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

Clinical features of acute esophageal mucosal lesions and reflux esophagitis Los Angeles classification grade D: A retrospective study

BACKGROUND

Acute esophageal mucosal lesions (AEMLs) are an underrecognized and largely unexplored disease. Endoscopic findings are similar, and a higher percentage of AEML could be misdiagnosed as reflux esophagitis Los Angeles classification grade D (RE-D). These diseases could have different pathologies and require different treatments.

AIM

To compare AEML and RE-D to confirm that the two diseases are different from each other and to clarify the clinical features of AEML.

METHODS

We selected emergency endoscopic cases of upper gastrointestinal bleeding with circumferential esophageal mucosal injury and classified them into AEML and RE-D groups according to the mucosal injury’s shape on the oral side. We examined patient background, blood sampling data, comorbidities at onset, endoscopic characteristics, and outcomes in each group.

RESULTS

Among the emergency cases, the AEML and RE-D groups had 105 (3.1%) and 48 (1.4%) cases, respectively. Multiple variables exhibited significantly different results, indicating that these two diseases are distinct. The clinical features of AEML consisted of more comorbidities [risk ratio (RR): 3.10; 95% confidence interval (CI): 1.68–5.71; P < 0.001] and less endoscopic hemostasis compared with RE-D (RR: 0.25; 95%CI: 0.10–0.63; P < 0.001). Mortality during hospitalization was higher in the AEML group (RR: 3.43; 95%CI: 0.82–14.40; P = 0.094), and stenosis developed only in the AEML group.

CONCLUSION

AEML and RE-D were clearly distinct diseases with different clinical features. AEML may be more common than assumed, and the potential for its presence should be taken into account in cases of upper gastrointestinal bleeding with comorbidities.

Risk factors and long-term course of gastroesophageal reflux disease after peroral endoscopic myotomy: A large-scale multicenter cohort study in Japan

BACKGROUND : Gastroesophageal reflux disease (GERD) and reflux esophagitis remain problems after peroral endoscopic myotomy (POEM). This study aimed to elucidate the risk factors and long-term course of reflux esophagitis and symptomatic GERD after POEM. METHODS : This multicenter cohort study involved 14 high volume centers. Overall, 2905 patients with achalasia-related esophageal motility disorders treated with POEM were analyzed for reflux esophagitis, severe reflux esophagitis (Los Angeles classification C or D), and symptomatic GERD. RESULTS : Reflux esophagitis was diagnosed in 1886 patients (64.9 %). Age ≥ 65 years (risk ratio [RR] 0.85), male sex (RR 1.11), posterior myotomy (RR 1.12), esophageal myotomy > 10 cm (RR 1.12), and gastric myotomy > 2 cm (RR 1.17) were independently associated with reflux esophagitis. Severe reflux esophagitis was diagnosed in 219 patients (7.5 %). Age ≥ 65 years (RR 1.72), previous treatments (RR 2.21), Eckardt score ≥ 7 (RR 0.68), sigmoid-type achalasia (RR 1.40), and esophageal myotomy > 10 cm (RR 1.59) were factors associated with severe reflux esophagitis. Proton pump inhibitors (PPIs) were more effective for reflux esophagitis at 5-year follow-up (P = 0.03) than after 1 year (P = 0.08). Symptomatic GERD was present in 458 patients (15.9 %). Symptom duration ≥ 10 years (RR 1.28), achalasia diagnosis (RR 0.68), integrated relaxation pressure ≥ 26 (RR 0.60), and posterior myotomy (RR 0.80) were associated with symptomatic GERD. The incidence of symptomatic GERD was lower at 5-year follow-up compared with that after 1 year (P = 0.04), particularly in PPI users (P < 0.001). CONCLUSIONS : The incidence of severe reflux esophagitis was low after POEM, but excessive myotomy for older patients with previous treatments should be avoided. Early phase symptomatic GERD is non-acid reflux dependent and the natural course is favorable, basically supporting conservative treatment.

Decline incidence in upper gastrointestinal bleeding in several recent years: data of the Japan claims database of 13 million accumulated patients

This study was to examine the recent trends in upper gastrointestinal bleeding in Japan using a large-scale real-world database. The incidence of upper gastrointestinal bleeding was evaluated in the Japan Medical Data Center claims database of 13,019,713 patients aged 20 to 74 years with traceability for 3 months from 2009 to 2014. The incidence was compared with peptic ulcers and gastroesophageal reflux disease. The prescription of medications was also evaluated. The incidence of bleeding was 0.137%, 0.121%, 0.113%, 0.106%, 0.099%, and 0.105% during 2009 to 2014 with a time-dependent decline (p<0.001). Peptic ulcers (>10 times higher than the incidence of bleeding) decreased with time (p<0.001), whereas gastroesophageal reflux disease increased (p = 0.006). Upper gastrointestinal bleeding was higher in male patients and older patients (60–74 years old) (p<0.001 respectively). The prescription rate of antithrombotic medications and proton pump inhibitors increased from 2009 to 2014 (p<0.001 respectively). The incidence of upper gastrointestinal bleeding decreased from 2009 to 2014 in this relatively large-scale real-world database in Japan, concomitant with the decrease in peptic ulcers. The decreased incidence might have been due to changes in the disease structure and therapeutic strategies over time.

Increase in lumbar kyphosis and spinal inclination, declining back muscle strength, and sarcopenia are risk factors for onset of GERD: a 5-year prospective longitudinal cohort study

PURPOSE

The objective was to identify risk factors for new development of gastroesophageal reflux disease (GERD) 5 years later in a prospective longitudinal cohort study.

METHODS

A total of 178 subjects (male 72, female 106, mean age 68 years) without GERD in 2013 were examined for GERD in 2018. A Frequency Scale for Symptoms of GERD score ≥ 8 was used for diagnosis of GERD. Body mass index, spinal alignment, muscle strength, physical ability, number of oral drugs per day, sarcopenia, and frailty determined in 2013 and 2018 were compared between the GERD(+) and GERD(-) groups in 2018. Aggravation of lumbar kyphosis and spinal inclination from 2013 to 2018 was defined as a change of ≥ 5° or ≥ 10°, and weakening of back muscle strength as a change of ≥ 10 kg. QOL (SF-36) was also examined.

RESULTS

Of the 178 subjects, 38 (21%) were diagnosed as GERD(+) in 2018. Sarcopenia in 2018 was significantly related to a GERD(+) status (p < 0.05). The GERD(+) group had significantly higher rates of changes of lumbar kyphosis ≥ 5° (p < 0.005) and ≥ 10° (p < 0.0001), of spinal inclination ≥ 5° (p < 0.0001), and of decreased back muscle strength ≥ 10 kg (p < 0.05). SF-36 were also significantly worse in the GERD(+) group (p < 0.05).

CONCLUSIONS

This prospective longitudinal study firstly demonstrated that lumbar kyphotic change, aggravation of spinal inclination, decreased back muscle strength, and sarcopenia are significant risk factors for new development of GERD. Management and prevention of these factors may contribute to reduction of GERD symptoms and increased QOL in middle-aged and elderly people. These slides can be retrieved under Electronic Supplementary Material.

Curcumin prevents the bile reflux-induced NF-κB-related mRNA oncogenic phenotype, in human hypopharyngeal cells

The presence of bile is not an uncommon finding in acidic oesophageal and extra‐oesophageal refluxate, possibly affecting the hypopharyngeal mucosa and leading to neoplastic events. We recently demonstrated that acidic bile (pH ≤ 4.0) can induce NF‐κB activation and oncogenic mRNA phenotype in normal hypopharyngeal cells and generate premalignant changes in treated hypopharyngeal mucosa. We hypothesize that curcumin, a dietary inhibitor of NF‐κB, may effectively inhibit the acidic bile‐induced cancer‐related mRNA phenotype, in treated human hypopharyngeal primary cells (HHPC), supporting its potential preventive use in vivo. Luciferase assay, immunofluorescence, Western blot, qPCR and PCR microarray analysis were used to explore the effect of curcumin in HHPC exposed to bile (400 μmol/L) at acidic and neutral pH. Curcumin successfully inhibited the acidic bile‐induced NF‐κB signalling pathway (25% of analysed genes), and overexpression of NF‐κB transcriptional factors, c‐REL, RELA(p65), anti‐apoptotic bcl‐2, oncogenic TNF‐α, EGFR, STAT3, WNT5A, ΔNp63 and cancer‐related IL‐6. Curcumin effectively reduced bile‐induced bcl‐2 overexpression at both acidic and neutral pH. Our novel findings suggest that, similar to pharmacologic NF‐κB inhibitor, BAY 11‐7082, curcumin can suppress acidic bile‐induced oncogenic mRNA phenotype in hypopharyngeal cells, encouraging its future in vivo pre‐clinical and clinical explorations in prevention of bile reflux‐related pre‐neoplastic events mediated by NF‐κB.

Clinical Manifestations of Huge Diaphragmatic Hernias

Translocation of abdominal organs into the thoracic cavity may cause dyspnea, heart disorders, and gastric symptoms. Diaphragmatic hernias can cause diagnostic difficulties, since both clinical and radiological symptoms might imitate different disorders. In these cases computed tomography of the chest is the method of choice. The aim of this study was to assess clinical manifestations, risk factors, and prognosis in patients with huge diaphragmatic hernias with displacement of abdominal organs into the thorax, depending on the action taken. We carried out a retrospective study using data of patients hospitalized in the years 2012-2016. Ten patients were qualified for the study (8 women and 2 men). The mean age of the subjects was 86.5 ± 10.5 years. Thirty percent of the hernias were post-traumatic. All of the patients reported cardiovascular or respiratory symptoms. Upper gastrointestinal symptoms occurred in half of the patients. Twenty percent of patients underwent surgery with a positive outcome, while 30% of patients, who were not qualified for surgery due to numerous co-morbidities, died. The main risk factors predisposing to the occurrence of large diaphragmatic hernias were the following: old age, female gender, and thoracic cage deformities.

Iranian lifestyle factors affecting reflux disease among healthy people in Qom

Background and aim

Gastroesophageal reflux disease (GERD) is one of the most common digestive system disorders. Life style factors may increase the risk of reflux disease. We aimed to determine prevalence of reflux and related life style-factors in the population living in Qom.

Methods

This cross-sectional study was conducted among 1500 residents of Qom in 2014. Individuals were selected through multi-stage sampling. They completed two questionnaires: FSSG questionnaire for diagnosis of GERD and a general questionnaire to measure demographic and lifestyle factors. Univariate and multivariate were used for analysis of data. Data were analyzed using IBM SPSS version 20.

Results

A total of 1130 individuals were analyzed in which 52.4% of them were female. Prevalence of GERD was 28%. Adjusted findings showed use of PPIs (OR: 2.2, 95% CI: 2–5), taking H2RAs (OR: 4.7, 95% CI: 2.3–9.4), the habit of quick eating (OR: 1.5, 95% CI: 1.1–2), extra salt consumption on daily meals (OR: 1.5, 95% CI: 1.05–2), lack of sleep (OR: 2.6, 95% CI: 1.5–4.8), and consumption of white bread (OR: 1.7, 95% CI: 1.05–2.7) were related to increased risk of GERD.

Conclusion

Our findings showed lifestyle factors such as habit of quick eating, extra salt on regular meals, lack of sleep and use of white bread were associate with increased risk of GERD. However, habit of midnight snack, having dinner just before bedtime, lack of breakfast, smoking, drinking tea and coffee were not associated with increased risk of GERD. It is recommended to carry out a cohort study among the Iranian population to evaluate the effect of life-style risk factors on GERD.

Circumferential Locations of Different Shapes of Short-segment Barrett's Esophagus

Objective To clarify the relationship between the shape and circumferential location of non-circumferential short-segment Barrett's esophagus (SSBE). Methods We examined 3,788 subjects (2,497 males, 1,291 females; mean age 52.4 years) who underwent upper GI endoscopy as part of a detailed medical checkup. The presence of columnar-appearing mucosa ≥10 mm long in the distal esophagus was diagnosed as BE and then divided into circumferential and non-circumferential localized types. Localized SSBE was further divided into round and sharp types based on the shape of the proximal margin. Results SSBE was endoscopically observed in 197 subjects (5.2%). The numbers of patients with circumferential SSBE, round localized SSBE, and sharp localized SSBE were 38, 114 and 69, respectively. Round and sharp types of localized SSBE were simultaneously observed in 25 patients. Reflux esophagitis was more frequently observed in subjects with BE, regardless of type, in comparison to those without BE. Round localized SSBE was found mainly in the left posterior wall of the esophagus in a location similar to the main area of the esophageal cardiac glands. In contrast, sharp localized SSBE was observed mainly in the right anterior wall of the esophagus in a location similar to that of esophageal mucosal injury caused by mild type reflux esophagitis. Conclusion The location differs between round and sharp localized SSBE, possibly due to differences in the process of BE development.

Improvement of gastroesophageal reflux disease in Japanese patients with spinal kyphotic deformity who underwent surgical spinal correction

BACKGROUND AND AIM

Spinal kyphotic deformity occasionally results in gastroesophageal reflux disease (GERD). The effects of acid reflux on the esophagus in kyphotic patients are unclear, however, and it is unknown whether acid reflux, endoscopic GERD, and reflux-related symptoms improve following surgical spinal correction in these patients. Herein, we investigated the characteristics of GERD in kyphotic patients and the improvement in GERD following surgical correction.

METHODS

In 48 patients with severe kyphotic deformity scheduled for surgical spinal correction, we conducted esophagogastroduodenoscopy, 24-h pH monitoring and three questionnaire surveys, including the frequency scale for the symptoms of GERD (FSSG). We repeated these measurements after surgical correction and compared pre- and post-surgery values.

RESULTS

Of 48 patients, 70.8% [95% CI: 55.9-83.0%, 34/48] had endoscopically evaluated esophageal mucosal injury. Regarding pH before surgery, 64.9% (CI: 47.5-79.8%, 24/37) had abnormal acid reflux (intraesophageal pH < 4 more than 5% of the time). FSSG score was significantly associated with the severity of GERD, and the positive rate was 52.6% (CI: 35.8-69.0%, 20/38). Following surgical correction, esophageal mucosal injury improved endoscopically in 90% of patients, and median total FSSG score significantly decreased from 8 (0-30) to 5 (0-19) (P = 0.005). Regarding pH after surgery, prevalence of abnormal acid reflux decreased from 66.7% (95% CI: 41.0-86.7%) to 33.3% (95% CI: 13.3-59.0%) (P = 0.045).

CONCLUSION

Surgical spinal correction in kyphosis patients improves not only kyphotic deformity-related disorders but also esophageal mucosal injury, abnormal acid reflux, and reflux-related symptoms.

[Prevalence of erosive esophagitis and peptic esophageal strictures]

Gastroesophageal reflux disease is a widespread among population in economically developed countries including Russia. It was analyzed the results of 34 903 endoscopic examinations of upper gastrointestinal tract in ethnically and socially homogeneous population of Leningrad region with symptoms of gastric dispepsia. Procedures were performed for the period 2007-2013. Prevalence of erosive esophagitis was 4.9%. Peptic esophageal strictures due to chronic reflux-associated inflammation were revealed in 0.2% of examined patients (3.7% of patients with erosive esophagitis). Obtained data allow to considergastroesophageal reflux disease as a socially significant problem in Russia requiring close attention and further study.

The effect of kyphotic deformity because of vertebral fracture: a finite element analysis of a 10° and 20° wedge-shaped vertebral fracture model

BACKGROUND CONTEXT

Kyphotic deformity associated with vertebral fracture is believed to be a significant risk factor for additional vertebral fractures. However, previously published research is limited.

PURPOSE

The purpose of this study was to estimate the biomechanical stresses that kyphotic deformity, with an initial vertebral fracture, place on adjacent vertebrae using three-dimensional finite element (FE) of the spine, head, and ribs.

STUDY DESIGN

This study is based on the basic science.

METHODS

Total Human Model for Safety, a three-dimensional FE model of the human body, was used and adjusted to represent an elderly osteoporotic woman. The 12th thoracic vertebra (T12), which is a frequent site of osteoporotic vertebral fractures, was transformed to a wedge shape at 0°, 10°, and 20° to create a normal model, a 10° kyphosis model, and a 20° kyphosis model. Additionally, compensated postures were created for the 10° and 20° kyphosis models. Thus, five models were created: (A) a normal model, (B) a 10° kyphosis model, (C) a 20° kyphosis model, (D) a 10° kyphosis model with compensated posture, and (E) a 20° kyphosis model with compensated posture. Compressive principal stresses (CPSs) on T1-L5 in each model were calculated.

RESULTS

The highest CPS value was 7.78 MPa placed on the anterior part of the T10 vertebra in the 20° kyphosis model. In the 20° kyphosis model, the higher CPS values showed bimodal peaks at T6 and T7 in the midthoracic spine and at T10 and T11 in the two superior adjacent vertebrae. The maximum CPS values in the A, B, C, D, and E models at T10 were 3.12, 6.74, 7.78, 6.61, and 5.78 MPa. At T11, they were 1.70, 4.41, 6.45, 4.07, and 4.79 MPa.

CONCLUSIONS

The existence of an initial vertebral fracture at T12 caused an increase in stress on adjacent vertebrae. Higher CPS values showed bimodal peaks in midthoracic vertebrae and in two superior adjacent vertebrae when T12 was transformed to a wedge shape in the 20° kyphosis model.

Lifestyle measures in the management of gastro-oesophageal reflux disease: clinical and pathophysiological considerations

Several lifestyle and dietary factors are commonly cited as risk factors for gastro-oesophageal reflux disease (GORD) and modification of these factors has been advocated as first-line measures for the management of GORD. We performed a systematic review of the literature from 2005 to the present relating to the effect of these factors and their modification on GORD symptoms, physiological parameters of reflux as well as endoscopic appearances. Conflicting results existed for the association between smoking, alcohol and various dietary factors in the development of GORD. These equivocal findings are partly due to methodology problems. There is recent good evidence that weight reduction and smoking cessation are beneficial in reducing GORD symptoms. Clinical and physiological studies also suggest that some physical measures as well as modification of meal size and timing can also be beneficial. However, there is limited evidence for the role of avoiding alcohol and certain dietary ingredients including carbonated drinks, caffeine, fat, spicy foods, chocolate and mint.

Gender differences in the time-course changes of reflux esophagitis in Japanese patients

OBJECTIVE

Obesity is related to an increased prevalence of reflux esophagitis and gastroesophageal reflux disease symptoms. This study was performed to clarify the influence of gender on time-course changes in the rate of a high BMI and incidence of reflux esophagitis in Japanese subjects.

METHODS

The subjects included individuals who visited a medical center for medical checkups between April 2000 and March 2001, April 2005 and March 2006 and April 2010 and March 2011. At each examination, the subjects underwent upper gastrointestinal endoscopy to determine the presence of reflux esophagitis, size of the diaphragmatic hiatus and degree of gastric mucosal atrophy. A body mass index (BMI) of ≥ 25 kg/m(2) was defined as a high BMI.

RESULTS

A multiple logistic regression analysis showed that a high BMI, milder degree of gastric mucosal atrophy and larger size of diaphragmatic hiatus were significant predictive factors for the presence of reflux esophagitis in both men and women. The number of male subjects with reflux esophagitis and a high BMI increased during the 10-year examination period. In contrast, the number of individuals with reflux esophagitis and a high BMI was not increased among women. For both men and women, the proportions of patients with a large diaphragmatic hiatus and mild gastric mucosal atrophy increased during the 10-year period.

CONCLUSION

The prevalence of reflux esophagitis in the female subjects remained constant over 10 years, different from that observed in the men. A lack of change in BMI may be an important factor accounting for the constant prevalence of reflux esophagitis in women.

A randomized, placebo-controlled, double-blind clinical trial of rikkunshito for patients with non-erosive reflux disease refractory to proton-pump inhibitor: the G-PRIDE study

BACKGROUND

The aim of this study was to investigate the efficacy of rikkunshito (RKT), a traditional Japanese medicine, combined with proton pump inhibitor (PPI) in patients with PPI-refractory non-erosive reflux disease (NERD).

METHODS

Patients with PPI-refractory NERD (n = 242) were randomly assigned to the RKT group [rabeprazole (10 mg/day) + RKT (7.5 g/t.i.d.) for 8 weeks] or the placebo group (rabeprazole + placebo). After the 4- and 8-week treatments, we assessed symptoms and quality of life (QOL) using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG), Gastrointestinal Symptom Rating Scale (GSRS), and Short-Form Health Survey-8 (SF-8).

RESULTS

There were no significant differences in FSSG and GSRS score improvement between these groups after the 4- and 8-week treatments. The mental component summary (MCS) scores of the SF-8 improved more in the RKT group (from 45.8 ± 8.1 to 48.5 ± 7.4) than in the placebo group (from 47.7 ± 7.1 to 48.4 ± 7.5) after the 4-week treatment (P < 0.05). The 8-week treatment with RKT was more effective for improvement of the degree of MCS score in patients with a low body mass index (<22) (P < 0.05) and significantly improved the acid-related dysmotility symptoms of FSSG in female and elderly patients (≥ 65 years).

CONCLUSION

There were no significant differences in improvement of GERD symptoms in patients with PPI-refractory NERD between these groups. However, RKT may be useful for improving mental QOL in non-obese patients and acid-related dyspeptic symptoms, especially in women and the elderly.

Clinical characteristics of elderly patients with proton pump inhibitor-refractory non-erosive reflux disease from the G-PRIDE study who responded to rikkunshito

BACKGROUND

The incidence and severity of gastroesophageal reflux disease (GERD) in Japan tends to increase in elderly women. Rikkunshito (RKT), a traditional Japanese medicine, acts as a prokinetic agent and improves gastric emptying and gastric accommodation. Our previous prospective randomized placebo-controlled study showed that RKT combined with a standard-dose of rabeprazole (RPZ) significantly improved the acid-related dysmotility symptoms (ARD) in elderly patients with proton pump inhibitor (PPI)-refractory non-erosive reflux disease (NERD). This study aimed to evaluate clinical characteristics of elderly PPI-refractory NERD patients with ARD symptoms who responded to RKT.

METHODS

Two hundred forty-two patients with PPI-refractory NERD were randomly assigned to 8 weeks of either RPZ (10 mg/q.d.) + RKT (7.5 g/t.i.d.) (RKT group) or RPZ + placebo (PL group). Among them, 95 were elderly (≥65 years) with ARD (RKT group: n = 52; PL group: n = 43). We analyzed the changes using the 12 subscale score of frequency scale for the symptoms of GERD (FSSG) and 15 items of the Gastrointestinal Symptom Rating Scale at 4 and 8 weeks and compared the therapeutic efficacy between the 2 groups.

RESULTS

There were no marked differences in baseline demographic or clinical characteristics in the 2 groups except for rate of current smoking. The FSSG score (mean ± SD at 0, 4, and 8 weeks) in both the RKT (16.0 ± 7.0; 9.9 ± 8.4; 7.0 ± 6.4) and PL (15.1 ± 6.4; 10.9 ± 6.7, 11.1 ± 8.5) groups significantly decreased after treatment. However, the degree of improvement of total and ARD scores of FSSG after the 8-week treatment was significantly greater in the RKT group than in the PL group. Combination therapy with RKT for 8 weeks showed significant improvement in 3 subscale scores (abdominal bloating, heavy feeling in stomach and sick feeling after meals) of the ARD domain and 1 subscale score (heartburn after meals) of the reflux symptom domain.

CONCLUSIONS

RKT may be useful for improving GERD symptoms in elderly PPI-refractory NERD patients with ARD. Thus, RKT was particularly effective for resolving postprandial GERD symptoms (heavy feeling in stomach, sick feeling, and heartburn after meals).

TRIAL REGISTRATION

(UMIN000005880).

Increased immunoreactivity of cathepsins in the rat esophagus under chronic acid reflux esophagitis

We have designed a stable rat chronic acid reflux esophagitis (RE) model. In gastrointestinal lesions, several lysosomal cathepsins are known to participate in epithelial permeability in cell-cell connections, such as tight junctions in ulcerative colitis. However, very few studies have focused on the distribution of cathepsins in the esophageal multilayer squamous epithelium. Therefore to clarify the role of cathepsins in RE, we investigated their immunohistological localization in the esophageal epithelium under normal conditions and after RE. Of the cathepsins examined (cathepsins B, C, D, F, H, L, S, and X), granular immunoreactivity for cathepsins B, C, D and L was observed in the control esophageal epithelia; although, their distribution differed depending on the enzyme examined. In the RE model, immunoreactivity of these cathepsins was increased in esophageal epithelial cells and activated macrophages. The immunoreactivity for cathepsins F, H, S and X was barely detectable in the control esophageal epithelium. However, in the RE model, we noticed a slight increase in the expression of cathepsins H and X in the epithelial cells. Furthermore, activated macrophages of the RE model possessed intense immunoreactivity for these cathepsins, which may have been related to esophageal inflammatory mechanisms.

A case of intestinal obstruction caused by prominent kyphosis resulting in compression of the intestine by the costal arch

An 85-year-old woman with no history of abdominal surgery complained of abdominal pain and vomiting and was referred to us with a diagnosis of intestinal obstruction a few days later. Upon admission to our facility, she presented with marked abdominal swelling and prominent kyphosis. Because of the kyphosis, most of the dilated bowel was compressing her thoracic cavity. No obvious strangulation or free air was observed via abdominal computed tomography imaging. We attempted decompression using a nasogastric tube, but the symptoms persisted. Surgery was performed 2 days after admission. The origin of the obstruction was a compression of the ileocecal region by the costal arch. The bowel was discolored, and thus surgically excised. There were no major postsurgical complications other than a mild wound infection. Until now, there have been no reports of advanced kyphosis inducing ileus, but there are concerns of an increase in similar cases as society continues to age.

Prevalence of and risk factors for gastrointestinal diseases in korean americans and native koreans undergoing screening endoscopy

BACKGROUND/AIMS

In South Korea, health check-ups are readily accessible to the public. We aimed to compare the prevalence of upper gastrointestinal (GI) and lower GI diseases in Korean Americans and native Koreans to determine differences and risk factors.

METHODS

In total, 1,942 subjects who visited Gangnam Severance Hospital from July 2008 to November 2010 for a health check-up were enrolled. Basic characteristics and laboratory data for the subjects were collected. Esophagogastroduodenoscopy and colonoscopy were performed. In total, 940 Korean Americans (group 1) and 1,002 native Koreans (group 2) were enrolled.

RESULTS

The overall prevalence of GI diseases for each group (group 1 vs group 2) were as follows: reflux esophagitis (RE) (9.65% vs 7.9%), gastric ulcer (2.8% vs 3.4%), duodenal ulcer (2.3% vs 3.6%), gastric cancer (0.4% vs 0.3%), colorectal polyp (35.9% vs 35.6%), colorectal cancer (0.5% vs 0.5%), and hemorrhoids (29.4% vs 21.3%). The prevalence of hemorrhoids was significantly higher in group 1 than in group 2 (p=0.001). In the multivariable analysis of group 1, male sex, age over 50 years, hypercholesterolemia and hypertriglyceridemia predicted colorectal polyps. Male sex and high fasting glucose levels were associated with RE.

CONCLUSIONS

Our study showed that the prevalence of GI diseases (except hemorrhoids) in Korean Americans was similar to that observed in native Koreans. Therefore, the Korean guidelines for upper and lower screening endoscopy may be applicable to Korean Americans.

Association between metabolic syndrome and prevalence of gastroesophageal reflux disease in a health screening facility in Japan

BACKGROUND

Abdominal fat accumulation, which induces high intra-abdominal pressure that causes increase in the gastroesophageal pressure gradient and hiatal hernia, as well as obesity, has been shown to increase the prevalence of gastroesophageal reflux disease (GERD). This study was performed to clarify the association between metabolic syndrome and the prevalence of GERD.

METHODS

The study subjects were an adult population who visited a medical center for annual medical check-ups from April 2010 to March 2011. GERD was diagnosed by the presence of endoscopically proven reflux esophagitis, GERD symptoms (QUEST score ≥6), or current medical therapy for GERD. The presence of metabolic or pre-metabolic syndrome was diagnosed based on the Japanese criteria for metabolic syndrome.

RESULTS

Six hundred four (16.0 %) of 3775 study subjects were positively diagnosed with GERD, with the number of those with metabolic and pre-metabolic syndrome being 477 (12.6 %) and 384 (10.2 %), respectively. Multiple logistic regression analysis showed that male gender, presence of hiatal hernia, and metabolic or pre-metabolic syndrome, as well as absence of gastric mucosal atrophy, were significant predictive factors for the prevalence of GERD, as were visceral fat accumulation and untreated dyslipidemia. Untreated hypertension and untreated hyperglycemia were also considered to be positive risk factors. Subjects undergoing treatment for hypertension showed an increased risk of GERD, while those undergoing treatment for dyslipidemia and diabetes mellitus showed a decreased risk.

CONCLUSION

Metabolic syndrome is a reliable predictive factor for the prevalence of GERD, and medical therapy for metabolic syndrome may modify the risk of GERD occurrence.

Characterization of bacterial biota in the distal esophagus of Japanese patients with reflux esophagitis and Barrett's esophagus

BACKGROUND

The distal esophagus harbors a complex bacterial population. We hypothesized that a better understanding of bacterial communities in the esophagus would facilitate understanding of the role of bacteria in esophageal disease. Here, we investigated bacterial composition in the distal esophagus in subjects with a normal esophagus, reflux esophagitis, and Barrett's esophagus.

METHODS

Two biopsy specimens were obtained from the distal esophagus at 1 cm above the gastroesophageal junction under endoscopic examination in 18 patients (6 each with normal esophagus, reflux esophagitis, and Barrett's esophagus) and used for histological examination and DNA extraction. Fragments of 16S rDNA genes were amplified by PCR using general bacterial primers, and bacterial populations were examined. A third biopsy specimen was taken from the patients with Barrett's esophagus to histologically confirm the replacement of squamous epithelium with columnar epithelium in the distal esophagus.

RESULTS

Endoscopic diagnoses of normal esophagus, esophagitis, and Barrett's esophagus were confirmed by histological findings. The total amount of bacterial DNA detected did not significantly differ among groups (p > 0.1). On average, each of the 18 subjects yielded about 350 clones, of which 40 were randomly picked and sequenced. Analysis of 147 16S rDNA sequences from 240 clones of 6 subjects with normal esophagus yielded four phyla, Proteobacteria (49%), Firmicutes (40%), Bacteroidetes (8%), and Actinobacteria (3%). Similar analysis of 139 16S rDNA sequences from 240 clones of 6 patients with reflux esophagitis yielded 6 phyla, Proteobacteria (43%), Firmicutes (33%), Bacteroidetes (10%), Fusobacteria (10%), Actinobacteria (2%), and TM7 (2%). while that of 138 16S rDNA sequences from 240 clones of 6 cases of Barrett's esophagus yielded 5 phyla, Firmicutes (55%), Proteobacteria (20%), Bacteroidetes (14%), Fusobacteria (9%), and Actinobacteria (2%). Thus, microbial communities differed among patients with a normal esophagus, reflux esophagitis and Barrett's esophagus.

CONCLUSIONS

Esophageal bacterial composition differs under conditions of normal esophagus, reflux esophagitis, and Barrett's esophagus. Diverse bacterial communities may be associated with esophageal disease.

Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population

BACKGROUND

We aimed to clarify the lifestyle factors associated with erosive esophagitis and non-erosive reflux disease (NERD) in a Japanese population.

METHODS

Among 886 subjects who underwent health screening, we selected, according to their scores on the FSSG (frequency scale for symptoms of gastroesophageal reflux disease; GERD) questionnaire and the findings of upper gastrointestinal endoscopy, 138 subjects with erosive esophagitis (EE), 148 subjects with NERD (absence of esophagitis, FSSG score ≥8, and acid reflux-related symptoms score ≥4), and 565 control subjects (absence of esophagitis and FSSG score ≤7). We compared clinical characteristics and various lifestyle factors in these three groups.

RESULTS

The lifestyle factors significantly associated with NERD compared with findings in the control group were intake of egg (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.01-3.50), sleep shortage (OR 2.44, 95% CI 1.54-3.88), and strong psychological stress (OR 1.77, 95% CI 1.18-2.62). In male subjects, current smoking (OR 2.06, 95% CI 1.13-3.74; OR 1.87, 95% CI 1.09-3.20) was a significant risk factor for both NERD and EE. Moreover, alcohol >200 kcal/day (OR 3.99, 95% CI 1.03-15.55) and intake of a large quantity of food at supper (OR 7.85, 95% CI 1.66-37.05) were significant risk factors for EE in subjects with hiatal hernia. Intake of a large quantity of food at supper (OR 2.09, 95% CI 1.06-4.13) was more common in the NERD group than in the EE group.

CONCLUSIONS

There were differences in the associated lifestyle factors between patients with NERD and those with EE, and there was also a gender-related difference between these groups.

Prevalence and risk factors of gastroesophageal reflux symptoms in a Chinese retiree cohort

Background

Data about prevalence of gastroesophageal reflux diseases (GERD) from Asian populations are still scarce. To provide additional data on prevalence of GERD and investigate its potential risk factors, we performed this cross-sectional study in the Taizhou Retiree Cohort.

Methods

After physical examination, the participants were asked whether they suffered with heartburn or acid regurgitation in the last 12 months by trained interviewers, and if yes, the severity and frequency of the symptoms were recorded. Odds ratios (ORs) with 95% confidence intervals (CIs) for the associations of obesity and other risk factors with GERD were derived from logistic regression models.

Results

8831 retirees completed the questionnaire and physical examination. In total 150 (1.7%) reported the symptoms occurring at least once per week within the last 12 months before the interview. Compared with subjects without GERD, having a history of diabetes mellitus (OR 2.2, 95% CI 1.4-3.5), hypertension (OR 1.4, 95% CI 1.0-2.1), gastritis (OR 8.2, 95% CI 5.8-11.5), peptic ulcer (OR 3.3, 95% CI 1.8-6.1) and high triglyceride level (≥1.81mmol/L) (OR 2.0, 95% CI 1.2-3.4) were associated with a significantly increased risk of GERD. However, there was no significant association between body mass index, waist-to-hip ratio or waist alone, smoking, consumption of alcohol & tea, and the occurrence of reflux symptoms.

Conclusions

Compared with Western populations, the prevalence of GERD in this Chinese retiree cohort is low. A history of diabetes mellitus, hypertension, gastritis, peptic ulcer or hypertriglyceridaemia increases GERD risk in this population.

Arm span-height difference is correlated with gastroesophageal reflux symptoms in aged Japanese subjects

Previous studies have indicated an association between the symptoms of gastroesophageal reflux disease (GERD) and aging plus height. In this study we investigated whether the arm span–height difference was related to GERD symptoms with a focus on aged subjects in the general population, since the arm span reflects the height in young adulthood before decreasing due to vertebral deformities from aging. A total of 285 elderly individuals (105 females) who visited nursing homes for the elderly in Japan were enrolled in this study. The GERD symptoms were evaluated by the Frequency Scale for the Symptoms of GERD (FSSG). The body weight, height and arm span were measured, and information regarding medications and complications were reviewed in each nursing record. 50.5% of women had more than 3 cm of arm span–height difference. In contrast, only 37.3% of men had more than 3 cm of arm span–height difference. The FSSG scores indicated more than 70% of subjects complained of any GERD symptoms. There was a significant correlation between the FSSG score and the arm span–height difference in the subjects with more than 3 cm of arm span-height difference (r = 0.236; p = 0.012). The correlation between the arm span–height difference and the FSSG score was significant only in women in females in the present study. In conclusion, our findings indicate that vertebral deformity evaluated by the arm span–height difference might have some positive relationship to the pathogenesis of GERD symptoms in elderly Japanese individuals.

Clinical symptoms of FSSG in gastroesophageal reflux disease are critical for PPI treatment: Japanese multi-centers with 185 patients

AIM

The main aim of this study was to determine whether questionnaire evaluations of clinical symptoms in gastroesophageal reflux disease were useful to assess proton pump inhibitor therapy.

METHODS

A total of 185 Japanese patients (men, 88; women, 97; age: 55.7 ± 16.1 years) with gastroesophageal reflux disease were enrolled. The patients were divided based on the frequency scale for symptoms of gastroesophageal reflux disease: severe symptoms with scores ≥8 and mild symptoms with scores ≤7. Quality of life was evaluated with the Medical Outcomes Study 8-Item Short-Form Health Survey. All patients were treated with a proton pump inhibitor, rabeprazole (10 mg/day), for 8 weeks.

RESULTS

Patients were classified into four groups: reflux esophagitis with severe symptoms (n = 92, 49.7%); reflux esophagitis with mild symptoms (n = 17, 9.2%); non-erosive reflux disease with severe symptoms (n = 66, 35.7%); and non-erosive reflux disease with mild symptoms (n = 10, 5.4%). The dysmotility score was high in non-erosive reflux disease with severe symptoms compared with reflux esophagitis with severe symptoms (9.1 ± 0.5 vs 6.8 ± 0.5, P < 0.05). The symptom score and quality of life in the severe symptoms groups for both reflux esophagitis and non-erosive reflux disease were significantly improved by rabeprazole treatment. Only the reflux score was improved by rabeprazole in the reflux esophagitis with mild symptoms group; no therapeutic effect was observed for the non-erosive reflux disease with mild symptoms group.

CONCLUSIONS

Low scores on the frequency scale for the symptoms of gastroesophageal reflux disease indicate poor responsiveness to proton pump inhibitor treatment, and high scores indicate good responsiveness.

Differences in the risk factors of reflux esophagitis according to age in Korea

The prevalence of gastroesophageal reflux disease in Korea has been believed to be low, but the incidence of gastroesophageal reflux disease in Korea is expected to increase because of the longer life expectancy and more ingestion of westernized food. The aim of this study was to report differences in the risk factors of reflux esophagitis (RE) according to age in Korea. We prospectively recruited the subjects who had RE among those who visited a health promotion center for upper gastrointestinal cancer surveillance at Hallym Medical Center (five institutions) between January 2008 and February 2009. The enrolled study participants comprised 742 subjects with RE and 1484 healthy controls. The independent risk factors of RE in young and adult group were male sex, smoking, coffee, body mass index ≥ 25, hiatal hernia, and Helicobacter pylori negativity. The risk factors of RE in elderly group were smoking, coffee, and hiatal hernia. The risk factors for RE according to age group were found to differ. In elderly group, Helicobacter pylori infection was not a significant protective factor contrary to young and adult groups.

Clinical feature of asymptomatic reflux esophagitis in patients who underwent upper gastrointestinal endoscopy

BACKGROUND AND AIM

Prevalence of gastroesophageal reflux disease (GERD) varies in regions, but few reports on clinical features and quality of life (QOL) of asymptomatic GERD exist in Japan.

METHODS

Endoscopy was performed in our department between April 2008 and September 2010. Among 6409 cases answering Frequency of Scale for the Symptoms of GERD (FSSG) and SF8 QOL (PCS: physical component summary; MCS: mental component summary), proton pump inhibitor or histamine 2 receptor antagonist users were excluded, and 388 cases diagnosed as reflux esophagitis (RE) (Los Angeles Classification grade A, B, C, D) were analyzed. Asymptomatic cases with FSSG total score = 0 were defined as asymptomatic RE (AsymRE) and FSSG total score ≥ 1 as symptomatic RE (SymRE). Each clinical feature was analyzed.

RESULTS

The frequency of AsymRE was 11.6% of RE (AsymRE, n = 45; SymRE, n = 343). Patient characteristics in AsymRE, SymRE were male/female = 35/10; 239/104 (not significant), mean age (year) = 63.5 ± 14.3; 58.3 ± 12.7 (P < 0.01), body mass index = 23.9 ± 4.3; 23.5 ± 3.7 (ns), respectively. Regarding the grade of RE, grade A 80.0%, B 17.8%, C 2.2% and D 0% in AsymRE, and grade A 72.6%, B 24.8%, C 2.0% and D 0.6% in SymRE (ns). PCS in SF8 was AsymRE; SymRE = 51.8 ± 9.8; 49.0 ± 7.7 (P < 0.01) and MCS in SF8 was AsymRE; SymRE = 51.4 ± 9.4; 48.2 ± 7.6 (P < 0.01), respectively.

CONCLUSION

The prevalence of asymptomatic RE was high, particularly in elderly subjects. Unlike symptomatic RE, QOL was not impaired at all with asymptomatic RE. No differences were seen between groups in clinical features such as endoscopic severity of RE, indicating that asymptomatic RE is a condition that should not be overlooked clinically.

Systematic review of the epidemiology of gastroesophageal reflux disease in Japan

BACKGROUND

Epidemiological studies of gastroesophageal reflux disease (GERD) in Japan vary in design. This systematic review examines the prevalence of GERD in Japan, distinguishing between study methodologies, and reports on changes over time and factors potentially associated with GERD.

METHODS

PubMed and Embase searches identified studies reporting the prevalence of GERD in the general population, primary care patients, and individuals undergoing routine health checks.

RESULTS

Of the twenty eligible studies, half excluded individuals taking acid-suppressive medication, so these studies would have been likely to have underestimated the prevalence by 2-3%. Nine studies reported the prevalence of at least weekly reflux symptoms (the definition closest to the Montreal definition): in seven studies this was 6.5-9.5%, but in two studies that included individuals who underwent upper gastrointestinal endoscopy the prevalence was 19.0 and 21.8%. Eight studies used symptom scores: prevalence estimates ranged from 10.2 to 29.0% in five studies using the Carlsson-Dent self-administered questionnaire (QUEST), and from 27.0 to 37.6% in three studies using the frequency scale for the symptoms of GERD. Prevalence estimates were 15.1-24.3% in three studies that reported the presence of reflux symptoms of undefined frequency. Six studies reported the prevalence of reflux esophagitis as 4.9-8.2%. Changes in prevalence over time and factors associated with reflux symptoms were inconsistent.

CONCLUSIONS

Few studies have reported the prevalence of GERD in Japan using standardized criteria. Thus, prevalence estimates vary substantially, reflecting differences in study populations and GERD definitions. However, seven studies reported that the prevalence of at least weekly symptoms was 6.5-9.5%, a finding which approaches that reported in Western populations (10-20%).

Dissociation and dispersion of claudin-3 from the tight junction could be one of the most sensitive indicators of reflux esophagitis in a rat model of the disease

BACKGROUND

The aim of this study was to characterize pathological lesions of the esophageal epithelial tight junction (TJ) complex in a rat reflux esophagitis (RE) model in a search for a reliable diagnostic indicator.

METHODS

Rats underwent an operation to induce RE, with or without rabeprazole treatment (1.0 and 10.0 mg/kg/day). Sham-operated rats served as a control. Fourteen days after the operation, esophagi were isolated from the rats and submitted to double-label confocal immunofluorescence microscopy, and biochemical analyses.

RESULTS

Immunofluorescence microscopy revealed that claudins-1, -3, and -4 were located on the surfaces of epithelial cells in the normal esophagus of the control group, although there were differences in the distribution patterns between claudin-3 and claudins-1 and -4 in the epithelial layer. However, in RE, the immunoreactivity of claudin-3 on the cell surface was decreased, and it appeared instead as a faint granular pattern within the epithelial cytoplasm. Claudin-3 expression in the entire esophageal epithelium was also decreased. The expression and location of claudins-1 and -4 in epithelial cells were basically unaffected in RE. Gastric acid-induced dissociation of claudin-3 elicited instability of the epithelial TJ complex, which was confirmed by sedimentation analysis using centrifugation in a sucrose density gradient. Rabeprazole (10.0 mg/kg/day) attenuated these alterations.

CONCLUSIONS

Our data indicate that the dispersion of claudin-3 from esophageal epithelial plasma membranes to cytoplasm and the resulting instability of the TJ complex could be one of the most specific and sensitive indicators for monitoring inflammatory and recovery processes in RE.

Diagnosis and treatment of dyspeptic patients in Japan

BACKGROUND AND AIM

Although functional gastrointestinal (GI) disorders has been paid more attention recently in Japan, similar to Western countries, the clinical characteristics of dyspeptic patients, current diagnostic approach to dyspeptic patients and current standard treatments for dyspeptic patients are not well known in Japan. This review, in the most part, summarizes two topics about Japanese dyspeptic patients. The first topic is the pros and cons of the diagnosis of Japanese dyspeptic patients using Rome III classification on the basis of our data and the second topic deals with standard treatments for dyspeptic patients-especially by primary care doctors in Japan.

METHODS

We conducted a PubMed search using the following key words alone or in combination: functional dyspepsia (FD), medical treatment, Rome III classification and Japanese.

RESULTS

The Rome III classification for FD does not adequately identify a large proportion of Japanese dyspeptic patients, primarily due to their earlier presentation for medical evaluation. There are many kinds of options for the treatment of FD in Japan: proton-pump inhibitors, histamine H(2) receptor antagonists, mucoprotective agents, Japanese traditional herbal medicines, Helicobacter pylori eradication therapy and prokinetics. Under the current situation, Japanese primary care doctors choose drugs according to each subtype of FD, which means that they prescribe medicine according to the pathogenesis of each patient.

CONCLUSIONS

While the Rome III classification seems logical, some aspects need further evaluation for Japanese dyspeptic patients. Japanese primary care doctors choose drugs appropriately based on the pathogenesis of FD. However, efforts to further elucidate underlying pathophysiologic mechanisms and identify the appropriate patient population using modified Rome classification will be required.

Relationship between kyphosis and Barrett's esophagus in Japanese patients

BACKGROUND

Kyphosis is a risk factor for the presence of hiatal hernia, which is a strong predictor of Barrett's esophagus. However, the association between kyphosis and Barrett's esophagus has not yet been clarified. To investigate this relationship, the Cobb angle, a marker of kyphosis, was measured in patients with and without Barrett's esophagus.

METHODS

From January 2006 to December 2010, 26 patients with long-segment Barrett's esophagus (LSBE) were retrospectively enrolled. As the comparative groups, 100 consecutive patients with short-segment Barrett's esophagus (SSBE) and 100 consecutive control patients without Barrett's esophagus were also enrolled in this study. Cobb angles were measured on lateral chest radiographs, and kyphosis was defined as a Cobb angle of greater than 50°. Kyphosis, along with other patient characteristics, were evaluated as possible predictors for SSBE and LSBE.

RESULTS

The mean Cobb angles in the non-BE, SSBE, and LSBE groups were 31.6° (95% CIs, 29.3°-33.9°), 34.8° (32.1°-37.4°) and 49.4° (44.9°-53.9°), respectively. Statistically significant differences were found between the LSBE and the other 2 groups (p<0.001). The mean Cobb angles were 33.3°±12.4° and 37.0°±14.1°, respectively in patients without and with hiatal hernia (p=0.039). Predictors for Barrett's esophagus of any length were erosive esophagitis and hiatal hernia. Kyphosis had the highest odds ratio for the presence of LSBE (OR, 1.50; 95% CI, 1.05-1.94; p=0.033). Other predictors were hiatal hernia and the absence of Helicobacter pylori infection.

CONCLUSION

Kyphosis is a risk factor for the presence of LSBE in Japanese patients.

Lifestyle change influences on GERD in Japan: a study of participants in a health examination program

BACKGROUND

Though gastroesophageal reflux disease (GERD) has been a prevalent disease in Western countries, the incidence of GERD has only just started to increase in Japan.

AIM

The aim of this study was to determine which lifestyle factors may be associated with GERD in Japan.

METHODS

A total of 2,853 participants who took part in a health examination program between July 2004 and March 2005 were enrolled. GERD symptoms were assessed using the Japanese version of the Carlsson-Dent self-administered questionnaire (QUEST). The GERD group consisted of participants with a QUEST score ≥6 and/or endoscopic findings. The GERD group was divided into asymptomatic ERD (erosive reflux disease with no symptoms), symptomatic ERD (erosive reflux disease with symptoms) and NERD (non-erosive reflux disease) groups. Associated factors for these diseases were analyzed by logistic regression analysis.

RESULTS

GERD was diagnosed in 667 (23.4%) participants. Among the subjects placed in the GERD group, asymptomatic ERD, symptomatic ERD and NERD were diagnosed in 232 (8.1%), 91 (3.2%) and 344 (12.1%) participants, respectively. Factors associated with GERD included a high BMI (body mass index), hiatus hernia, fewer hours of sleep, lack of exercise, and drinking green tea.

CONCLUSIONS

Relationships between lifestyle, gender and GERD were investigated in the present study. Both lifestyle improvements and consideration of gender differences can be used to help prevent GERD development.

Changes of upper gastrointestinal symptoms and endoscopic findings in Japan over 25 years

BACKGROUND AND AIMS

In Japan, the prevalence of Helicobacter pylori infection has decreased recently, but there has been little longitudinal research on the changes of symptoms and endoscopic findings over many years. The aim of this study was to evaluate the changes in endoscopic findings and symptoms over time in patients undergoing upper gastrointestinal endoscopy for assessment of upper abdominal symptoms.

METHODS

Over a period of 25 years, between 1981 and 2005, we performed three investigations (1981-2, 1990-1 and 2004-5) on the symptoms and endoscopic findings of patients undergoing endoscopy at Kawasaki Medical School Hospital for the assessment of upper abdominal symptoms.

RESULTS

The most common complaint for all ages was "discomfort and/or pain". Over time, the percentage of patients complaining of "heartburn" increased almost 5-fold. With respect to endoscopic findings, the prevalence of peptic ulcers decreased, whereas the detection of no abnormalities and the detection of erosive esophagitis increased.

CONCLUSION

In the future in Japan, there will be fewer patients with peptic ulcers and more patients with gastro-esophageal reflux disease or dyspeptic patients who display no endoscopic abnormal findings.

Reversal of the tolerance phenomenon by the intermittent administration of a histamine H2-receptor antagonist

BACKGROUND AND AIM

The attenuated antisecretory activity of H2-receptor antagonists (H2RA) during continuous administration is referred to as the tolerance phenomenon. A previous study indicated that Helicobacter pylori (H. pylori) infection prevents the occurrence of tolerance to H2RA. In the present study, we investigated whether intermittent (every other day) administration prevents the tolerance phenomenon in H. pylori-negative patients.

METHODS

Ten H. pylori-negative, healthy volunteers were included in the study. All of the patients underwent two courses of H2RA (lafutidine) administration: 21-day continuous administration (every day), followed by 21-day intermittent administration (every other day), with at least a 21-day lafutidine-free period between the first and second courses. All of the patients were examined by ambulatory intragastric pH monitoring five times: before medication, and on days 1 and 21 of the first (continuous) and second (intermittent) courses of lafutidine (10 mg b.d.) in a crossover fashion.

RESULTS

The continuous administration of lafutidine had a significantly attenuated, acid-suppressing effect in H. pylori-negative patients, and showed evidence of the tolerance phenomenon. However, the tolerance phenomenon was not observed through intermittent administration.

CONCLUSIONS

These results demonstrated that in H. pylori-negative patients, tolerance to H2RA, induced by continuous lafutidine administration, was reversed by subsequent intermittent administration.

Reflux esophagitis and the risk of stroke in young adults: a 1-year population-based follow-up study

BACKGROUND AND PURPOSE

Reflux esophagitis (RE) is the most common manifestation of gastro-esophageal reflux disease with esophageal injury. To the best of our knowledge, there has been no specific study to evaluate the risk of stroke after diagnosis of RE in young adults. This study aims to evaluate the risk of stroke among RE patients aged 18 to 50 years during a 1-year period after diagnosis of RE compared to a cohort of non-RE patients during the same period.

METHODS

This study used the Taiwan Longitudinal Health Insurance Database 2005. A total of 2340 RE patients were included as the study cohort and 11 700 non-RE patients were included as the comparison cohort. Each patient was individually tracked for 1 year from the index ambulatory visit to identify those in whom stroke developed.

RESULTS

Out of the sample of 14 040 patients, 78 patients (0.56%) had strokes develop during the 1-year follow-up period: 22 from the study cohort (0.94% of the RE patients) and 56 from the comparison cohort (0.48% of patients without RE). Patients with RE were 1.68-times more likely to have strokes develop (95% confidence interval, 1.03-2.76) than patients in the comparison cohort during the follow-up period after adjusting for patients' medical comorbidities, such as hypertension, diabetes, coronary heart disease, renal disease, heart failure, and hyperlipidemia, as well as their demographic differences, such as the level of urbanization of their communities, monthly income, and geographical location.

CONCLUSIONS

We conclude that RE is associated with an increased risk of subsequent stroke in young adults.

Abdominal ultrasonography as a new modality for the diagnosis of gastroesophageal reflux disease

BACKGROUND AND AIMS

Thickening and abnormal architecture of the esophageal wall in gastroesophageal reflux disease (GERD) have been reported using endoscopic ultrasonography (US), but whether extracorporeal abdominal US is a useful diagnostic modality has not been investigated.

METHODS

Subjects were 37 GERD, 24 non-erosive reflux disease (NERD) patients and 32 controls who visited our hospital from 2006-2009 and underwent upper gastrointestinal endoscopy and extracorporeal abdominal US. The US operator was unaware of any clinical information and examined the following: (i) thickness (>or=5 mm) and (ii) architecture of the esophageal wall; and (iii) presence of reflux. GERD was diagnosed when two or more of these items were positive.

RESULTS

Thickening of the lower esophageal wall in erosive GERD, NERD and controls was 5.7 +/- 0.6, 4.4 +/- 0.8 and 4.7 +/- 0.9 mm, respectively. The thickness in erosive GERD was significantly greater (P < 0.05) than that in NERD patients and controls. Sensitivity, specificity and accuracy of abdominal US diagnosis for erosive GERD and NERD (vs control) was 84.6% (11/13), 25% (6/24), 91.1% (31/34) and 91.1% (31/34), 89.4% (42/47) and 63.8% (37/58), respectively.

CONCLUSION

Extracorporeal abdominal US could be a new useful modality for diagnosing GERD.

Brief Questioning by Nursing Staffs before Endoscopic Examination May Not Always Pick Up Clinical Symptoms of Endoscopic Reflux Esophagitis

The clinical features of patients reflux esophagitis without any symptoms have not been clearly demonstrated. This study evaluated the clinical features of patients with endoscopy-positive reflux esophagitis, who did not complain of symptoms, as detected by brief questioning by nursing staffs. Eight thousand and thirty-one patients not taking medication for gastrointestinal disease, were briefly asked about the presence of heartburn, dysphagia, odynophagia and acid regurgitation by nursing staffs before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification. Endoscopically, 1199 (14.9%) patients were classified as positive for reflux esophagitis. The endoscope positive subjects who complain heartburn were 539/1199 (45.0%).The endoscope positive subjects who do not complain symptoms were 465 in 1199 positive reflux esophagitis (38.8%). We compared endoscopic positive subjects without any complain by brief question by nursing staffs to endoscopic positive subjects with heartburn. Male gender, no obesity, absence of hiatus hernia, and low-grade esophagitis were associated with endoscopy-positive patients who do not complain of symptoms. The results of this study indicated correct detection of clinical symptoms of reflux esophagitis might be not easy with brief questioning by nursing staffs before endoscopic examination.

Recent advances in endoscopic antireflux techniques

Heartburn is the most common symptom associated with gastroesophageal reflux disease, and life-long proton pump inhibitor therapy is often required to control symptoms. Antireflux surgery is an alternative, but there may be significant side effects and the duration of therapeutic effect is variable. Several endoscopic antireflux techniques (E-ARTs) have been developed to enhance the function of the lower esophageal sphincter or alter the structure of the angle of His with the goal of recreating or augmenting the reflux barrier. Many methods are no longer available, and some await regulatory approval. This article reviews available data for the most common E-ARTs.

Short-term and long-term outcome of endoluminal gastroplication for the treatment of GERD: the first multicenter trial in Japan

PURPOSE

Endoluminal gastroplication (ELGP) was the first endoscopic therapy for gastroesophageal reflux disease (GERD). Data on the long-term outcomes, including the plication status and data from Asian populations, are limited. The aim of this study was to evaluate the short-term and long-term effectiveness and safety of ELGP for GERD in the Japanese population.

METHODS

This was an open-label, prospective, multicenter trial of ELGP. Forty-eight patients with GERD were enrolled. The procedure involved placing circumferential plications 1-2 cm below the GE junction using the EndoCinch system. Outcome measurements were improvement of heartburn, medication use, endoscopic Los Angeles grade, durability of plications, 24-h esophageal acid exposure, esophageal manometry, and frequency of adverse events.

RESULTS

During the 24-month follow-up, the rate of complete resolution of heartburn ranged from 54 to 66%, the rate of discontinuation or reduction of PPI/H2RA use ranged from 65 to 76%, and the rate of endoscopic classification to grade O ranged from 66 to 81%. The status with more than one plication remaining was associated with higher rates of improvement of heartburn, PPI/H2RA use, and endoscopic findings as compared with those associated with the loss of all plications. A modest decrease of the esophageal acid exposure level, but no change of the manometric parameters, was observed after ELGP. No serious adverse events were observed.

CONCLUSIONS

In this 24-month follow-up study conducted in Japanese subjects, ELGP was found to be effective in about 60% of patients with GERD, and the procedure was safe.

Epidemiology and clinical characteristics of GERD in the Japanese population

We reviewed articles on the epidemiology and clinical characteristics of gastroesophageal reflux disease (GERD) in Japan to clarify these features of GERD in this country. Although the definition of GERD depends on the individual study, the prevalence of GERD has been increasing since the end of the 1990s. The reasons for the increase in the prevalence of GERD may be due to increases in gastric acid secretion, a decrease in the Helicobacter pylori infection rate, more attention being paid to GERD, and advances in the concept of GERD. More than half of GERD patients had non-erosive reflux disease, and the majority (87%) of erosive esophagitis was mild type, such as Los Angeles classification grade A and grade B. There were several identified risk factors, such as older age, obesity, and hiatal hernia. In particular, mild gastric atrophy and absence of H. pylori infection influence the characteristics of GERD in the Japanese population. We also discuss GERD in the elderly; asymptomatic GERD; the natural history of GERD; and associations between GERD and peptic ulcer disease and H. pylori eradication. We examined the prevalence of GERD in patients with specific diseases, and found a higher prevalence of GERD, compared with that in the general population, in patients with diabetes mellitus, those with obstructive sleep apnea syndrome, and those with bronchial asthma. We provide a comprehensive review of GERD in the Japanese population and raise several clinical issues.

Association of Heartburn and Laryngopharyngeal Symptoms with Endoscopic Reflux Esophagitis, Smoking, and Drinking

OBJECTIVES: This study was conducted to investigate the association of laryngopharyngeal symptoms and heartburn with endoscopic esophagitis, smoking, and drinking. The clinical importance of the Reflux Symptom Index (RSI) in predicting endoscopic esophagitis was also evaluated.

STUDY DESIGN: Case series with planned data collection.

SUBJECTS AND METHODS: From November 2006 to February 2007, 156 adults received a whole-body physical check-up. They filled out the RSI questionnaire and were dichotomized into either a “no problem group” or a “possible patients group” according to their scores on the RSI. All subjects received an esophagoscopy. The relationship between RSI score and endoscopic esophagitis, smoking, and drinking was analyzed.

RESULTS: Voice change, but not heartburn, was significantly associated with endoscopic reflux esophagitis. Based on the RSI scores, some items in addition to voice change were significantly associated with smoking or drinking but not with endoscopic esophagitis.

CONCLUSIONS: While screening patients for reflux esophagitis by using the RSI questionnaire, there is little value in using heartburn to predict endoscopic esophagitis in Taiwanese people. On the other hand, a husky voice might be a good clinical indicator of patients at risk of having reflux esophagitis.

Characteristic pathological findings and effects of ecabet sodium in rat reflux esophagitis

AIM: To explore the pathological findings in the entire esophagus in rats with reflux esophagitis, and the effects of ecabet sodium (ES).

METHODS: A rat model of chronic acid reflux esophagitis was used. In the treatment group, ES was administered after surgery (n = 16). No drug was administered postoperatively to the esophagitis group (n = 9). Sham-operated rats were used as a control group (n = 5). Rats were sacrificed on day 7 after the operation. The epithelial thickness and leukocyte infiltration were examined in the upper, middle and lower areas of the esophagus. The survival rate, incidence of esophageal ulcer, and mean surface area and number of esophageal ulcers were determined in the esophagitis and ES groups. Esophageal histology was assessed in all three groups.

RESULTS: Leukocyte infiltration in the esophagitis group was 26.3 ± 22.0 in the middle esophagus and 8.2 ± 4.9 in the upper esophagus, which was significantly greater than that in the controls (1.3 ± 1.1 and 1.4 ± 1.0, respectively) (P < 0.05). The thickness of the epithelium in the esophagitis group was 210.8 ± 47.7 &mgr;m in the lower esophagus and 204.2 ± 60.1 &mgr;m in the middle esophagus, which was significantly greater than that in the controls (26.0 ± 5.5 and 21.0 ± 6.5 &mgr;m, respectively) (P < 0.05). The mean number of ulcers per animal in the ES group in the entire esophagus was 5.4 ± 2.5, which was significantly less than that in the esophagitis group (9.0 ± 3.5) (P < 0.05). The epithelial thickness in the ES group was 97.5 ± 32.2 &mgr;m in the lower esophagus, which was decreased compared with that in the esophagitis group (210.8 ± 47.7 &mgr;m) (P < 0.05).

CONCLUSION: Mucosal inflammation extended to the upper esophagus close to the hypopharynx. Our study suggested that ES may have a useful defensive role in reflux esophagitis.

Changing prevalence of upper gastrointestinal disease in 28 893 Koreans from 1995 to 2005

OBJECTIVES

Changes in the pattern of gastrointestinal diseases in a population tend to be influenced by changes in diet and lifestyle. Shifts in gastrointestinal disease from 1995 to 2005 in Korea were evaluated, retrospectively.

METHODS

Seventeen nationwide medical centers participated in this study. The cross-sectional review of endoscopic findings in 28 893 patients included 8441 patients from 1995, 10 350 patients from 2000, and 10 102 patients from 2005.

RESULTS

The prevalence of reflux esophagitis increased from 1.8% in 1995 to 5.9% in 2000 and 9.1% in 2005 (P<0.001, the P value was only for the comparison between 1995 and 2005, the followings were as same). The prevalence of peptic ulcer diseases was 18.0% in 1995, 19.1% in 2000, and 20.2% in 2005 (P<0.001). Although no significant differences were noted in duodenal ulcers (8.4, 8.7, and 8.2%, P=0.449), gastric ulcers showed an increasing trend (9.6, 10.5, and 12.0%, P<0.001). The prevalence of gastric cancer increased from 3.4% in 1995 to 4.5% in 2000 (P<0.001), but then decreased to 2.4% in 2005 (P<0.001). The incidence of advanced gastric cancer was 2.5, 3.2, and 1.3%, respectively (P<0.001), and that of early gastric cancer remained constant with rates of 0.8%, 1.3, and 1.1%, respectively (P=0.056).

CONCLUSION

The cross-sectional review of data collected in 1995, 2000, and 2005 showed an increase in reflux esophagitis and peptic ulcer diseases. Meanwhile, the prevalence of gastric cancer increased until 2000, but decreased in 2005.

Impact of spinal kyphosis on gastroesophageal reflux disease symptoms in patients with osteoporosis

SUMMARY

Spinal kyphosis has been speculated to participate in the increased frequency of gastroesophageal reflux disease (GERD) in patients with osteoporosis. The present study provides further evidence that increases in lumbar kyphosis and number of vertebral fractures represent very important risk factors for GERD in patients with osteoporosis.

INTRODUCTION

Osteoporosis and spinal kyphosis have been speculated to participate in the increased frequency of gastroesophageal reflux disease (GERD). The present study examined whether GERD in patients with osteoporosis is affected by spinal factors including spinal kyphosis in the presence of oral pharmacotherapies.

METHODS

Subjects comprised 112 patients with osteoporosis (mean age, 78 years) who responded to the Frequency Scale for Symptoms of GERD (FSSG) questionnaire, regardless of complaints. Relationships between total FSSG score and number of vertebral fractures, angles of kyphosis, use of bisphosphonates and nonsteroidal anti-inflammatory drugs (NSAIDs), and total number of oral medicines per day were evaluated. Logistic regression identified factors associated with GERD.

RESULTS

Bisphosphonates and NSAIDs did not affect total FSSG score. Total FSSG score showed significant positive correlations with total number of medicines (r = 0.283, p = 0.0025), angle of lumbar kyphosis (r = 0.576, p = 0.0001), and numbers of thoracic vertebral fractures (r = 0.214, p = 0.0232) and lumbar vertebral fractures (r = 0.471, p < 0.0001). Angle of lumbar kyphosis and number of lumbar vertebral fractures were identified by multivariate analysis as indices affecting the presence of GERD.

CONCLUSION

Increases in angle of lumbar kyphosis and number of lumbar vertebral fractures may represent very important risk factors for GERD in osteoporotic patients.

Comparison of endoscopic findings with symptom assessment systems (FSSG and QUEST) for gastroesophageal reflux disease in Japanese centres

BACKGROUND AND AIM

We compared endoscopic findings of the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), a written questionnaire developed in Japan, to that for the questionnaire for the diagnosis of reflux esophagitis (QUEST) for the diagnosis of reflux esophagitis.

METHODS

We registered 475 patients with untreated symptoms of upper abdominal pain (male/female: 252/223, average age 52.4 +/- 17.8 years). Subjects were assessed first with the FSSG and QUEST questionnaires, then by endoscopy, before allocation to a gastric ulcer (GU), duodenal ulcer (DU), gastroesophageal reflux disease (GERD) or functional dyspepsia (FD) group.

RESULTS

On the basis of the endoscopic findings the diagnoses for the 475 subjects were as follows: FD 52.2%, DU 7.6%, GU 7.8%, and GERD 32.4% (Grade M 10.1%, Grade A + B 20.2%, Grade C + D 2.3%). There was no difference between the FSSG and QUEST in sensitivity, specificity or accuracy for any condition. The FSSG score rose with increasing endoscopic severity of GERD, but there was no correlation between the QUEST score and endoscopic severity. The FSSG total score was inferior to QUEST in terms of distinguishing GERD from other conditions, but when only the questions relating to reflux symptoms were used, the FSSG was able to distinguish GERD from other conditions as well as QUEST.

CONCLUSIONS

The FSSG score reflects the severity of the endoscopic findings of GERD.

Gastroesophageal reflux disease (GERD): risk factors, and impact on quality of life-a population-based study

BACKGROUND

We aimed to determine the prevalence of gastroesophageal reflux disease (GERD) and associated risk factors, and assess quality of life (QoL) in relation to the frequency and severity of reflux symptoms.

METHODS

A random sample of 1000 residents of Western Sydney were mailed a validated self-report questionnaire. GERD symptoms, risk factors, psychologic distress, QoL, and demographics were measured.

RESULTS

The response rate was 73% (n=672; mean age, 46 y; 52% female). A total of 78 [12%, 95% confidence interval (CI): 9-14] had GERD (at least weekly heartburn and/or acid regurgitation). Independent risk factors for GERD were high cholesterol [odds ratio (OR) =3.28, 95% CI: 1.42-7.57, P=0.005] and current smoker (OR=2.47, 95% CI: 1.07-5.70, P=0.03). Anxiety, depression, and neuroticism were not risk factors. Worse physical functioning was the only QoL domain associated with GERD (OR=0.98, 95% CI: 0.97-0.99, P=0.006). QoL was significantly impaired regardless of the severity of GERD for the QoL domains physical function, body pain, vitality, and social function. The frequency of heartburn and acid regurgitation were not associated with significantly reduced QoL domain scores.

CONCLUSIONS

Cardiac risk factors (high cholesterol and smoking) were independently associated with GERD. Increasing GERD symptom severity is associated with worse QoL scores, whereas GERD symptom frequency did not impact the QoL scores.

Bleeding and stenosis caused by reflux esophagitis was not common in emergency endoscopic examinations: a retrospective patient chart review at a single institution in Japan

BACKGROUND

Bleeding and stenosis are serious complications of reflux esophagitis, although few studies have been performed in Japan regarding these complications. This study aimed to indicate the characteristics of reflux esophagitis observed during emergency endoscopic examination in Japan.

METHODS

All subjects who had emergency endoscopic examination performed between 1990 and 2004 at Saga Medical School Hospital were evaluated. Patients with endoscopic reflux esophagitis were evaluated with a retrospective patient chart review.

RESULTS

A total of 1621 subjects underwent emergency endoscopy; 1420 of the endoscopies were because of hematemesis or melena. Endoscopic examination revealed that 19 cases with bleeding were caused by reflux esophagitis (19/1621, 1.2%). The 19 patients with bleeding and the four patients with stenosis (0.2%) had emergency endoscopy performed for complications of reflux esophagitis. The Los Angeles classification of these 23 cases showed that most were severe esophagitis (grade A, 0; B, 2; C, 8; and D, 13). The frequency of comorbidity with diabetes mellitus and collagen disease and the proportion of heavy drinkers were higher in patients who received emergency endoscopy because of reflux esophagitis than in those diagnosed with reflux esophagitis but who received emergency endoscopy because of other diseases.

CONCLUSIONS

Relatively small numbers of patients with reflux esophagitis undergo emergency endoscopy in Japan, and most such patients have underlying diseases, including diabetes mellitus and collagen disease. This finding is supported by a previous report that severe esophagitis is not common in Japan.

Epidemiological study of gastro-oesophageal reflux disease: reflux in spouse as a risk factor

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is a growing health-care problem with variable distribution.

AIM

To assess GERD prevalence and risk factors and their possible correlation with pathophysiology in a population-based study.

METHODS

Individuals aged 18-65 years were enrolled through random cluster sampling in Tehran. Previously validated self-administered questionnaires were used.

RESULTS

Of the 2500 questionnaires, 2057 were analysed (mean age: 34.8 +/- 13.0 years, 55.1% female). Frequent GERD was seen in 18.2%. Minor symptoms increased prevalence. Female gender (OR: 1.55, 95% CI: 1.01-2.41), BMI >30 kg/m(2) (OR: 1.79, 95% CI: 1.03-3.12), less education (OR: 1.52, 95% CI: 1.02-2.27), smoking (OR: 1.83, 95% CI: 1.12-2.99), NSAID use (OR: 4.23, 95% CI: 1.66-10.74) and GERD in spouse (OR: 1.82, 95% CI: 1.18-2.82) were associated with frequent GERD on multivariable analysis. GERD in first-degree relatives (OR: 1.73, 95% CI: 1.23-2.43) and asthma (OR: 4.09, 95% CI: 1.27-13.15) correlated with infrequent GERD. Minor symptoms correlated with GERD history in first-degree relatives, coffee consumption and NSAID use. Prevalence in the past 3 months was similar to that in the past 12 months (P < 0.05).

CONCLUSIONS

Gastro-oesophageal reflux disease is common in Tehran. The association of 'infrequent symptoms' with GERD history in first-degree relatives and 'frequent symptoms' with GERD history in spouse may point to the presence of yet unknown precipitating environmental factors inducing GERD in a genetically susceptible host. Minor GERD symptoms seem to have independent contribution to GERD. Assessing GERD in the past 3 months predicts prevalence in the past year.