the lower end of the esophagus indicate, that the DDE is reflux damaged, dilated, gastric type folds forming esophagus and cannot be differentiated from proximal stomach by endoscopy. While the endoscopically visible squamocolumnar junction (SCJ) defines the proximal limit of the SOG, the assessment of the distal limit requires the histopathology of measured multilevel biopsies. Within the SOG, CLE types distribute along a distinct zonation with intestinal metaplasia (IM; Barrett's esophagus) and/or cardiac mucosa (CM) at the SCJ and oxyntocardiac mucosa (OCM) within the distal portion of the SOG. The zonation follows the pH-gradient across the distal esophagus. Diagnosis of SOG and DDE includes endoscopy, histopathology of measured multi-level biopsies from the distal esophagus, function, and radiologic tests. CM and OCM do not require treatment and are surveilled in 5 year intervals, unless they associate with life quality impairing symptoms, which demand medical or surgical therapy. In the presence of an increased cancer risk profile, it is justified to consider radiofrequency ablation (RFA) of IM within clinical studies in order to prevent the progression to dysplasia and cancer. Dysplasia justifies RFA ± endoscopic resection.

CONCLUSIONS

SOG and DDE represent novel concepts fusing the morphological and functional aspects of CLE. Future studies should examine the impact of SOG and DDE for monitoring and management of gastroesophageal reflux disease (GERD).

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.