Review article: diagnosis and clinical investigation of gastro-oesophageal reflux disease: a European view

Analysis of attitudes and practices toward gastroesophageal reflux disease among the general population of Pakistan

Aim: Gastro-esophageal reflux disease (GERD) is a growing health concern. Methods: In this cross-sectional study, participants' knowledge, attitude and practice toward GERD were assessed using a questionnaire. Results: In our study of 411 participants, 92.5% knew about GERD. Correctly identified risk factors were smoking (62.3%), fatty food (84.2%), spicy food (91.2%) and meal timing (80.8%). Identified symptoms were burning sensation (92.2%) and regurgitation (81.0%). 43.6% of participants were unaware of GERD's complications. Only 46.2% would seek medical advice for feeling full after eating, but 85% would for severe symptoms. 88.7 and 86.8% of participants showed willingness to amend diet and lifestyle. Conclusion: General population has knowledge regarding GERD and its risk factors but poor attitude and practices toward the condition.

Clinicopathological characteristics and prognosis of adolescents and young adults with gastric cancer after gastrectomy: a propensity score matching analysis

Background

Gastric cancer (GC) among adolescents and young adults (AYAs, aged 15-39 years) has limited data on clinicopathological characteristics and prognosis. This study aimed to compare the clinicopathological characteristics, perioperative outcomes, and long-term outcomes of AYAs and older adults (OAs, aged > 39 years) with GC who underwent curative gastrectomy.

Methods

From January 1994 to June 2019, patients with GC undergoing curative gastrectomy were enrolled and divided into AYA group and OA group. The clinicopathological characteristics, treatment variables, perioperative outcomes and long-term outcomes were compared between the two groups, both before and after propensity score matching (PSM).

Results

AYAs had fewer comorbid conditions and were more likely to be females, have normal carcinoembryonic antigen (CEA) levels, poorly differentiated tumors with perineural invasion, and receive adjuvant chemotherapy. AYA patients had lower incidence of postoperative complications and shorter length of postoperative hospital stay than OA patients. No significant differences in postoperative 30-day or 90-day mortality were observed between AYAs and OAs, both before and after PSM. In the entire cohort, AYAs had similar median overall survival (OS) to OAs. However, in the PSM cohort, AYAs had significantly shorter median OS. Young age (15-39 years) was an independent risk factor for OS in GC patients following gastrectomy.

Conclusion

The clinicopathological characteristics were significantly different between AYA and OA patients with GC. AYA patients with GC had worse long-term prognosis than OA patients, and young age was an independent risk factor for OS in GC patients following gastrectomy.

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.

Clinicopathological features and prognosis of gastric cancer in young patients

BACKGROUND

The clinicopathological features and prognosis of gastric cancer in young patients are both limited and controversial. Therefore, the aim of this study was to define the clinicopathological features and prognosis of gastric cancer in young patients after curative resection.

METHODS

From May 2008 to December 2014, 198 young patients (age ≤ 40 years) and 1096 middle-aged patients (55 ≤ age ≤ 64 years) were enrolled in this study. The clinicopathological features and prognosis of gastric cancer in these patients were analyzed.

RESULTS

Compared with middle-aged patients, the proportion of females, lower third tumors, tumor size less than 5 cm, poorly differentiated tumors and T1 tumors were significantly higher in young patients (all P < 0.05). The proportions of comorbidity, upper third tumors, well and moderately differentiated tumors, T4 tumors, and positive carcinoembryonic antigen (CEA), alpha fetoprotein (AFP) and carbohydrate antigen (CA) 19-9 were significantly lower in young patients (all P < 0.05). The distributions of N status and CA125 were comparable between young and middle-aged patients (all P > 0.05). The five-year overall survival rates were comparable between young patients and middle-aged patients (62.8 vs 54.7 %, P = 0.307). The tumor location, T status, N status and CA125 were independent predictors of prognosis in young patients. The overall survival of patients with tumors located in the upper or middle third was significantly lower than for those located in the lower third (60.8 vs 50.6 % vs 68.4 %, P = 0.016). The overall survival of CA125-positive patients was significantly lower than CA125-negative patients (49.0 vs 64.4 %, P = 0.001).

CONCLUSION

The clinicopathological features were significantly different between young and middle-aged patients. The prognosis of gastric cancer in young patients was equivalent to that of middle-aged patients. Tumor location, T status, N status and CA125 were independent risk factors for prognosis in young patients.

Influence of lumbar kyphosis and back muscle strength on the symptoms of gastroesophageal reflux disease in middle-aged and elderly people

Objective

The objectives of this study was to clarify the relationship between kyphosis and Gastroesophageal reflux disease (GERD) by evaluation of spinal alignment, obesity, osteoporosis, back muscle strength, intake of oral drugs, and smoking and alcohol history in screening of a community population to determine the factors related to GERD symptoms.

Summary of background data

GERD increases with age and is estimated to occur in about 30% of people. Risk factors for GERD include aging, male gender, obesity, oral medicines, smoking, and alcohol intake. It has also been suggested that kyphosis may influence the frequency of GERD, but the relationship between kyphosis and GERD is unclear.

Subjects and methods

We examined 245 subjects (100 males and 145 females; average age 66.7 years old) in a health checkup that included evaluation of sagittal balance and spinal mobility with SpinalMouse^®, GERD symptoms using the Frequency Scale for Symptoms of GERD (FSSG) questionnaire, body mass index, osteoporosis, back muscle strength, number of oral drugs taken per day, intake of nonsteroidal anti-inflammatory drugs (NSAIDs), intake of bisphosphonates, and smoking and alcohol intake.

Results

Multivariate logistic regression analysis including all the variables showed that lumbar lordosis angle, sagittal balance, number of oral drugs taken per day, and back muscle strength had significant effects on the presence of GERD (OR, 1.10, 1.11, 1.09 and 1.03; 95%CI, 1.03–1.17, 1.02–1.20, 1.01–1.18 and 1.01–1.04; p = 0.003, 0.015, 0.031 and 0.038, respectively). The other factors showed no association with GERD.

Conclusion

This study is the first to show that lumbar kyphosis, poor sagittal balance; increased number of oral drugs taken per day, and decreased back muscle strength are important risk factors for the development of GERD symptoms. Thus, orthopedic surgeons and physicians should pay attention to GERD in elderly patients with spinal deformity.

A substantial incidence of silent short segment endoscopically suspected esophageal metaplasia in an adult Japanese primary care practice

AIM: To determine the incidence and characteristics of endoscopically suspected esophageal metaplasia (ESEM) in a primary adult care institution.

METHODS: Eight hundred and thirty two consecutive individuals (mean age, 67.6 years) undergoing upper gastrointestinal endoscopy between January 2009 and December 2010 were included in this study. The diagnosis of ESEM was based on the criteria proposed by the Japan Esophageal Society, and was classified as long segment ESEM (3 cm or more) or short segment ESEM (< 3cm). Short segment ESEM was further divided into circumferential and partial types. Age, gender, hiatus hernia, esophagitis, gastroesophageal reflux disease (GERD)-suggested symptoms, and antacid medications were recorded as background factors. Esophagitis was graded according to the Los Angeles classification. Hiatus hernia was divided into absent and at least partially present.

RESULTS: Long and short segment ESEM were found in 0 and 184 (22.1%) patients, respectively (mean age of short segment ESEM patients, 68.3 years). Male gender and hiatus hernia were shown to be significant factors affecting short segment ESEM by both univariate (P = 0.03 and P = 9.9x10^-18) and multivariate [Odds ratio (OR) = 1.45; P = 0.04, and OR = 43.3; P = 1.5x10^-7)] analyses. Two thirds of patients with short segment ESEM did not have GERD-suggested symptoms. There was no correlation between short segment ESEM and GERD-suggested symptoms.

CONCLUSION: The incidence of short segment ESEM in our community practice seems higher than assumed in Asian countries. As GERD-suggested symptoms are a poor predictor of ESEM, endoscopists should bear in mind that silent short segment ESEM does exist and, in fact, was found in the majority of our patients.

Lansoprazole for long-term maintenance therapy of erosive esophagitis: double-blind comparison with ranitidine

In a study evaluating the efficacy and safety of lansoprazole to prevent the relapse of erosive esophagitis (EE), 206 of 241 patients (85%) healed after open-label treatment with lansoprazole 30 mg once daily for 8 weeks and received double-blind maintenance treatment with lansoprazole 15 mg once daily or ranitidine 150 mg twice daily for up to 1 year. At 1 year, 67% of lansoprazole-treated and 13% of ranitidine-treated patients remained healed (P<0.001). Lansoprazole-treated patients experienced significantly greater symptom relief (P<0.001), and, if asymptomatic at entry into the maintenance phase, remained asymptomatic for significantly longer than ranitidine-treated patients (P<0.001). Symptom status correlated with healing (P=0.001), supporting the symptom-directed management of EE. Both treatments were well tolerated and no unexpected events occurred. Daily therapy with lansoprazole to prevent the relapse of EE is effective, well tolerated, and superior to ranitidine in the maintenance of healing and symptom relief.

Chest pain without established ischaemic heart disease in primary care patients: associated comorbidities and mortality

BACKGROUND

Ischaemic heart disease (IHD) can be excluded in the majority of patients with unspecific chest pain. The remainder have what is generally referred to as non-cardiac chest pain, which has been associated with gastrointestinal, neuromusculoskeletal, pulmonary, and psychiatric causes.

AIM

To assess morbidity and mortality following a new diagnosis of non-specific chest pain in patients without established IHD.

DESIGN OF STUDY

Population-based cohort study with nested case-control analysis.

SETTING

UK primary care practices contributing to the General Practice Research Database.

METHOD

Patients aged 20-79 years with chest pain who had had no chest pain consultation before 2000 and no IHD diagnosis before 2000 or within 2 weeks after the index date were selected from the General Practice Research Database. The selected 3028 patients and matched controls were followed-up for 1 year.

RESULTS

The incidence of chest pain in patients without established IHD was 12.7 per 1000 person-years. In the year following the index date, patients who had chest pain but did not have established IHD were more likely than controls to receive a first IHD diagnosis (hazard ratio [HR] = 18.2, 95% confidence interval [CI] = 11.6 to 28.6) or to die (HR = 2.3, 95% CI = 1.3 to 4.1). Patients with chest pain commonly had a history of gastro-oesophageal reflux disease (GORD; odds ratio [OR] = 2.0, 95% CI = 1.5 to 2.7) or went on to be diagnosed with GORD (risk ratio 4.5, 95% CI = 3.1 to 6.4).

CONCLUSION

Patients with chest pain but without established IHD were found to have an increased risk of being diagnosed with IHD. Chest pain in patients without established IHD was also commonly associated with GORD.

Airway acidification and gastroesophageal reflux

Although challenging to study, researchers recently recognized the relevance of airway pH to the pathophysiology of several respiratory diseases, ranging from asthma and cystic fibrosis to pneumonia. The airway epithelium is extraordinarily sensitive to acid. Gastroesophageal reflux can and does cause respiratory symptoms, through both neurally mediated pathways and direct aspiration. Direct aspiration has a variety of immunologic, biochemical, and physiologic effects that aggravate asthma and other respiratory diseases, yet strategies to diagnose and treat gastroesophageal reflux-related respiratory symptoms remain imprecise.

How do people with gastro-oesophageal reflux disease perceive their disease? Results of a multinational survey

OBJECTIVE

To determine how patients with gastro-oesophageal reflux disease (GERD) perceive their condition.

METHODS

Subjects with a formal diagnosis of GERD (n = 929) and those who did not have a formal diagnosis but regularly suffered from symptoms suggestive of GERD (heartburn or acid regurgitation, n = 924) were identified as part of a multinational survey.

RESULTS

Symptoms had been present for a mean of 11 years in diagnosed individuals and 8 years in undiagnosed individuals. Over-the-counter (OTC) antacids were used by 78% of undiagnosed individuals. Most patients (68% of undiagnosed and 46% of diagnosed subjects) did not consider themselves to have a serious condition, while 70% of undiagnosed and 58% of diagnosed respondents believed that their condition would not have any long-term health consequences. A key perception driving the decision to seek medical care was the belief that a physician, and prescribed medication, could help. Conversely, the perception that OTC medications work effectively was the greatest barrier to visiting a physician. Diagnosed patients, who, on average, waited 2 years before seeking medical advice, indicated that prescription medication reduced the severity and frequency of their symptoms.

CONCLUSIONS

There is widespread perception that GERD is a non-serious disease without long-term health consequences, and some patients find that OTC medications are a sufficiently effective treatment option. Educational initiatives should perhaps be targeted at those in greatest medical need, overcoming the barriers that dissuade many of these patients from seeking appropriate medical care.

Airway acidification: interactions with nitrogen oxides and airway inflammation

Airway acidification is increasingly appreciated to occur in inflammatory obstructive airway diseases, resulting from acid reflux and aspiration and from direct acid formation in the airways. Acidity activates oxidants and nitrogen oxides to create a potent antimicrobial environment. Neurogenic inflammation is triggered by airway or esophageal acidification, innate immune cells are affected by acidity, and there are pathways by which the acquired immune system also can be activated by the chemistry of an acidic airway. Measuring airway acidity is now readily achievable with noninvasive breath assays, a procedure that has opened a window on the need to understand airway pH homeostasis in health and pH dysregulation in disease.

Treatment of patients with heartburn without endoscopic evaluation: on-demand treatment after effective continuous administration of lansoprazole 15 mg

BACKGROUND

Relapse is frequent after initial treatment for gastro-oesophageal reflux. An alternative strategy to intermittent or continuous therapy may be on-demand treatment.

AIM

To compare the efficacy and safety of on-demand lansoprazole 15 mg and placebo treatment in patients with gastro-oesophageal reflux.

METHODS

This was a multicentre, randomized, double-blind study in two parallel groups of patients. In the acute study phase, all included patients (n = 203) were treated with lansoprazole 15 mg (once per day) for 4 weeks. At week 4, asymptomatic patients entered the 6-month, on-demand, follow-up phase and were randomized to receive either lansoprazole 15 mg (once per day) or placebo.

RESULTS

A higher percentage of patients in the lansoprazole group completed the 6-month follow-up than in the placebo group [81% vs. 61% (P = 0.003)]. Only 16% of patients in the lansoprazole group discontinued the study for insufficient control of heartburn vs. 28% in the placebo group (P = 0.046). The mean daily intake in patients who completed the study was 1-5 capsules/day in the lansoprazole 15 mg group.

CONCLUSIONS

On-demand treatment with lansoprazole 15 mg in symptomatic patients after short-term, continuous treatment is a promising therapeutic alternative to intermittent and continuous treatment to maintain heartburn control in patients with gastro-oesophageal reflux.