International validation of ReQuest in patients with endoscopy-negative gastro-oesophageal reflux disease

Population-based assessment of gastrointestinal symptoms and diseases: Cappadocia Cohort, Turkey

BACKGROUND/AIMS

The aim of this study was to determine the prevalence of symptoms and diseases of the lower and upper gastrointestinal system (GIS) in a population-based sample.

MATERIALS AND METHODS

The cross-sectional cohort study was conducted in Cappadocia cohort comprising the Gülşehir and Avanos districts. The "Gastrointestinal Symptom Questionnaire" was applied to persons over the age of 18 years.

RESULTS

The GI Symptom Questionnaire was applied to 3369 subjects, and height and body weight were measured in 2797 consenting subjects. Of the participants, 61% were female and the mean patient age was 50±15 years. At least one GI symptom was present in 70.6% of the cohort. The most common upper GI symptoms were gastric bloating (31.0%) and heartburn (29.1%). The most common lower GI symptom was abnormal defecation (33.5). The prevalence of upper GIS and lower GIS diseases was 32.7% and 12.9%, respectively, and the prevalence of togetherness of upper and lower GIS diseases was 9.9%. Prevalence of GIS disease was approximately 3 times higher in females (p<0.001). All of the upper and lower GI symptoms and the prevalence of upper GIS disease increased in line with Body mass index (BMI).

CONCLUSION

This first population-based, cross-sectional cohort study revealed that the prevalence of GIS diseases is critically high for optimal public health. Special attention must be paid to these diseases while planning health policies and reimbursements.

Gastrointestinal endoscopy satisfaction questionnaire is a valid tool to measure patient satisfaction in Asian country

Patient satisfaction is a key quality indicator of gastrointestinal endoscopy (GIE). The gastrointestinal endoscopy satisfaction questionnaire (GESQ) was recently developed to assess patient satisfaction undergoing GIE in Europe; however, it was not validated in Asian countries. We aimed to translate and validate the GESQ in Korea and identify predictors for patient satisfaction during GIE.Translation of the original GESQ was performed according to accepted linguistic validation guidelines. Between March 2016 and July 2016, 350 consecutive patients were asked to complete a GESQ after GIE at Kyung Hee University Hospital. Total sum of scores was transformed from 0 to 100 by the formula: (Score-lowest possible/Score range) × 100.Exploratory and confirmatory factor analyses for construct validation reconfirmed that 4 factors were extracted from the Korean GESQ. Internal consistency reliability was acceptable with an overall Cronbach α score of 0.87. Female and nonsmoker were associated with less satisfaction with GIE (P = .021 and .006, respectively). Other factors, including age, alcohol, education or economic level, sedative endoscopy, gastroscopy with or without colonoscopy, experience of previous endoscopy, and additional examinations such as biopsy, were not associated with patient satisfaction during GIE.The Korean version of the GESQ was a valid and acceptable tool to measure satisfaction in patients who had undergone a GIE in Korea. Patient satisfaction measurement could contribute to systematic improvement of qualified GIE.

The suitability of the GERDyzer instrument in pH-test-proven laryngopharyngeal reflux patients

The use of validated patient-reported outcome (PRO) instruments for the treatment outcome measure of laryngopharyngeal reflux (LPR) is crucial given the lack of objective markers. However, current symptom-based PRO instruments can only partially capture the impact of LPR. The GERD Analyzer (GERDyzer), an existing disease-specific PRO instrument, which measures multidimensional health-related quality of life (HRQL) affected by the illness rather than by any specific symptoms, has been validated in patients with erosive gastroesophageal reflux disease (GERD). Following the U.S. Food and Drug Administration PRO guidance, we cross-culturally adapted the GERDyzer instrument into Chinese, and examined the qualitative and quantitative psychometric properties of the Chinese version GERDyzer in pH-test-proven LPR patients.The GERDyzer comprises 10 dimensions of HRQL, including general well-being, pain/discomfort, physical health, diet, energy, activities, leisure activities, social life, mood, and sleep. To examine the content validity, we recruited 26 pH-test-proven LPR participants to conduct 4 focus group meetings for direct patient input on clinical manifestations and HRQL impacts. We also tested the quantitative psychometric properties, including reliability, validity, and responsiveness in 100 pH-test-proven LPR patients.Saturation of concept elicitation was achieved from the 4 focus groups, and a strong conceptual match was evident between the GERDyzer contents and responses from the focus group participants. Cognitive debriefing assessment showed that the Chinese version GERDyzer was adequate for use by patients as it demonstrated linguistic validation and cultural harmonization. Quantitative psychometric properties showed evidence of high internal consistency (Cronbach α: 0.96), good to excellent test-retest reliability (intraclass correlation coefficient: 0.84-0.98). Confirmatory factor analysis supported a 2-factor structure. Convergent validity was confirmed by moderate correlation assessments referencing the Reflux Symptoms Index and the Reflux Questionnaire. The discriminant validity was supported by the ability to discriminate moderate-to-severe disease from mild disease. The responsiveness was also high in participants with and without typical GERD symptoms (effect sizes 1.20 and 1.21, respectively).In conclusion, the Chinese version GERDyzer instrument is a reliable, valid, and responsive instrument for assessing HRQL in Taiwanese patients with LPR.

Factors influencing treatment outcome in patients with gastroesophageal reflux disease: outcome of a prospective pragmatic trial in Asian patients

BACKGROUND

Predicting response to proton pump inhibitor (PPI) treatment can aid the effective management of gastroesophageal reflux disease (GERD). The aim was to investigate the predictors of symptomatic response to pantoprazole in Asian patients with GERD; the first study of its kind in Asian patients.

METHODS

Asian patients with GERD symptoms (N = 209) received pantoprazole 40 mg daily for 8 weeks in a multinational, prospective, open-label study. Response was assessed using ReQuest™. Baseline and demographic factors were examined using logistic regression to determine if they were related to treatment response.

RESULTS

Response rates were 44.3% (Week 4) and 63.6% (Week 8) in Asian patients versus 60.7% (P < 0.001) and 72.2% (P = 0.010) for the rest of the world. Higher response rates at 8 weeks occurred in patients with erosive reflux disease (ERD; 71.3%) versus those with non-erosive reflux disease (NERD) at baseline (48.5%). The presence of ERD (P = 0.0143) and lower ReQuest™-GI scores at baseline (P = 0.0222) were associated with response. Improvements in quality of life (QoL) and anxiety and depression at 4 and 8 weeks were associated with treatment response (both P < 0.0001). Patient satisfaction correlated with treatment response (P < 0.0001), and improvement in anxiety and depression (P < 0.0001) and QoL (P < 0.0001).

CONCLUSIONS

Asian patients with GERD, especially those with NERD, may have lower response rates to PPIs than Western populations. ERD and less severe gastrointestinal symptoms may help to predict symptomatic responses to PPIs in Asian patients.

TRIAL REGISTRATION

ClinicalTrial.gov identifier: NCT00312806.

Development of an online library of patient-reported outcome measures in gastroenterology: the GI-PRO database

OBJECTIVES

Because gastrointestinal (GI) illnesses can cause physical, emotional, and social distress, patient-reported outcomes (PROs) are used to guide clinical decision making, conduct research, and seek drug approval. It is important to develop a mechanism for identifying, categorizing, and evaluating the over 100 GI PROs that exist. Here we describe a new, National Institutes of Health (NIH)-supported, online PRO clearinghouse-the GI-PRO database.

METHODS

Using a protocol developed by the NIH Patient-Reported Outcome Measurement Information System (PROMIS(®)), we performed a systematic review to identify English-language GI PROs. We abstracted PRO items and developed an online searchable item database. We categorized symptoms into content "bins" to evaluate a framework for GI symptom reporting. Finally, we assigned a score for the methodological quality of each PRO represented in the published literature (0-20 range; higher indicates better).

RESULTS

We reviewed 15,697 titles (κ>0.6 for title and abstract selection), from which we identified 126 PROs. Review of the PROs revealed eight GI symptom "bins": (i) abdominal pain, (ii) bloat/gas, (iii) diarrhea, (iv) constipation, (v) bowel incontinence/soilage, (vi) heartburn/reflux, (vii) swallowing, and (viii) nausea/vomiting. In addition to these symptoms, the PROs covered four psychosocial domains: (i) behaviors, (ii) cognitions, (iii) emotions, and (iv) psychosocial impact. The quality scores were generally low (mean 8.88 ± 4.19; 0 (min)-20 (max). In addition, 51% did not include patient input in developing the PRO, and 41% provided no information on score interpretation.

CONCLUSIONS

GI PROs cover a wide range of biopsychosocial symptoms. Although plentiful, GI PROs are limited by low methodological quality. Our online PRO library (www.researchcore.org/gipro/) can help in selecting PROs for clinical and research purposes.

Systematic review of patient-reported outcome instruments for gastroesophageal reflux disease symptoms

Gastroesophageal reflux disease (GERD) symptoms are best assessed using patient-reported outcome (PRO) instruments. Guidance on developing well-defined and reliable instruments that capture optimal information from the patient's perspective was recently published by the US Food and Drug Administration and the European Medicines Agency. The aim of this systematic review was to identify and evaluate existing PRO instruments for GERD symptoms with regard to regulatory requirements. Systematic literature searches were conducted in PubMed and Embase to identify PRO instruments for GERD symptoms that have undergone psychometric evaluation. Content, construct and test-retest reliability, internal consistency, and responsiveness were evaluated in relation to regulatory recommendations. Supplementary searches were conducted to assess whether identified instruments had been used as clinical trial endpoint measures. The systematic literature searches identified 15 PRO instruments for GERD symptoms that have undergone psychometric evaluation. Eight were designed to evaluate GERD symptoms, two were to diagnose GERD, four were designed for both evaluative and diagnostic purposes, and one was designed for screening purposes. Five instruments were developed and reported to include most steps recommended by the Food and Drug Administration and European Medicines Agency, and have also been used as endpoint measures in clinical trials: the GERD Symptom Assessment Scale, the Nocturnal Gastro-oesophageal Reflux Disease Symptom Severity and Impact Questionnaire, the Reflux Questionnaire, the Reflux Disease Questionnaire, and the Proton pump inhibitor Acid Suppression Symptom test. Existing PRO instruments for GERD do not meet all the regulatory requirements for an outcome instrument in reflux trials and may need further validation.

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.

Prediction of response to PPI therapy and factors influencing treatment outcome in patients with GORD: a prospective pragmatic trial using pantoprazole

Background

Management of patients with gastro-oesophageal reflux disease (GORD) can be assisted by information predicting the likely response to proton pump inhibitor (PPI) treatment. The aim was to undertake a study of GORD patients designed to approximate ordinary clinical practice that would identify patient characteristics predicting symptomatic response to pantoprazole treatment.

Methods

1888 patients with symptoms of GORD were enrolled in a multicentre, multinational, prospective, open study of 8 weeks pantoprazole treatment, 40 mg daily. Response was assessed by using the ReQuest™ questionnaire, by the investigator making conventional clinical enquiry and by asking patients about their satisfaction with symptom control. Factors including pre-treatment oesophagitis, gender, age, body mass index (BMI), Helicobacter pylori status, anxiety and depression, and concurrent IBS symptoms were examined using logistic regression to determine if they were related to response, judged from the ReQuest™-GI score.

Results

Poorer treatment responses were associated with non-erosive reflux disease, female gender, lower BMI, anxiety and concurrent irritable bowel syndrome symptoms before treatment. No association was found with age, Helicobacter pylori status or oesophagitis grade. Some reflux-related symptoms were still present in 14% of patients who declared themselves 'well-satisfied' with their symptom control.

Conclusions

Some readily identifiable features help to predict symptomatic responses to a PPI and consequently may help in managing patient expectation. ClinicalTrial.gov identifier: NCT00312806.

Questionnaire based gastroesophageal reflux disease (GERD) assessment scales

Questionnaire based assessment scales for gastroesophageal reflux disease (GERD) have been utilized for assessment of the patient's symptomatology, assessment of symptom severity and frequency, assessment of health-related quality of life and for assessment of response to treatment. A multitude of unidimensional and multidimensional questionnaires exist for making symptom assessment and monitoring quality of life in GERD. Many of the scales meet some of the parameters of an ideal evaluative GERD specific assessment instrument. Yet, there are certain shortcomings and challenges which are faced in development of GERD questionnaires. This review discusses the features of an ideal symptom assessment instrument, examines the strengths and weaknesses of currently available questionnaires.

Gastrointestinal complaints in shift-working and day-working nurses in Iran

Background

There is evidence in the scientific literature of the adverse physiological and psychological effects of shift work. The work of nurses in hospitals is connected with shift and night work. Several publications have described gastrointestinal disturbances in shift workers. The aim of this study was to compare the frequency of gastrointestinal (GI) complaints of nurses on a rotating shift with that of nurses on a regular day shift.

Methods

The study involved 160 nurses (133 working in shifts and at night and 27 working on day shifts) in the Shahid Beheshti Hospital in Kashan, Iran. These nurses answered a Gastrointestinal Symptom Questionnaire regarding the presence of gastrointestinal symptoms (including heartburn, regurgitation, constipation, diarrhea and bloating). Positive responses required frequent symptom occurrence in the past 4 weeks. Significance of group differences was assessed by chi-square and Fisher-exact tests.

Results

Prevalence of GI symptoms was significantly higher (p = 0.009) in rotating-shift nurses (81.9%) than in day-shift nurses (59.2%). Irregular meal consumption (p = 0.01) and GI medications (p = 0.002) were all significantly higher among the rotating shift nurses. In both groups, regurgitation was the most common symptom.

Conclusion

Nurses on rotating shifts in Iran experience more GI disturbances than do nurses on day shifts.

Gastro-oesophageal reflux disease – experience in daily practice: Symptoms and symptom assessment

Gastro-oesophageal reflux disease is one of the most common medical problems in daily practice, with many guidelines on diagnosis and treatment available. The prevalence and incidence of reflux disease are rising. In a period of 10 years, the incidence of reflux oesophagitis has almost doubled, as has the number of pills and tablets of acid-suppressive therapy sold. The decreased number of patients with severe reflux oesophagitis is indicative of increased public awareness. Heartburn and regurgitation are the hallmarks of reflux disease. The symptom score in patients with the mild reflux oesophagitis is significantly higher than it is in patients presenting with severe oesophagitis, NERD or Barrett's oesophagus. Patients with mild oesophagitis also suffer from more reflux. Dysphagia is often the only presenting symptom in severe oesophagitis. Patients with reflux oesophagitis have a significantly higher symptom score than patients with Barrett's oesophagus. The scores for heartburn and acid regurgitation are significantly higher in reflux oesophagitis. The primary goal of treatment is complete clinical remission and prevention of long-term complications. In a study with a follow-up of 4.5 to 7.5 years in patients with reflux oesophagitis it was shown that 85% still used acid-suppressive therapy, mostly on a daily basis. However, the majority were never completely free of reflux. Despite the fact that the degree of reflux oesophagitis correlates with the risk of relapse, also patients in whom initially the most severe grade of reflux oesophagitis (grades III and IV) was diagnosed no longer use medication. Treatment of reflux disease with acid suppressants is a major component in national and international drug budgets, and health-care authorities and insurance companies are eager to reduce these budgets. Since diagnosis and treatment are already discussed in many guidelines, cut-backs could be achieved in patients on maintenance therapy. For this reason, more data have to be assessed on therapy outcome in cases of chronic maintenance therapy. Guidelines for maintenance or on-demand therapy are necessary.

Impact of PPIs on patient focused symptomatology in GERD

About half of patients with gastroesophageal reflux disease (GERD) have a normal endoscopy, so symptom assessment is the only appropriate outcome measure for these persons. Symptom assessment is also of great importance in persons with erosive esophagitis. There is currently no fully validated questionnaire to compare symptom response to treatment of patients with GERD. The aim of this review is to consider ReQuest^™ assessment tool to evaluate esophageal, supra-esophageal, and infra-esophageal symptoms, as well as any modification of the patient’s quality of life. The ReQuest^™ may be combined with the Los Angeles classification of esophagitis (LA A–D), to include the normal endoscopic finding in normal endoscopy reflux disease. The ReQuest^™ score declines rapidly towards normal with patient treatment with a proton pump inhibitor. A proportion of patients need more than the usual 8 weeks of therapy. For example, in GERD patients with Los Angeles B–D, the ReQuest^™ score falls more with pantoprazole 40 mg than with esomoprazole 40 mg after 12 weeks of therapy. Now that the simplified ReQuest in Practice^™ is available, this validated brief questionnaire has potential as an instrument for use in GERD patients seen in everyday clinical practice.

International validation of a health-related quality of life questionnaire in patients with erosive gastro-oesophageal reflux disease

BACKGROUND

Although erosive gastro-oesophageal reflux disease (GERD) is a highly prevalent condition, there is no specific, valid, reliable and sensitive questionnaire that allows evaluating treatment-induced changes in health-related quality of life (HRQoL).

AIM

To design a self-administered questionnaire, the GERD Analyzer (GERDyzer), for use in clinical studies.

METHODS

The GERDyzer comprises 10 dimensions each illustrated by pictogram-like drawings, simplifying communication with the patients. Self-assessment is performed by 100 mm Visual Analogue Scales. For validation, a 5-week clinical trial involving 395 patients (per-protocol) with oesophagitis was conducted. Patients were treated with pantoprazole (40 mg o.d.) for 28 days. Psychometric analyses included internal consistency, test-retest reliability, responsiveness and construct validity.

RESULTS

Factor analysis showed consistency of the dimensions and no reduction was necessary. Validation of GERDyzer indicated high internal consistency (Cronbach's alpha = 0.95) and test-retest reliability (intraclass correlation coefficient =0.91). Responsiveness of the total score expressed by nonparametric effect size was 1.38. Comparison of scores with other questionnaires resulted in logical correlation levels depending on the respected concepts measured. Conclusions GERDyzer proved to be highly valid, reproducible and responsive. It allows reliably assessing treatment-induced changes in HRQoL in erosive GERD.

Symptom evaluation in gastroesophageal reflux disease

The evaluation of the success of therapy for gastroesophageal reflux disease (GERD) has thus far been primarily on the basis of the endoscopic evaluation of the ability of drugs to heal esophageal mucosal breaks and to a lesser extent on their ability to decrease the diverse symptoms of acid reflux. However, because most patients with GERD have no visible esophageal lesions using conventional endoscopic methods, this paradigm requires serious reconsideration. As patients with nonerosive reflux disease (NERD) are just as symptomatic as patients with erosions and are no easier to treat the use of endoscopic end points alone, as criteria for determining healing and efficacy of therapy requires reassessment. In addition, the symptoms of GERD are now appreciated to be broad-based, including many extraesophageal symptoms that contribute to the marked reduction in quality of life for GERD patients. For this reason, and because endoscopic criteria cannot be applied to evaluating therapy in NERD, the success of GERD therapy should be judged primarily in terms of diminishment of GERD-related symptoms--a return to the traditional way that patients judge therapeutic success. To objectively determine the success of therapy in GERD, multisymptom GERD questionnaires have been developed. The most promising are those that reflect the numerous types of GERD symptoms, are patient-administered, quantitative, responsive, and have been validated in both NERD and erosive GERD patients. The ReQuest instrument is especially attractive as it records the entire range of GERD symptoms on a daily basis (including also their frequency and intensity) and is responsive to changes with time and with therapy. Symptom-based evaluative tools should greatly aid the objective evaluation of GERD symptoms, monitor precisely how patients respond to therapy and thereby lead to improvements in GERD management.

Validation of a brief symptom questionnaire (ReQuest in Practice) for patients with gastro-oesophageal reflux disease

BACKGROUND

A clinical need exists for a means of assessing symptom control in patients with gastro-oesophageal reflux disease. The ReQuest questionnaire has been extensively validated for symptom assessment in both erosive and non-erosive gastro-oesophageal reflux disease but was designed for research purposes. We derived a shorter version (ReQuest in Practice) that would be more convenient for clinical practice.

AIM

To validate ReQuest in Practice in patients suffering from gastro-oesophageal reflux disease.

METHODS

Multicentre, non-interventional, crossover comparison. Patients completed ReQuest in Practice followed by ReQuest or vice versa. Before and after a planned endoscopy, patients completed the health-related quality of life questionnaire GERDyzer. Internal consistency and the Intraclass Correlation Coefficient were calculated. Construct validity was evaluated by correlation with ReQuest and GERDyzer.

RESULTS

There was high internal consistency of ReQuest in Practice (Cronbach's alpha: 0.9) and a high Intraclass Correlation Coefficient of 0.99. The measurement error of ReQuest in Practice was 4.1. High correlation between ReQuest in Practice and ReQuest (Spearman correlation coefficient: 0.9) and GERDyzer (Spearman correlation coefficient: 0.8) demonstrated construct validity.

CONCLUSIONS

ReQuest in Practice was proven to be valid and reliable. Its close correlation with ReQuest makes it a promising tool to guide the clinical management of patients across the full spectrum of both erosive and non-erosive gastro-oesophageal reflux disease.

Validation of the reflux disease questionnaire for an Italian population of patients with gastroesophageal reflux disease

BACKGROUND/AIMS

The reflux disease questionnaire (RDQ) is a very simple questionnaire based on only 12 questions that can be answered and evaluated quickly in a primary care setting, which was already found to be valid and reliable in the diagnosis of gastroesophageal reflux disease (GERD). As an English and a German version of the RDQ exist, but not an Italian one, we aimed at translating the RDQ into Italian and evaluating its reliability for the use of Italian-speaking GERD patients.

PATIENTS/METHODS

For the purpose of linguistic validation, we translated backward and forward the original RDQ into Italian and again into English. For the purpose of assessing internal consistency, test-retest, and interrater reliability, 130 GERD patients were used, of whom 57 patients had an endoscopic oesophagitis of grade A to C according to the Los Angeles classification and 63 patients had uninvestigated GERD symptoms but with a frequency of heartburn and/or regurgitation at least twice a week.

RESULTS

After professional translation, the Italian RDQ was judged to retain fully the meaning of the original RDQ. Internal consistency, as judged by the (Cronbach's alpha) was satisfactory, with an overall RDQ scale alpha=0.86 (minimum acceptable value=0.70). Test--retest reliability (Spearman coefficient) was again found to be optimal, with individual item values ranging between 0.74 (for 'pain in the upper stomach: frequency') and 0.90 (for 'burning feeling behind breastbone: severity'). Finally, the correlation coefficient was 0.96 for the total scale and a range of 0.85-0.98 for individual items, indicating extremely satisfactory concordance.

CONCLUSIONS

The Italian RDQ appears to be a simple, reproducible, and reliable tool for the diagnosis of GERD. We believe that this questionnaire is well suited for use, both in primary care settings and in epidemiological studies, in particular for the assessment of so-called typical symptoms.

A clinical trial comparing pantoprazole and esomeprazole to explore the concept of achieving 'complete remission' in gastro-oesophageal reflux disease

BACKGROUND AND AIM

The outcome of gastro-oesophageal reflux disease treatment is traditionally assessed by measuring endoscopically confirmed healing and symptom relief separately. Both terms together, indicating complete remission, are intuitively a more realistic clinical endpoint but are assessed less often.

AIM

To explore this concept, we formally compared the efficacy of the proton pump inhibitors (PPIs) pantoprazole and esomeprazole using rates of complete remission judged against rates of healing and symptom relief separately.

METHODS

Five hundred and eighty-two patients with erosive gastro-oesophageal reflux disease were randomized to treatment for 4, 8, or 12 weeks with either pantoprazole or esomeprazole 40 mg daily. Symptom relief was assessed with the validated ReQuesttrade mark-GI subscale.

RESULTS

Approximately 75% of patients were free of symptoms or had no oesophageal lesions after 4 weeks' treatment, rising to about 93% and 96%, respectively, at 12 weeks. Complete remission rates were, however, lower at these time points; approximately 60% and about 90%, respectively. Both PPIs had similar efficacy.

CONCLUSIONS

Endoscopically confirmed healing and symptom relief assessed separately over-estimated the benefits of both drugs. In contrast, complete remission indicates that patients may be treated inadequately when given the standard 4- to 8-week treatment. We suggest that complete remission is a more reliable and clinically relevant endpoint of treatment.

Symptom assessment tools for gastroesophageal reflux disease (GERD) treatment

Relief of symptoms, both typical and atypical, is the mainstay of therapy for patients with gastroesophageal reflux disease (GERD); however, evaluation of GERD symptoms' response to treatment has been hampered by the lack of a questionnaire that meets all the criteria of an ideal evaluative GERD symptom assessment tool. These criteria are: sensitivity in GERD patients, covering all symptom dimensions (multidimensional construct), assessment of frequency and intensity of "typical" and "atypical" GERD symptoms, practical and economical, easy to understand, responsive over short time intervals, use as a patient self-assessment tool, amenable to daily use, psychometrically validated, and translation into many languages with cross-cultural adaptation. Thus far, 14 instruments have been developed to assess GERD symptoms and potentially can be used to evaluate treatment response during a therapeutic trial in GERD patients. However, comparison of the different evaluative tools is needed.

GERD evaluation: time for a new paradigm?

In the past there has been reliance on heartburn and acid regurgitation as the cardinal symptoms of gastro-esophageal reflux. Now it is recognized that diverse additional symptoms including extraesophageal manifestations are essential components of gastroesophageal reflux disease (GERD). Furthermore, previous reliance in mucosal damage at endoscopy as evidence of therapeutic success in the management of GERD has proven of only limited value in the diverse world of GERD symptoms. Indeed is now apparent that the relationship between symptoms and lesions is modest at best. Most patients with GERD have no overt erosions or ulceration at endoscopy and they frequently suffer from a wide array of complaints other than heartburn that contribute to their diminished perception of life's quality. To address these problems, multidimensional questionnaires designed to encompass the diverse symptomatology of GERD have been investigated, principally, to provide a reproducible metric of change in the subjective response to pharmacologic therapy during trials for patients with nonerosive reflux disease. The most promising of these instruments is The ReQuest questionnaire, because it has been extensively validated in multiple patient groups and cultures, appears highly promising in this regard and for erosive disease too and may ultimately prove to be of value for the initial evaluation of patients with GERD. We propose that accurate symptom delineation complemented with endoscopy performed in selected groups of patients will become the mainstay in diagnosis of GERD and the assessment of therapy efficacy.

Evaluation of a gastrointestinal symptoms questionnaire

Questionnaires are widely used instruments to monitor gastrointestinal (GI) symptoms. However, few of these questionnaires have been formally evaluated. We sought to evaluate our GI symptoms questionnaire in terms of clarity and reproducibility. Primary care patients referred for open access Helicobacter pylori urea breath testing reported GI symptoms (type+severity) and demographic information by written questionnaire. In an interview, patients gave a personal description of the meaning of the GI symptoms on the questionnaire. Patients' descriptions of GI symptoms were compared with current definitions. Symptom severity scores were compared before and after, interview versus questionnaire. Of the 45 patients included, 19 (42%) described all symptoms correctly, whereas 17 (38%) described one symptom incorrectly. None of the patients made more than three mistakes. Regurgitation was the most common incorrectly described symptom (16 patients [36%]), whereas the other individual symptoms were well explained. Symptom severities before the interview, after the interview and reported by questionnaire (mean value+/-SEM) were 2.1 +/- 0.2, 2.1 +/- 0.2, and 1.5 +/- 0.2 points on a 7-point Likert scale (0-6), respectively. Mean severity reported by interview (95% CI) was 1.4 (1.3-1.5) times higher than reported by questionnaire (P < .05). In conclusion, the GI symptom questionnaire is understandable and has good reproducibility for measuring the presence of GI symptoms, although symptom severity is consistently rated higher when reported by interview.

Gastroesophageal reflux disease and irritable bowel syndrome: a common overlap syndrome

Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) are very common disorders in the general population. Symptoms of IBS are commonly encountered in GERD patients, and symptoms of GERD are not uncommon in IBS patients. GERD patients consistently report lower abdominal symptoms, which may be part of the spectrum of GERD symptoms. Alternatively, GERD and IBS may be two distinct manifestations of a similar underlying pathophysiologic process that can affect different levels of the gastrointestinal tract. Although the reason for the overlap observed between GERD and IBS remains to be elucidated, recent studies have demonstrated that GERD patients who also suffer from IBS-like symptoms perceive their GERD-related symptoms as more severe and are less likely to respond to antireflux treatment, as compared with those without IBS.

Review article: from gastrin to gastro-oesophageal reflux disease--a century of acid suppression

To commemorate Edkins' discovery of gastrin in 1905, we review a century of progress in the physiology and pathobiology of gastrin and acid secretion especially as it pertains to clinical aspects of gastro-oesophageal reflux disease. Although initially ignored, Edkins' observations eventually led to the enthusiastic investigation of gastrin and acid regulation in peptic ulcer disease, culminating in important therapeutic advances in the management of acid peptic disease. Following the improved understanding of gastric secretory physiology, and the development of acid suppressants with increasing efficacy, the use of surgical intervention for peptic ulcer disease was almost eliminated. Surgery became obsolete with the discovery of Helicobacter pylori. Three other advances are also influencing modern practice: the gastrotoxicity of aspirin and non-steroidal anti-inflammatory drugs is now increasingly appreciated, the role of endoscopy in the diagnosis and therapy of upper gastrointestinal bleeding, and the use of intravenous acid-suppressive agents. The major issue for the future resides within the epidemic of gastro-oesophageal reflux disease. How to diagnose, categorize and treat this condition and how to identify and prevent neoplasia, are the challenges of the new century.

GERD 2004: issues from the past and a consensus for the future

In the early 1900's, gastroesophageal reflux disease (GERD) was an almost unknown entity with less than 200 cases reported worldwide. Currently the disease is regarded as almost endemic with as much as 25% of the population in some countries exhibiting signs or symptoms of reflux. Early therapies directed at chemical neutralization (milk drip, antacids) were of modest effect and required constant administration for efficacy. The introduction of histamine 2 receptor antagonists in the 1970's dramatically improved the management of GERD, but was limited by problems of tachyphylaxis and adverse events. The advent of the PPI class of drugs revolutionized medical care of GERD, given their efficacy and safety profile. As a consequence, the surgical approach with its pronounced dependence on individual operator skill and its high morbidity and even mortality has fallen into disregard. Thus, modest surgical outcome results as compared to the efficacy of PPIs has led to the widespread recognition that pharmacological therapy for GERD represents the platinum standard of care and the current consensus is that the PPI class of drugs provide the safest and most effective form of therapy for GERD. Furthermore, it is apparent based on acid suppression, symptom relief and healing rates, that all PPIs are on a milligram for milligram basis similarly efficacious for the management of GERD. While a consensus exists in regard to the current management of GERD with PPIs there is little agreement as to the management of the associated mucosal metaplastic process. At this time there is inadequate understanding of the biological basis of the mucosal transformation and minimal information about the mechanistic regulation of this event and its perpetuation. A future consensus thus requires the identification of the appropriate tools to detect Barrett's early, identify the specific molecular markers associated with neoplastic transformation and establish a definitive therapeutic algorithm.

ReQuest-- the challenge of quantifying both esophageal and extra-esophageal manifestations of GERD

Gastroesophageal reflux disease (GERD) is highly prevalent in Western countries. It is characterized by esophageal and extra-esophageal symptoms (both typical and atypical) as well as by a number of potential complications. As the majority of patients have normal gross endoscopic findings, the assessments of symptom severity and quality of life, as well as the patients' response to treatment have become increasingly important. Self-assessed symptom questionnaires are now key instruments in clinical trials. An ideal GERD symptom questionnaire, suitable as a primary end-point for clinical trials, should: (1) be sensitive in patients with GERD, (2) cover frequency and intensity of typical and atypical GERD symptoms, (3) be multidimensional (cover all symptom dimensions), (4) have proven psychometric properties (validity, reliability and responsiveness), (5) be practical and economical, (6) be self-assessed, (7) use 'word pictures' which are easy to understand for patients, (8) respond rapidly to changes (responsiveness in short-time intervals), (9) be used daily to assess changes during and after therapy, and (10) be valid in different languages for international use. A literature review revealed five evaluative scales that met some of the above characteristics, but none fulfilled all of them. Therefore, a new evaluative tool for the assessment of GERD symptoms and their response to therapy is needed. The Reflux Questionnaire (ReQuest) is a self-assessed questionnaire developed and validated to assess the effect of treatment on the spectrum of GERD-related symptoms. Initially, GERD symptoms were identified on the basis of available literature, knowledge from previous clinical trials, experienced physicians, and patient interviews. An overall of 67 typical and atypical symptom descriptions were grouped into six different dimensions of GERD (acid complaints, upper abdominal/stomach complaints, lower abdominal/digestive complaints, nausea, sleep disturbances, other complaints). To these six dimensions a seventh, general well-being was added. Each dimension was tested by questions for frequency and intensity (except general well-being, for which only the intensity was determined). Thereafter, ReQuest was translated into different languages and tested in mother tongue patient focus groups. ReQuest psychometric properties (test-retest reliability, internal consistency, construct validity, responsiveness) were validated in two clinical trials of erosive GERD and endoscopic negative (en) GERD. In the first open, multicenter study, ReQuest was assessed in 430 patients with erosive GERD grade A-D. Patients with GERD grade A were treated with pantoprazole 20 mg od whereas those with GERD grade B-D received 40 mg od. The second open, multicenter, multinational trial with pantoprazole 20mg od assessed the ReQuest in over 800 patients with endoscopic negative GERD. Furthermore, ReQuest was used to determine the 'normal' ranges of GERD symptoms in individuals without GERD evidence. Over 300 healthy volunteers took part in a 4-day evaluation by completing ReQuest on each of the four study-days, as well as GSRS and PGWB on day 1. Based on the 90% percentiles determined in this study, a 'normal' range was calculated for ReQuest and relative subscales. The study showed that even individuals without GERD evidence can experience mild GERD symptoms. The derived 'normal' ranges within the population can be used for classification of symptom relief. In conclusion, ReQuest proved to be a valid, reliable, and responsive tool for measuring both typical and atypical GERD symptoms, and to be particularly suitable for measuring daily symptom changes and identifying normalization of the clinical picture in therapeutic trials.