Review article: quality-of-life issues in gastro-oesophageal reflux disease

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.

The Effect of Dexlansoprazole on Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis evaluated the efficacy of dexlansoprazole (a proton pump inhibitor-PPI) in resolving heartburn, reflux, and other symptoms and complications resulting from gastroesophageal reflux disease (GERD). The study followed PRISMA 2020 and was registered in PROSPERO (CRD42020206513). The search strategy used MeSH and free terms appropriately adapted for each database. Only randomized clinical trials (RCTs) were included. The Cochrane tool (RoB 2.0) was used to assess the risk of bias, and the certainty of evidence was rated using GRADE. Ten RCTs were included. Dexlansoprazole outperformed the placebo and other PPIs in the resolution of heartburn and reflux symptoms in patients with GERD, with benefits during and after treatment, especially in those with moderate and severe symptoms. The meta-analyses indicated that dexlansoprazole at doses of 30 and 60 mg had more 24 h heartburn-free days and nights compared to the placebo medications; no difference was reported between dexlansoprazole at doses of 30 and 60 mg in heartburn-free nights. A low bias risk and a moderate certainty of evidence were observed. This review confirms the therapeutic effect of dexlansoprazole (placebo-controlled) and its improvements in GERD symptoms compared to another PPI. However, the interpretation of the results should be carried out cautiously due to the small number of included studies and other reported limitations.

Factors influencing the quality of life of GERD patients in the Aseer Region, Saudi Arabia

Gastroesophageal reflux disease (GERD) is a common upper gastrointestinal disorder characterized by troublesome symptoms, including heartburn and acid regurgitation. GERD is associated with complications such as peptic stricture, Barrett's esophagus, and esophageal adenocarcinoma, and it negatively affects quality of life (QoL).

Aims

To assess the factors influencing the QoL of GERD patients in the Aseer region of Saudi Arabia.

Settings and Design

This descriptive cross-sectional study used self-administered questionnaires in a study population of patients aged ≥18 years from Aseer, Saudi Arabia, between January 15, 2023-February 15, 2023.

Materials and Methods

A previously validated GERD health-related QoL (GERD-HRQoL) questionnaire was used to assess the patients' sociodemographic data, GERD, and GERD-HRQoL.

Statistical Analysis Used

Descriptive analysis included describing the frequency distribution and percentage for study variables, including demographic data, GERD-related QoL symptoms, and QoL, which were graphed. Cross-tabulation presented the distribution of GERD-HRQoL scores by their personal data and other factors using the Pearson Chi-square and exact probability tests.

Results

Overall, 502 participants previously diagnosed with GERD completed the questionnaire. Participants' were aged 18-65 years (mean age of 31.5 ± 14.6 years), and 384 (76.5%) were male. The most frequent symptom affecting QoL was heartburn (85.9%), followed by postprandial heartburn (84.3%), heartburn while lying down (82.7%), bloating or gassy feelings (79.9%), and heartburn while standing up (77.3%).

Conclusions

Our study showed that patients with GERD had a poor QoL due to GERD-related symptoms, mainly heartburn. Younger age, male sex, and lower educational status were associated with lower GERD-HRQoL scores.

Exploring the Impact of Covid-19-Related Perceptions on Psychological Distress and Quality of Life in an International Gastrointestinal Cohort Over Time Guided by the Common Sense Model

The aim of this longitudinal study was to examine changes in COVID-19 and illness-related perceptions, gastrointestinal symptoms, coping, catastrophising, psychological distress, and QoL during the COVID-19 pandemic. A total of 831 adults with a gastrointestinal condition completed an online questionnaire at baseline (May-October 2020). Of those, 270 (32.5%) participants (85.2% female, mean age = 47.3 years) provided follow-up data (March-May 2021). Repeated-measures multiple analysis of variance and a cross-lagged panel model were used to test the study hypotheses. Gastrointestinal symptoms and COVID-19 perceptions at follow-up were strongly predicted by their baseline values, while illness perceptions were predicted by baseline gastrointestinal symptoms. Cross-lagged relationships indicated a reciprocal relationship between gastrointestinal symptoms and psychological distress. Moreover, gastrointestinal symptoms had substantial predictive utility, strongly predicting future gastrointestinal symptoms, and to a lesser extent, more negative illness perceptions, greater psychological distress, and greater use of adaptive coping strategies across time.

Randomised clinical trial: comparison of tegoprazan and placebo in non-erosive reflux disease

BACKGROUND

Tegoprazan is a novel, fast- and long-acting potassium-competitive acid blocker that suppresses gastric acid secretion, which could benefit patients with non-erosive reflux disease (NERD), a type of gastroesophageal reflux disease.

AIM

To evaluate the efficacy and safety profiles of tegoprazan compared with those of a placebo in Korean patients with NERD.

METHODS

In this phase 3, double-blind, placebo-controlled, multicentre study, 324 Korean patients with NERD were randomised into three treatment groups: tegoprazan 50 mg, tegoprazan 100 mg and placebo. These drugs were provided once daily for 4 weeks. The primary endpoint was the proportion of patients with complete resolution of major symptoms (both heartburn and regurgitation) for the last 7 days of the 4-week treatment period. Other outcomes related to efficacy, safety and tolerability were also evaluated.

RESULTS

Among all, 42.5% (45/106), 48.5% (48/99) and 24.2% (24/99) of patients showed complete resolution of major symptoms at week 4 after receiving tegoprazan 50 mg, tegoprazan 100 mg, and placebo, respectively. Both doses of tegoprazan showed superior efficacy than the placebo (P = 0.0058 and P = 0.0004, respectively). The complete resolution rates of heartburn and proportions of heartburn-free days (as other efficacy outcomes) were significantly higher in both tegoprazan groups than in the placebo group (P < 0.05 for all). No significant difference in the incidence of treatment-emergent adverse events were noted.

CONCLUSIONS

Tegoprazan 50 and 100 mg showed superior therapeutic efficacy compared with the placebo, as well as a favourable safety profile in patients with NERD. Registration number: ClinicalTrials.gov identifier NCT02556021.

How dyspepsia, gastroesophageal reflux symptoms, and overlapping symptoms affect quality of life, use of health care, and medication - a long-term population based cohort study

BACKGROUND AND AIM

The prevalence of gastroesophageal reflux symptoms (GERS) and dyspepsia is high. Overlapping of GERS and dyspepsia has been described to affect quality of life. However, studies are few. This long-term population-based study evaluates how GERS, dyspepsia, and overlapping symptoms, affect quality of life, and the use of health care and medication.

METHODS

This study presents data for the control group of the randomised population study, HEP-FYN. At baseline 10,000 individuals, aged 40-65 years, received questionnaires at baseline and after 1, 5 and 13 years. The questionnaire included questions regarding demographics, use of health care resources, gastrointestinal symptoms (the Gastrointestinal Symptom Rating Scale (GSRS)), and the Short-Form 36-Item Health Survey (SF-36) to assess quality of life.

RESULTS

Complete data was available for 4.403 individuals at 13-year follow-up. Of these 13.6% reported GERS only, 11.6% dyspepsia only, and 27.1% overlapping symptoms during follow-up. Individuals reporting overlapping symptoms had compared to individuals reporting GERS only or dyspepsia only more visits at general practitioner (last year:16.7% vs. 8.5% vs. 12.3%), more sick leave days (last month: 4.3% vs. 2.9% vs 0.7%), used more ulcer drugs (last month: 30.5% vs 16.4% vs 9.4%). In addition, individuals with overlapping symptoms reported a lower quality of life in all eight dimensions of SF-36 compared to individuals with GERS alone or dyspepsia alone.

CONCLUSIONS

Overlapping symptoms was associated with lower quality of life scores and substantial use of health-care resources. Having solely GERS affected quality of life and health care use least.

Gastroesophageal Reflux Disease - Health-Related Quality of Life Questionnaire: prospective development and validation in Italian

OBJECTIVE

To date, two questionnaires investigating the symptoms of gastroesophageal reflux disease (GERD) (Quality of Life Reflux and Dyspepsia and Reflux Disease Questionnaire) are validated in Italian, but neither of the two questionnaires was correlated with an instrumental examination. The aim of the present study is to improve the GERD-Health Related Quality of Life (HRQL) questionnaire, to evaluate the reliability and validity of its Italian translation, and its sensitivity and specificity.

METHODS

A modified Italian GERD-HRQL (MI-GERD-HRQL) questionnaire was developed adding six questions investigating on regurgitation, for a total of 15 questions. The forward-backward translation process was employed to obtain a definitive from-English-to-Italian version. Data obtained from the questionnaire were compared to upper gastrointestinal endoscopy findings.

RESULTS

The questionnaire was administered twice to 130 Italian-speaking patients by two different and independent raters. Cronbach's α of the first and second questionnaire was 0.944 and 0.942, respectively. Spearman correlation and inter-rater reliability were 0.923 and 0.929, respectively. Sensitivity and specificity were 73.3 and 64%, and 69.5 and 64%, respectively, for the first and second questionnaire.

CONCLUSION

The MI-GERD-HRQL questionnaire proved good consistency, reliability, sensitivity and specificity in the evaluation of typical GERD symptoms.

The Determinants of the Quality of Life of Gastroesophageal Reflux Disease Patients Attending King Saud University Medical City

Background

Gastroesophageal reflux disease (GERD) is a common gastrointestinal (GI) tract disease and has an adverse effect on the quality of life (QoL) of patients. Studies on the QoL of GERD patients would increase awareness among healthcare providers about the magnitude of the problem and how to manage it.

Objectives

This study aimed to determine the essential variables that affected the QoL of GERD patients at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia.

Method

This was a cross-sectional study performed using quantitative questionnaires, which was conducted at KSUMC during the period from September 1, 2019, to April 1, 2020. We used the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) questionnaire. Additionally, the authors collected information about sociodemographic variables and concomitant diseases from each participant.

Results

The study included 200 participants; 58.5% of them were males. Around 34.9% of participants in the age group A (18-34 years) had poor QoL compared to 57.5% and 50% of participants from the counterpart groups, respectively. There was a statistically significant difference in the QoL among various age groups (p: 0.006). Furthermore, 58.9% of obese participants had poor QoL; there was a statistically significant difference in the QoL between normal-weight and obese groups (p: 0.013).

Conclusion

The QoL of GERD patients was found to be affected negatively by increasing age and high body mass index (BMI). None of the other demographic variables and concomitant diseases had any significant effect on the QoL of the participants.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being  < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H₂ receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

Helicobacter pylori Infection in Gastroesophageal Reflux Disease in the Asian Countries

Helicobacter pylori infection, a common infection in many countries, is related to the clinical course of upper gastrointestinal diseases. Gastroesophageal reflux disease (GERD) is a common esophageal disease in Western countries and its prevalence is increasing in Asian countries. The pathophysiology of GERD is multifactorial. Although no single factor has been isolated as the cause of GERD, a negative association between the prevalence of H. pylori and the severity of GERD, including Barrett's esophagus, has been demonstrated in epidemiological studies. The high prevalence of H. pylori infection affects the incidence of GERD in Asian countries. In the subjects with East Asian CagA-positive strains, acid injury may be minimized by hypochlorhydria from pangastritis and gastric atrophy. Additionally, host genetic factors may affect the development of GERD. The interactions between genetic factors and the virulence of H. pylori infection may be the reason for the low prevalence of GERD in Asian countries. H. pylori eradication is not considered pivotal in GERD exacerbation based on evidence from Western studies. A recent meta-analysis demonstrated that eradication therapy of H. pylori was related to a higher risk of developing de novo GERD in Asian studies. H. pylori infection remains an inconclusive and important issue in GERD in Asian countries.

Increase of lower esophageal sphincter pressure after osteopathic intervention on the diaphragm in patients with gastroesophageal reflux

The treatment of gastroesophageal reflux disease may be clinical or surgical. The clinical consists basically of the use of drugs; however, there are new techniques to complement this treatment, osteopathic intervention in the diaphragmatic muscle is one these. The objective of the study is to compare pressure values in the examination of esophageal manometry of the lower esophageal sphincter (LES) before and immediately after osteopathic intervention in the diaphragm muscle. Thirty-eight patients with gastroesophageal reflux disease - 16 submitted to sham technique and 22 submitted osteopathic technique - were randomly selected. The average respiratory pressure (ARP) and the maximum expiratory pressure (MEP) of the LES were measured by manometry before and after osteopathic technique at the point of highest pressure. Statistical analysis was performed using the Student's t-test and Mann-Whitney, and magnitude of the technique proposed was measured using the Cohen's index. Statistically significant difference in the osteopathic technique was found in three out of four in relation to the group of patients who performed the sham technique for the following measures of LES pressure: ARP with P= 0.027. The MEP had no statistical difference (P= 0.146). The values of Cohen d for the same measures were: ARP with d= 0.80 and MEP d= 0.52. Osteopathic manipulative technique produces a positive increment in the LES region soon after its performance.

Cost-effectiveness of laparoscopic fundoplication versus continued medical management for the treatment of gastro-oesophageal reflux disease based on long-term follow-up of the REFLUX trial

Background

Laparoscopic fundoplication surgery has been shown to be a cost-effective alternative to continued medical management over 1 year for patients with gastro-oesophageal reflux disease (GORD). The longer-term cost-effectiveness is, however, uncertain. This study evaluated the long-term health benefits, costs and cost-effectiveness of laparoscopic fundoplication compared with continued medical management in patients with GORD.

Methods

Individual patient data were used from the 5-year follow-up of the REFLUX trial, a large multicentre, pragmatic, randomized trial in which 357 patients with GORD for at least 12 months at trial entry were allocated randomly to early laparoscopic fundoplication or continued medical management. Health outcomes were expressed in quality-adjusted life-years (QALYs). A UK National Health Service perspective was used for costs.

Results

The group randomized to surgery experienced better health outcomes in each year of follow-up, but the difference narrowed over time. At 5 years, the surgery group had experienced 0·216 (95 per cent confidence interval 0·021 to 0·412) more QALYs but also accrued €1832 (1214 to 2448) more costs. The incremental cost-effectiveness ratio was €8481 per QALY gained. The probability that surgery is the most cost-effective intervention was 0·932 at a threshold of €24 134/QALY (£20 000/QALY). Results were robust to most sensitivity analyses, except where patients with missing data randomized to surgery were assumed to have worse health outcomes.

Conclusion

Laparoscopic fundoplication is a cost-effective alternative to continued medical management over 5 years. No evidence was found to suggest that the cost-effectiveness of laparoscopic fundoplication diminishes over time.

Treatment of functional dyspepsia with sertraline: A double-blind randomized placebo-controlled pilot study

AIM: To evaluate sertraline, a selective serotonin reuptake inhibitor in the treatment of patients with functional dyspepsia.

METHODS: Consecutive tertiary hospital patients with a clinical diagnosis of functional dyspepsia (FD) according to the Rome II criteria with a Hong Kong dyspepsia index (HKDI) of greater than 16 were recruited. Patients commenced enrolment prior to the inception of the Rome III criteria for functional dyspepsia. All patients were ethnic Chinese, had a normal upper endoscopy and were Helicobacter pylori negative prior to enrolment. Study patients were randomized to receive sertraline 50 mg or placebo daily for 8 wk. HKDI symptom scores, quality of life, hospital anxiety and depression (HAD) scale and global symptom relief were evaluated before, during and after treatment. Adverse effects were monitored during and after treatment.

RESULTS: A total of 193 patients were randomized in the intention to treat (ITT), and 150 patients were included in the per protocol (PP) analysis. In both the ITT and PP, there was no difference in the primary outcome of global dyspepsia symptoms between the sertraline and placebo groups at week 8. In the ITT analysis, 98 and 95 patients were randomized to the sertraline and placebo groups respectively. A total of 43 patients withdrew from the study (22.3%) by week 8, with 23 of the 24 drop-outs in the sertraline group occurring prior to week 4 (95.8%). In contrast, in the placebo arm, 11 of 19 patients dropped out by week 4 (57.9%). Utilizing the last response carried forward to account for the drop-outs, there were no differences between the sertraline and placebo groups at baseline in terms of the HKDI, HKDI 26.08 ± 6.19 vs 26.70 ± 5.89, P = 0.433; and at week 8, HKDI 22.41 ± 6.36 vs 23.25 ± 7.30, P = 0.352 respectively. In the PP analysis, 74 and 76 patients were randomized to the sertraline and placebo groups respectively. At baseline, there were no statistically significant differences between the sertraline and placebo groups, HKDI 25.83 ± 6.313 vs 27.19 ± 5.929 respectively, P = 0.233; however by week 8, patients in the sertraline group demonstrated a statistically significant difference in their Hong Kong Dyspepsia Index compared to placebo, HKDI 20.53 ± 6.917 vs 23.34 ± 7.199, P = 0.02, respectively). There was also no statistically significant difference in overall quality of life measures or the HAD scale related to treatment in either the ITT or PP analysis at week 8.

CONCLUSION: This pilot study, the first to examine sertraline, a selective serotonin reuptake inhibitor, for the management of FD, did not find that it was superior to placebo.

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.

Predicting the efficacy of proton pump inhibitors in patients with non-erosive reflux disease before therapy using dual-channel 24-h esophageal pH monitoring

BACKGROUND AND AIM

We aimed to determine whether reflux- and symptom-related parameters can predict the efficacy of proton pump inhibitors (PPI) in non-erosive reflux disease (NERD).

METHODS

Twenty-seven NERD patients who had experienced heartburn more than once a week within the previous month were enrolled. Intraesophageal pH before therapy was measured simultaneously at 5 and 15 cm above the esophagogastric junction (EGJ) for 24 h. The PPI rabeprazole was administered at a dose of 10 mg once daily for 4 weeks. In the event that heartburn was not relieved, the dose was increased to 10 mg twice daily for an additional 2 weeks, and again to 20 mg twice daily for another 2 weeks.

RESULTS

Univariate analysis demonstrated no significant associations between any reflux- or symptom-related parameters at either site and complete heartburn relief after 4 weeks, or cumulative complete heartburn relief after 8 weeks. However, post-hoc analysis demonstrated more satisfactory heartburn relief after 4 weeks in patients with a high symptom index compared with those with a low symptom index, at 5 cm above the EGJ (P = 0.009). Cumulative satisfactory heartburn relief after 8 weeks was also greater in patients with a high total number of acid reflux episodes compared with those with a low total number of episodes, at 15 cm above the EGJ (P = 0.037).

CONCLUSIONS

Pre-therapeutic pH monitoring in the lower and mid-esophagus is useful for predicting the efficacy of PPI in NERD patients.

Work productivity and activity impairment in gastroesophageal reflux disease in Korean full-time employees: a multicentre study

INTRODUCTION

The costs of gastroesophageal reflux disease have not been assessed in Asia, even though the prevalence of gastroesophageal reflux disease is gradually increasing. We evaluated work presenteeism and absenteeism as indirect costs of gastroesophageal reflux disease in Korea.

METHODS

This was a cross-sectional and multicentre study using patient-reported outcome instruments. A total of 1009 full-time employees who visited the gastrointestinal department for any reason (281 patients with gastroesophageal reflux disease and 728 controls) were included. Main outcomes were presenteeism and absenteeism measured as work productivity loss and monetary cost per week.

RESULTS

Absenteeism and presenteeism were significantly higher in the gastroesophageal reflux disease than the control group (1.49% vs. 0.46%, P=0.0010; 34.13% vs. 9.23%, P<0.0001). Loss of work productivity was significantly greater in the gastroesophageal reflux disease than the control group (33.09% vs. 9.02%; P<0.0001). This loss of work productivity difference between the two groups represented an additional productivity loss of 11.7h/week in the gastroesophageal reflux disease group compared with the control group. Assuming average hourly wages of $14.12, the weekly burden of gastroesophageal reflux disease reached $165.07 per person.

CONCLUSIONS

Gastroesophageal reflux disease was associated with substantial work productivity loss, mainly due to presenteeism rather than absenteeism, in Korean full-time employees.

Nausea and vomiting in diabetic and idiopathic gastroparesis

BACKGROUND

Nausea and vomiting are frequent symptoms of gastroparesis. The aim of this study was to characterize nausea and vomiting in gastroparesis and to compare nausea and vomiting in patients with diabetic and idiopathic gastroparetics. We also quantitated the number of episodes of vomiting per day and the hours of nausea per day.

METHODS

Patients diagnosed with gastroparesis at Temple University Hospital between May 2009 and December 2010 completed the Patient Assessment of Upper GI Symptoms questionnaire along with questionnaires about nausea and vomiting.

KEY RESULTS

A total of 157 patients [43 diabetic (DG) and 114 idiopathic gastroparetics (IG)] comprised the study group. Nausea was present in 91% of DG and 90% of IG (P = 0.822). Nausea symptom severity score was 3.51 ± 0.24 in DG and 3.42 ± 0.15 in IG (P = 0.362). DG patients reported 8.1 ± 1.2 compared to 7.9 ± 0.8 in IG (P = 0.44). Vomiting was present in 72% of DG and 55% of IG (P = 0.083). Vomiting symptom severity score was 2.69 ± 0.34 in DG and 1.83 ± 0.21 in IG (P = 0.010). DG patients reported 7.3 ± 1.7 vomiting episodes per day compared to 3.5 ± 0.9 in IG (P = 0.027). Both nausea and vomiting had a significant correlation with reduced quality of life.

CONCLUSIONS & INFERENCES

Nausea and vomiting are significant symptoms of gastroparesis. Vomiting was greater in DG compared with IG, both in terms of severity score and number of vomiting episodes, whereas nausea severity was similar. Hours of nausea per day and episodes of vomiting per week appear to be useful parameters for assessing symptoms of gastroparesis. Nausea and vomiting have a significant impact on quality of life.

Acid-suppressive effect of rabeprazole 5 mg and 10 mg once daily by 24-hour esophageal pH monitoring in patients with non-erosive reflux disease in Japan: a multicenter, randomized, parallel-group, double-blind pharmacodynamic study

BACKGROUND

Acid suppression induced by rabeprazole 5 mg in patients with NERD has not been reported in the literature.

AIMS

The objective of this study was to investigate gastroesophageal acid suppression in NERD patients by rabeprazole 5 mg and 10 mg/day.

METHODS

Subjects were grade M (minimal changes) NERD patients. Twenty-two patients not responding to open label antacid therapy entered a double-blind treatment phase in which rabeprazole 5 mg or 10 mg/day for four weeks were compared. Twenty-four-hour esophageal pH monitoring was performed before and on treatment (at week 4) to assess the pharmacodynamic effect of these doses of rabeprazole.

RESULTS

The frequency of heartburn episodes and the number of acid reflux episodes in the esophagus corresponded well in grade M NERD patients (r=0.44, P=0.042). Median percentage of time at pH<4 was 4.3% before treatment and 1.1% on treatment with rabeprazole 5 mg (change from baseline; -2.5%), whereas the median percentage of time at pH<4 in the rabeprazole 10 mg group was 7.4% before treatment and 0.5% on treatment (change from baseline; -6.6%). Likewise, treatment-related changes of median number of reflux episodes were -18.0 with rabeprazole 5 mg and -44.0 with rabeprazole 10 mg. For each esophageal pH data, no significant differences were observed between the two groups (P=0.377, P=0.077).

CONCLUSIONS

Administration of 5 mg and 10 mg rabeprazole sufficiently inhibited pathological gastroesophageal acid reflux and relieved heartburn episodes in NERD patients who did not respond to an antacid. Further investigation would be necessary to determine proper usage of the two doses.

Treatment of non-erosive reflux disease with a proton pump inhibitor in Chinese patients: a randomized controlled trial

BACKGROUND

Evidence suggests that rates of gastroesophageal reflux disease are increasing in the Asia-Pacific region, where patients tend to have predominantly non-erosive reflux disease as opposed to erosive (reflux) esophagitis. At present, data for the responsiveness of non-erosive reflux disease to proton pump inhibition are scant. We aimed to study esomeprazole for the treatment of non-erosive reflux disease in Chinese patients.

METHODS

Patients with a clinical diagnosis of gastroesophageal reflux, and a locally validated reflux index, the Chinese GerdQ, of equal to or greater than 12 were recruited and randomized to receive esomeprazole 20 mg daily or placebo for 8 weeks. Reflux index scores, quality of life (SF-36), and the hospital anxiety and depression (HAD) scale and symptom relief were evaluated before, during, and after treatment.

RESULTS

A total of 175 patients were randomized. Patients in the esomeprazole group (n = 85) demonstrated statistically significant reductions in their GerdQ index, from 19.45 to 15.37 and to 14.32 (p = 0.013, p = 0.005) at weeks 4 and 8, respectively. Compared to placebo at week 8, 57.1% of patients on esomeprazole found that their symptoms had resolved or were acceptable compared with 37.2% in the placebo group (p = 0.001). There were no statistically significant differences in overall quality-of-life measures or the HAD scale related to treatment.

CONCLUSIONS

This study suggests that esomeprazole is efficacious in treating Chinese patients with non-erosive reflux disease.

Randomised clinical trial: a multicentre, double-blind, placebo-controlled study on the efficacy and safety of rabeprazole 5 mg or 10 mg once daily in patients with non-erosive reflux disease

BACKGROUND

The efficacy of rabeprazole 5 mg/day for patients with non-erosive reflux disease (NERD) has not been reported in the literature.

AIM

To evaluate the efficacy of rabeprazole 5 mg and 10 mg/day in Japanese NERD patients. The influence of baseline characteristics as well as genetic background on efficacy was also analysed.

METHODS

Subjects were grade M (minimal changes) NERD patients. Two hundred and eighty-eight of these subjects, who were nonresponders to open label antacid therapy, entered in a 4-week, double-blind treatment (placebo, rabeprazole 5 mg or 10 mg/day).

RESULTS

Complete heartburn relief rates were 21% in placebo, 34% in rabeprazole 5 mg and 44% in rabeprazole 10 mg (5 mg vs. placebo P = 0.074, 10 mg vs. placebo P = 0.001). Rabeprazole 5 mg was significantly more effective than placebo in elderly patients and in patients with low heartburn frequency or without hiatal hernia. The efficacy of rabeprazole 10 mg was not influenced by age, BMI, hiatal hernia, Helicobacter pylori infection, frequency and severity of heartburn or CYP2C19 genotypes.

CONCLUSIONS

Rabeprazole 5 mg was effective in a subgroup of Japanese NERD patients. Rabeprazole 10 mg provided more potent heartburn relief than 5 mg and was less fragile to baseline characteristics.

Prevalence of overlaps between GERD, FD and IBS and impact on health-related quality of life

OBJECTIVE

Gastroesophageal reflux disease (GERD), functional dyspepsia (FD), and irritable bowel syndrome (IBS) are common, and have negative impacts on health-related quality of life (HR-QOL). Several studies demonstrated a significant overlap between two of these three diseases. The purpose of this study was to examine the prevalence of GERD, FD, and IBS, their overlap rates, and HR-QOL for each disease and each overlap compared with healthy controls in the Japanese general population.

METHODS

We performed a cross-sectional study of Japanese workers who visited a clinic for a routine health check-up, and asked them to fill out a self-report questionnaire. Prevalence and overlap rate of GERD defined as heartburn and/or acid regurgitation at least weekly, FD and IBS based on Rome III criteria, and HR-QOL by SF-8 were examined.

RESULTS

Of the 2680 eligible subjects, 207 (7.7%) were diagnosed as having GERD, 269 (10.0%) as FD, and 381 (14.2%) as IBS. Overlaps were found in 46.9% in GERD, 47.6% in FD, and 34.4% in IBS. Prevalence of overlaps in subjects with IBS was significantly lower compared with those among GERD or FD. Sufferers from GERD, FD, or IBS reported significantly poorer HR-QOL across all domains compared with controls. Overlaps significantly worsened HR-QOL in most domains except in the 'role emotional' domain. HR-QOL was particularly poor in the physical component summary for overlapping GERD and in the mental component summary for overlapping IBS.

CONCLUSION

Overlaps among GERD, FD and IBS were common and worsened HR-QOL in Japanese general population.

Lack of correlation between a self-administered subjective GERD questionnaire and pathologic GERD diagnosed by 24-h esophageal pH monitoring

INTRODUCTION

Self-reported reflux symptoms do not always correspond to pathologic gastroesophageal reflux disease (GERD). We evaluated whether GERD-related symptoms in the self-reported Mayo-GERD questionnaire (GERDQ) were correlated with current gold standard definitions of pathologic GERD.

METHODS

Three hundred thirty-six consecutive consenting individuals with GERD symptoms referred for 24-h esophageal pH monitoring completed a baseline GERDQ. Univariate and multivariate analyses identified questions that were most associated with percent total time pH<4 at distal probe (DT) >4% or DeMeester score (DS) >or=14.7, two accepted definitions of pathologic GERD. A risk score was created from these analyses, followed by generation of receiver operating characteristic curves and determination of C-statistics, sensitivity, and specificities at various cut points, with prespecified minimal values of each that would be required to meet the definition of "potential clinical utility."

RESULTS

Forty-nine percent of patients were found to have pathologic GERD; half the patients (not necessarily those with pathologic GERD) described suffering from severe or very severe heartburn or acid regurgitation in the past year. Univariate logistic regression analysis identified six of 22 key GERD questions that were significantly related to DT or DS, in addition to age and gender. Three questions (duration of symptoms, nocturnal heartburn, hiatal hernia) along with age and gender remained significant in multivariate analyses. A risk score (RS) was created from these five questions separately for DT and DS. For DT, the C-statistic for RS was 0.75, and at the optimal cut point of >or=6 that maximizes sensitivity (SS) and specificity (SP), SS was 68% and SP was 72%. For DS, the C-statistic was 0.73, and at the optimal cut point, SS was 82%and SP 60%. When considering other cut points, the rare extreme case of very low RS (<or=2) was strongly predictive of lack of pathologic GERD: for DT, SS 100%/SP 18%, negative predictive value (NPV) 100%; and for DS, SS 97%, SP 25%, NPV 88%. However, only 10-15% of patients referred for pH testing had RS scores of <or=2.

CONCLUSION

Self-reported prolonged history of GERD-like symptoms, nocturnal heartburn, history of a hiatus hernia, and male gender were associated with abnormal 24-h esophageal pH monitoring. However, these factors lack clinical utility to predict pathologic GERD in patients referred for pH testing. We found that 51% of patients with severe GERD symptoms do not have true pathological GERD on objective testing. The clinical implications of this study are significant in that treatment with acid-suppressing medication in such patients would be inappropriate.

[Health-related quality of life issues in gastroesophageal reflux disease]

Several studies have reported significant Health-Related Quality of life (HRQOL) impairment in gastroesophageal reflux disease (GERD) patients compared with the general population. The evaluation of quality of life is important as a parameter for the treatment. Because GERD has diverse symptoms such as esophageal and extraesophageal syndromes, HRQOL of GERD should be determined by both disease and non-disease related factors. The purpose is to overview the HRQOL instruments used in the evaluation of GERD, published reports regarding HRQOL in GERD, and the effects of medical treatments on GERD.

Development and validation of a disease-specific quality of life questionnaire for gastro-oesophageal reflux disease: the GERD-QOL questionnaire

BACKGROUND

A simple and meaningful health-related quality of life (HRQoL) questionnaire for gastro-oesophageal reflux disease (GERD) patients is lacking.

AIM

To develop and validate a disease-specific HRQoL instrument (GERD-QOL) for GERD patients.

METHODS

An 18-item questionnaire was generated to measure the impact of GERD on sleep, exercise, diet, need for medication, sex life, work, social activity and psychological well-being. GERD patients were invited to complete the GERD-QOL, a visual analogue scale (VAS) and a validated Chinese generic QoL (SF-36) questionnaire before and after esomeprazole treatment. Factor analysis was performed for item selection and psychometric properties were measured. An English version was developed by a forward-backward translation process.

RESULTS

A final 16-item GERD-QOL questionnaire was developed. The items were grouped into four subscales (Daily activity, Treatment effect, Diet, and Psychological well-being) after factor analysis. GERD-QOL had good item-internal consistency (Cronbach's alpha: 0.64-0.88), high test-retest reliability (intraclass correlation coefficient: 0.73-0.94, P < 0.001). Its subscale scores were correlated with SF-36 and VAS, which demonstrated high construct validity (P < 0.001). Discriminant validity was verified by correlating GERD-QOL scores with symptom severity (P < 0.001). Responsiveness after esomeprazole treatment was significant (paired-t-test P < 0.001). An English version of GERD-QOL was developed.

CONCLUSION

The instrument, GERD-QOL, is valid and reliable.

Management of gastroesophageal reflux disease in primary care settings in Spain: SYMPATHY I study

OBJECTIVE

Our study was designed to assess the symptom loads, treatment strategies, and impact on daily life of patients with gastroesophageal reflux disease (GERD) symptoms who consulted primary care (PC) health care providers in Spain.

METHODS

This was a multicenter, observational, cross-sectional study in a sample of 5735 consecutive patients visiting PC clinics with GERD symptoms. Participating primary care physicians (PCPs) collected clinical data by using a questionnaire, and completed a survey on their perceptions of diagnostic and therapeutic approaches to GERD. Patients self-completed the GERD Impact Scale during the study visit.

RESULTS

In the week before visiting the PC clinic, typical GERD symptoms were present in a majority of patients (89.6% heartburn and 81.6% regurgitation), but extraesophageal symptoms were also frequent (55.6% reflux-related sleep disturbances, 45.7% noncardiac chest pain, 30.8% chronic cough, and 24.7% hoarseness), these being more prevalent in the patients diagnosed earlier. Although primary care physicians considered that 55.9% of the patients could be diagnosed on the basis of symptoms without further investigation, in their practice only one-third of new diagnoses of GERD and 71.1% of those already diagnosed were symptom-managed. Upon arrival at the clinic, patients with GERD symptoms were taking the following medications: 28.1% (47.8% in the case of those already diagnosed) proton pump inhibitors (PPIs), 16.6% antacids, 6.1% H2 antagonists, and 4.5% prokinetics. Most patients (90.2%) were treated with PPIs after the study visit. The evaluation of agreement between physicians and patients on the severity of GERD resulted in a kappa index of 0.19.

CONCLUSION

There is a high occurrence of typical and extraesophageal symptoms in patients in Spain complaining of GERD symptoms in PC settings. Two-thirds of new GERD patients were referred for further investigation. PPIs were the treatment prescribed in almost all cases. The degree of agreement between physicians and patients about the severity of the symptoms was limited.

Systematic review: frequency and reasons for consultation for gastro-oesophageal reflux disease and dyspepsia

BACKGROUND

Upper gastrointestinal symptoms impose a substantial illness burden and management costs. Understanding perceptions and reasons for seeking healthcare is a prerequisite for meeting patients' needs effectively.

AIM

To review systematically findings on consultation frequencies for gastro-oesophageal reflux disease (GERD) and dyspepsia and patients' reasons for consultation.

METHODS

Systematic literature searches.

RESULTS

Reported consultation rates ranged from 5.4% to 56% for GERD and from 26% to 70% for dyspepsia. Consultation for GERD was associated with increased symptom severity and frequency, interference with social activities, sleep disturbance, lack of timetabled work, higher levels of comorbidity, depression, anxiety, phobia, somatization and obsessionality. Some consulted because of fears that their symptoms represented serious disease; others avoided consultation because of this. Inconsistent associations were seen with medication use. Patients were less likely to consult if they felt that their doctor would trivialize their symptoms. Few factors were consistently associated with dyspepsia consultation. However, lower socio-economic status and Helicobacter pylori infection were associated with increased consultation.

CONCLUSION

Patients' perceptions of their condition, comorbid factors and external reasons such as work and social factors are related to consultation rates for GERD. Awareness of these factors can guide the clinician towards a more effective strategy than one based on drug therapy alone.

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.

Systematic review: health-related quality of life (HRQOL) questionnaires in gastro-oesophageal reflux disease

BACKGROUND

Although gastro-oesophageal reflux disease (GERD) has a well-established pathophysiology, the impact of GERD symptoms on the patients' quality of life can be profound. Therefore, health-related quality of life (HRQOL) questionnaires have become standard instruments to evaluate the effect of treatment in clinical trials.

AIM

To evaluate the reliability, validity and responsiveness of available GERD-specific HRQOL.

METHODS

A systematic literature search using the Medical Subject Headings terms: 'Gastro-oesophageal reflux', 'Heartburn' and 'Oesophagitis' with 'quality of life' and 'questionnaires' was preformed to identify the available HRQOL questionnaires. To analyse the psychometric properties of the respective tools, the actual guidelines for the use of patient-reported outcomes in clinical trials were applied.

RESULTS

We identified five GERD-specific HRQOL questionnaires but none of them fulfilled all quality criteria; either they did not meet the actual standards for psychometric properties (HBQOL, GERD-HRQL, Jasani et al.Aust Fam Physician 1999; 28: 515), or were impracticable to use in clinical trials. The generic and hybrid instruments lack specificity and sensitivity and were not designed for treatment evaluation in GERD patients.

CONCLUSION

There is need for a new evaluative tool in the assessment of HRQOL during GERD therapy.

Tricyclic antidepressants and the risk of reflux esophagitis

OBJECTIVE

Incompetence of the lower esophageal sphincter (LES) is a key factor in the pathogenesis of gastroesophageal reflux disease (GERD). Drugs with anticholinergic properties, such as tricyclic antidepressants (TCAs), may facilitate GERD by a relaxing effect on the LES.

AIM

To investigate whether the use of TCAs is associated with an increased risk of reflux esophagitis (RE).

METHOD

A population-based case-control study was conducted within a large Dutch primary care database over the period 1996-2005. Cases with endoscopy-confirmed RE were identified and matched with up to 10 controls on gender, age, GP practice, and calendar time. Exposure to TCAs was assessed in the year prior to diagnosis and categorized as current (last prescription covered or ended within one month prior to the index date), past, and no use. The relative risk of RE was estimated by odds ratios (OR) with 95% confidence intervals (95% CI) using multivariate conditional logistic regression analysis.

RESULTS

During the study period, 1,462 cases with endoscopy-confirmed RE were identified. The risk of RE was increased in current TCA users (OR(adj) 1.61, 95% CI 1.04-2.50). Drug-specific analyses revealed that only clomipramine was associated with an increased risk of RE (OR(adj) 4.6, 95% CI 2.0-10.6) in a duration- and dose-dependent manner (OR(adj) 7.1, 95% CI 2.7-19.2 for use >180 days and OR(adj) 9.2, 95% CI 1.6-51.5 for >1 DDD equivalent/day).

CONCLUSION

No association was observed between the risk of RE and the use of TCAs other than clomipramine. The association between RE and clomipramine might be drug-related or a result of the underlying indication.

Efficacy of rabeprazole on heartburn symptom resolution in patients with non-erosive and erosive gastro-oesophageal reflux disease: a multicenter study from Japan

BACKGROUND

Few studies have compared the efficacy of proton pump inhibitors in resolving the symptoms of non-erosive reflux disease (NERD) and of erosive gastro-oesophageal reflux disease (GERD) in Japan.

AIM

To investigate and compare the efficacy of 4-week course of rabeprazole 10 mg/day on symptom resolution in NERD and erosive GERD in Japan.

METHODS

The modified Los Angeles classification was used to grade endoscopically GERD in patients with heartburn (Grades N and M: NERD, Grades A and B: mild reflux oesophagitis (RO), and Grades C and D: severe RO). Rabeprazole 10 mg/day was administered for 4 weeks to 180 patients who kept symptom diaries.

RESULTS

Complete relief of the symptoms was achieved in 35.8% of the NERD group and 55.4% of the erosive GERD group (mild RO: 51.1% and severe RO: 77.8%). Rabeprazole was significantly more effective in erosive GERD than in NERD patients. Among the NERD subgroups (Grades N and M), no difference in symptom improvement was observed.

CONCLUSIONS

Four-week, rabeprazole 10 mg/day acid suppression therapy was effective in resolving symptoms in Japanese GERD patients. This therapy was more effective in erosive GERD than in NERD patients, and in those with severe RO than in those with mild RO.

Quality of life and patient satisfaction after laparoscopic antireflux surgery using the QOLARS questionnaire

BACKGROUND

Currently, evaluation of patient satisfaction and quality-of-life data to estimate the outcome of laparoscopic antireflux surgery is an important issue. This study aimed first to report the midterm results for the surgical management of gastroesophageal reflux disease (GERD) by laparoscopic fundoplication and to evaluate surgical outcome, including quality of life and patient satisfaction. The second aim was to determine whether preoperative quality-of-life measurement can predict which patients will be satisfied with antireflux surgery.

METHODS

The current prospective study evaluated the outcome of the quality-of-life data for 41 patients (13 men and 28 women) who underwent laparoscopic fundoplication in the author's department of surgery between 1 January 2002 and 31 May 2003. The mean age of the patients was 41 years. Quality of life was measured by using a new quality-of-life instrument (QOLARS) developed and validated by the author's study group. The patients completed the QOLARS questionnaire before surgery, then 6 weeks, 1 year, and 3 years after surgery.

RESULTS

Before surgery, all the patients had a poor quality of life. The general quality-of-life and heartburn scores improved significantly within 6 weeks after surgery and showed further improvement by the end of the first postoperative year, then remained stable 3 years after surgery. The patients who became completely free of reflux-related symptoms were divided into two groups according to their satisfaction with the operative result. The patients dissatisfied with surgery had significantly worse median preoperative scores in four domains (physical functioning, emotional functioning, sleep disturbance, constipation) than the patients satisfied with the procedure.

CONCLUSIONS

The findings show that QOLARS is a sensitive tool for assessing surgical outcome after laparoscopic antireflux surgery. The quality-of-life response closely follows the clinical outcome of surgical treatment, reflecting its side effects as well. This study suggests that a generic quality-of-life scale can preoperatively identify patients with GERD who are likely to be dissatisfied with antireflux surgery.

Patient-Reported Gastrointestinal Symptom Burden and Health-Related Quality of Life following Conversion from Mycophenolate Mofetil to Enteric-Coated Mycophenolate Sodium

BACKGROUND

The benefit of converting renal transplant recipients with gastrointestinal (GI) complaints from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS) has not been evaluated using patient-reported outcomes.

METHODS

A multicenter, open-label, prospective study was undertaken in MMF-treated renal transplant patients. Patients experiencing GI complaints were converted to equimolar EC-MPS (Cohort A). Patients without GI complaints remained on MMF (Cohort B). At baseline and Visit 2 (4-6 weeks postbaseline), patients completed the Gastrointestinal Symptom Rating Scale (GSRS), Gastrointestinal Quality of Life Index (GIQLI) and Psychological General Well-being Index (PGWBI). At Visit 2, patients and physicians completed the Overall Treatment Effect (OTE) scale for GI symptoms. Additionally, patients completed the OTE for health-related quality of life (HRQoL). Minimal important difference (MID) was calculated for GSRS and GIQLI based on patients' and physicians' OTE evaluation.

RESULTS

Of 328 patients enrolled (i.e. the intent-to-treat and safety populations), 278 formed the per-protocol population (Cohort A, n=177; Cohort B, n=101). At baseline, Cohort A had significantly worse scores on all GSRS, GIQLI and PGWBI subscales compared to Cohort B (all P<0.0001). All GSRS, GIQLI and PGWBI subscale scores improved significantly in Cohort A between baseline and Visit 2 (all P<0.0001). Mean improvements in all GSRS subscales and most GIQLI subscores exceeded the calculated MID. GSRS, GIQLI and PGWBI subscales remained stable in Cohort B.

CONCLUSION

This first exploratory study indicates that converting patients with mild, moderate or severe GI complaints from MMF to EC-MPS significantly reduces GI-related symptom burden and improves patient functioning and well-being.