Review article: from 1906 to 2006--a century of major evolution of understanding of gastro-oesophageal reflux disease

Practice-Changing Milestones in Anti-reflux and Hiatal Hernia Surgery: a Single Surgeon Perspective over 27 years and 1200 Operations

BACKGROUND

There have been steady innovations in hiatal hernia and anti-reflux surgery. The purpose of this article is to provide a historical perspective on practice-changing innovations in the context a single surgeon experience's over a career.

METHODS

Patients undergoing anti-reflux surgery or hiatal hernia repair by a single surgeon from 12/1992 to 3/2020 were reviewed.

DATA COLLECTED

sex, age, hiatal hernia type, operation type, adjuncts used, and additional procedure performed during index operation. Superimposed on this experience are the practice-changing innovations that occurred over this timeframe.

RESULTS

During the time period, 1200 operations were performed. Distributions: Hernia type: I, 707 (58.9%); II-IV, 325 (27.1%); Recurrent/Failed, 168 (14.0%). Type of operation, including laparoscopic and open: Nissen fundoplication: 889 (74.1%); Toupet fundoplication: 162 (13.5%); Collis-Nissen/Toupet fundoplication: 44 (3.7%); hiatal hernia repair without fundoplication (laparoscopic and open): 38 (3.2%); endoluminal fundoplication: 35 (2.9%); hiatal hernia repair with Heller myotomy/ Dor fundoplication: 10 (0.8%); transthoracic Belsey Mark IV: 2 (0.2%); hiatal hernia repair with magnetic sphincter augmentation: 20 (1.7%). Mesh reinforcement: 185 (15.4%). Additional procedures, 210 (17.5%). During this time, these practice-changing innovations occurred: laparoscopic surgery, 48-h pH monitoring, high-resolution manometry, tailoring of fundoplication, energy sources for tissue division and hemostasis, pyloroplasty for symptomatic gastroparesis, the rise and fall of endoluminal therapies, mesh reinforcement, abandonment of short gastric vessel division, and magnetic sphincter augmentation.

CONCLUSIONS

Over the last 27 years, a number of practice-changing advances have been made. These have led to changes in technique and operation selection of anti-reflux and hiatal hernia surgery.

HISTORICAL PERSPECTIVE OF GASTROESOPHAGEAL REFLUX DISEASE CLINICAL TREATMENT

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal diseases. GERD generates significant impairment in patients' quality of life and it is associated to relevant medical resources utilization. A better understanding of GERD pathophysiology in the past five decades has favored the evolution of therapeutic strategies from non-drug interventions and antacids to more efficacious and safer alternatives.

OBJECTIVE

To summarize data about the historical evolution of GERD management in Brazil, focusing on medical therapy and addressing evidence on efficacy and safety of drug classes currently recommended.

METHODS

A narrative review was conducted by systematizing information about discoveries on GERD pathophysiology. We also addressed efficacy and safety of medications currently used to reduce symptoms and improve endoscopic healing of esophageal lesions. A structured search on Pubmed was performed to identify systematic reviews and meta-analysis investigating GERD outcomes positively impacted by proton pump inhibitors (PPIs), the first choice of pharmacotherapy for the disease.

RESULTS

The chronological development of therapeutic measures for GERD in Brazil evolved from lifestyle interventions with relative poor effect on symptoms related to esophageal acid exposure, particularly heartburn, to effective and safe pharmacological interventions such as histamine H2-receptor antagonists and PPIs. In the present days, some drug classes play a minor role in disease management, namely prokinetics and antacids, due to their reduced efficacy and relevant safety concerns (particularly with prokinetics). The main challenge for prescribers and researchers seems to be finding long-acting acid suppressants strategies able to ameliorate patients' symptoms and quality of life, thereafter, reducing medical resource consumption. The dual delayed-release PPI dexlansoprazole seems to respond for some of the limitations other PPIs have.

CONCLUSION

Recognizing the historical evolution of GERD management can help care providers to better understand therapeutic options for their patients, as well as focus on unmet needs that deserve further attention. PPIs are still the first choice therapy, with good evidence in favor of their efficacy, despite some safety concerns. However, as with any medical intervention, it is recommended to prescribe PPIs for patients with clear indication, using adequate dosing and monitoring for adverse events.

[Gastric and duodenal secretory and motor-evacuatory activity in patients with gastroesophageal reflux disease associated with different types of reflux]

AIM

To estimate esophageal and gastric pH values on an empty stomach and after stimulation of gastric secretion and gastric and duodenal motor-evacuatory activity in patients with gastroesophageal reflux disease (GERD) associated with pathological refluxes, such as gastroesophageal reflux (GER) and duodenogastroesophageal reflux (DGER).

SUBJECTS AND METHODS

The observational cross-sectional study was conducted to investigate and compare the parameters of intraesophageal and intragastric pH metry and peripheral electrogastroenterography in 103 GERD patients with endoscopically positive distal reflux esophagitis in GER and DGER.

RESULTS

The patients with GERD developed pathological esophageal refluxes (both GER and DGER) in various degrees of impaired gastric production, from anacidity to hyperacidity. The patients with predominant DGER were found to have gastric hyperacidity and normal acidity slightly less frequently than those with predominant GER. The patients with GERD developing in the presence of predominant GER had moderate gastric stasis with discoordinated antroduodenal propulsion resulting from hypomotor dyskinesia of the stomach and duodenum. When DGER was predominant in the patients with GERD, the signs of gastric stasis and duodenal hyperkinesia were concurrent with discoordinated antroduodenal and duodenojejunal propulsion.

CONCLUSION

The specific features of the esophagogastroduodenal secretory and motor evacuatory disorders found create conditions for the pathological refluxes into the esophagus, which differ in the composition of refluxate.

Hiatal hernia and the risk of Barrett's esophagus

BACKGROUND AND AIM

Barrett's esophagus has been associated with the presence of hiatal hernia; however, to date no meta-analysis of the relationship has been performed. We aimed to conduct a systematic review and meta-analysis, providing a quantitative estimate of the increased risk of Barrett's esophagus associated with hiatal hernia.

METHODS

A search was conducted through four electronic databases (Medline, PubMed, Embase, and Current Contents Connect) to 4 April 2012, for observational studies of Barrett's esophagus patients. We calculated pooled odds ratios and 95% confidence intervals using a random effects model for the association of hiatal hernia with any length Barrett's esophagus, as well as with short segment Barrett's esophagus and long segment Barrett's esophagus. 33 studies comprising 4390 Barrett's esophagus patients were eligible for the meta-analysis.

RESULTS

Hiatal hernia was associated with an increased risk of Barrett's esophagus of any length (odds ratio 3.94; 95% confidence interval 3.02-5.13). Heterogeneity was present (I2 = 82.03%, P < 0.001), and the Egger test for publication bias was significant (P = 0.0005). The short segment Barrett's esophagus subgroup analysis likewise showed an increased risk (odds ratio 2.87; 95% confidence interval 1.75-4.70). The strongest association was between hiatal hernia and long segment Barrett's esophagus (odds ratio 12.67; 95% confidence interval 8.33-19.25). The increased risk was present even after adjusting for reflux and body mass index.

CONCLUSIONS

 The presence of hiatal hernia was associated with an increased risk of Barrett's esophagus, even after adjusting for clinically significant confounders. The strongest association was found between hiatal hernia and long segment Barrett's esophagus.

Partial symptom-response to proton pump inhibitors in patients with non-erosive reflux disease or reflux oesophagitis - a post hoc analysis of 5796 patients

BACKGROUND

Although most patients with gastro-oesophageal reflux disease (GERD) benefit from proton pump inhibitor (PPI) therapy, some experience only partial symptom relief.

AIM

To determine the prevalence of partial heartburn response to PPIs and its impact on health-related quality of life.

METHODS

Four randomised, double-blind studies in adults with reflux disease compared esomeprazole 40 mg/day or 20 mg/day with omeprazole 20 mg/day, or esomeprazole 40 mg/day with pantoprazole 40 mg/day. Patients with heartburn on ≥4 days during the 1-week recall period at baseline were included. Partial response was defined as heartburn on ≥3 days during the last treatment week and reduced heartburn frequency after 4 weeks of treatment compared with baseline.

RESULTS

The analysis included 2645 patients with non-erosive reflux disease (mean age: 48.8 years; 54.4% women) and 3151 patients with reflux oesophagitis (mean age: 50.6 years; 37.1% women). At baseline, most patients reported heartburn on 5-7 days (non-erosive reflux disease: 82.2%; reflux oesophagitis: 86.8%). Partial heartburn response occurred in 19.9% of patients with non-erosive reflux disease and 14.0% with reflux oesophagitis. Defining partial response as heartburn on ≥2 days increased these rates to 26.2% and 19.3%, respectively; defining partial response as heartburn of moderate or severe intensity on ≥3 days decreased these rates to 6.4% and 5.3%, respectively. Nonresponse to PPIs was rare (non-erosive reflux disease: 2.4%; reflux oesophagitis: 1.4%).

CONCLUSION

Using our conservative definition, partial heartburn response to proton pump inhibitor therapy occurred in 14-20% of gastro-oesophageal reflux disease patients, more commonly in non-erosive reflux disease than in reflux oesophagitis.

Heterogeneity in oesophageal dysfunction among patients with different reflux symptoms

BACKGROUND AND AIM

Ineffective oesophageal motility (IOM) often occurs in patients with gastro-oesophageal reflux disease. We aimed to examine the hypothesis of whether the presence of IOM differs between patients with gastro-oesophageal reflux disease with different symptom profiles.

METHODS

Eligible patients were subclassified according to their predominant symptom of heartburn (HB) or acid regurgitation (AR). All patients underwent combined multichannel intraluminal impedance and oesophageal manometry. IOM was further graded according to the presence of oesophageal transit abnormalities.

RESULTS

Fourteen healthy individuals, 16 HB patients and 24 AR patients participated in this study. The percentage of swallows with complete bolus transit was lower in AR than in HB patients during liquid and viscous swallowing (P<0.05). Abnormal bolus transit occurred more frequently in AR patients than in HB patients with liquid swallows (P<0.001) and viscous swallows (P<0.05). IOM occurred more frequently in AR patients than in HB patients (42.7 vs. 12.5%, P=0.049). In patients with IOM, severe functional abnormality was more frequently found in AR patients than in HB patients (P<0.05).

CONCLUSION

This study suggests a potential link between oesophageal body dysfunction and individual reflux symptom. Patients with a predominant symptom of AR are characterized by greater IOM and defective bolus clearance.

The effects of a novel metabotropic glutamate receptor 5 antagonist (AZD2066) on transient lower oesophageal sphincter relaxations and reflux episodes in healthy volunteers

BACKGROUND

Selective metabotropic glutamate receptor 5 (mGluR5) antagonists inhibit transient lower oesophageal sphincter relaxations (TLESRs) in animals and acid reflux in humans.

AIM

To assess the effect of single doses of the mGluR5 antagonist AZD2066 on TLESRs and reflux in humans.

METHODS

Healthy male volunteers received AZD2066 13 mg and placebo (part A), or AZD2066 2 mg and AZD2066 6 mg and placebo (part B), in a randomised crossover study. Postprandial manometry/pH-impedance measurements were taken after each dose.

RESULTS

A total of 13 individuals completed part A of the study and 19 individuals completed part B. There was a significant reduction in the geometric mean number of TLESRs (27%; P = 0.02) and the geometric mean number of reflux episodes (51%; P = 0.01) in subjects receiving AZD2066 13 mg compared with placebo. Adverse events in participants receiving AZD2066 13 mg were mostly related to the nervous system [dizziness (3/13); disturbance in attention (3/13)]. Adverse events were reversible and of mild intensity. There were no serious adverse events. The effects of AZD2066 appeared dose-dependent, with smaller reductions in TLESRs and reflux episodes (relative to placebo) and fewer adverse events observed for AZD2066 2 mg and AZD2066 6 mg compared with AZD2066 13 mg.

CONCLUSION

The mGluR5-mediated inhibition of TLESRs may be a useful approach for inhibiting gastro-oesophageal reflux.

The enteric nervous system and neurogastroenterology

Neurogastroenterology is defined as neurology of the gastrointestinal tract, liver, gallbladder and pancreas and encompasses control of digestion through the enteric nervous system (ENS), the central nervous system (CNS) and integrative centers in sympathetic ganglia. This Review provides a broad overview of the field of neurogastroenterology, with a focus on the roles of the ENS in the control of the musculature of the gastrointestinal tract and transmucosal fluid movement. Digestion is controlled through the integration of multiple signals from the ENS and CNS; neural signals also pass between distinct gut regions to coordinate digestive activity. Moreover, neural and endocrine control of digestion is closely coordinated. Interestingly, the extent to which the ENS or CNS controls digestion differs considerably along the digestive tract. The importance of the ENS is emphasized by the life-threatening effects of certain ENS neuropathies, including Hirschsprung disease and Chagas disease. Other ENS disorders, such as esophageal achalasia and gastroparesis, cause varying degrees of dysfunction. The neurons in enteric reflex pathways use a wide range of chemical messengers that signal through an even wider range of receptors. These receptors provide many actual and potential targets for modifying digestive function.

Systematic review: Patterns of proton pump inhibitor use and adherence in gastroesophageal reflux disease

BACKGROUND & AIMS

Variation in how proton pump inhibitors (PPIs) are taken likely influences their clinical effectiveness, and must be considered when estimating PPI failure rates. This review aimed to systematically investigate the literature on patterns of PPI use in patients with gastroesophageal reflux disease (GERD).

METHODS

PubMed and Embase were searched (1989-May 2010) to identify observational studies providing information on patterns of PPI use in patients with GERD.

RESULTS

Of 902 studies identified, 13 met prespecified selection criteria. Across 2 database studies, 53.8%-67.7% of patients with GERD had a medication possession ratio (MPR) of >0.80. Across 2 more database studies, the mean MPR for the study population was 0.68 to 0.84. Across 3 surveys, 70%-84% of patients reported daily PPI use. In 2 surveys, the presence and severity of reflux symptoms increased PPI adherence, as did Barrett's esophagus in another 2 studies. Across 3 surveys, 11%-22.2% of patients reported twice daily PPI use, and across 6 studies 11.0%-44.8% of patients took GERD medication in addition to a PPI.

CONCLUSIONS

The results of this systematic review suggest that the majority of patients with GERD are relatively adherent to their PPI, although substantially different estimates were obtained using MPR data compared with surveys. Severe symptoms and the presence of Barrett's esophagus may increase PPI adherence, and other GERD medication is frequently taken in addition to a PPI. Limitations of studies in this area include inferring adherence from indirect MPR data, and recall bias associated with patient surveys.

Review of the persistence of gastroesophageal reflux disease in children, adolescents and adults: does gastroesophageal reflux disease in adults sometimes begin in childhood?

OBJECTIVE

Understanding the natural history and outcomes of gastroesophageal reflux disease (GERD) in children could help to identify patients at risk of having GERD complications during adulthood. This review aimed to assess evidence of whether GERD in children or adolescents persists into adulthood.

MATERIAL AND METHODS

PubMed searches (1966-2010) identified longitudinal studies of GERD extending from childhood/infancy into adulthood, as well as longitudinal studies within pediatric age groups.

RESULTS

In one study, heartburn during childhood was more often recalled by adults with reflux symptoms than by those without (30% vs. 9%; p < 0.001), as was medication or surgery for GERD (both p < 0.01). Another study found that GERD symptoms were more common in adults diagnosed with reflux esophagitis during childhood/adolescence than in those who were not (46% vs. 30%). Regurgitation during infancy increased the risk of feeding problems after 1 year (odds ratio 4.2 (95% confidence interval: 1.4-12.0)) and of reflux symptoms at 9 years of age (relative risk 2.3 (95% confidence interval: 1.3-4.0)). In one study, abnormal esophageal histology persisted in infants after 12 months without reflux symptoms. A proportion (59-100%: three studies) of patients with reflux symptoms and/or reflux esophagitis during the pediatric years still required treatment after 1-8 years. In another study, however, just 7% of patients with healed reflux esophagitis relapsed after 9 months without treatment.

CONCLUSION

The limited available evidence suggests that some infants, children, and adolescents with GERD are more likely than those without GERD to have symptoms later in life.

Gastroesophageal reflux disease and Barrett's esophagus

Gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. The spectrum of injury includes esophagitis, stricture, the development of columnar metaplasia in place of the normal squamous epithelium (Barrett's esophagus), and adenocarcinoma. Barrett's esophagus is a premalignant lesion detected in the majority of patients with esophageal and gastroesophageal adenocarcinoma. The incidence of these cancers has been increasing in the United States and they are associated with a low rate of survival (5-year survival rate, 15-20%). When symptoms of gastroesophageal reflux disease are typical and the patient responds to therapy, no diagnostic tests are necessary to verify the diagnosis. Endoscopy is the primary test in patients whose condition is resistant to empirical therapy but its yield in this setting is low because of the poor correlation between symptoms attributed to the condition and endoscopic features of the disease. Clinical experience suggests that lifestyle modifications may be beneficial for gastroesophageal reflux disease although trials of the clinical efficacy of dietary or behavioral changes are lacking. Abundant data from randomized trials show benefits of inhibiting gastric acid secretion and suggest that proton-pump inhibitors are superior to H2-blockers and that both are superior to placebo. In patients with Barrett's esophagus, antireflux interventions are intended to control symptoms of reflux and promote healing of the esophageal mucosa. If a patient has symptoms refractory to proton-pump inhibitors or cannot tolerate such therapy, antireflux surgery, most commonly Nissen fundoplication, may be an alternative management approach. In patients with high-grade dysplasia, endoscopic therapies or surgical resection must be considered.

Long-term outcomes in pediatric-onset esophageal eosinophilia

BACKGROUND

Pediatric eosinophilic esophagitis (EoE) is a newly recognized antigen-induced form of chronic esophagitis (CE).

OBJECTIVE

Characterization of long-term clinical outcomes in patients with pediatric EoE is needed.

METHODS

From histologic review of 3817 pediatric esophageal biopsy specimens from 1982-1999, we conducted a nested case-control study of patients with retrospectively identified histologic eosinophilic esophagitis (rEoE) and CE, as well as an age-matched control cohort. Participants were asked to complete validated health-related outcome questionnaires.

RESULTS

At an average of 15 years after initial endoscopy, both cohorts (42/198 patients with rEoE and 67/468 patients with CE, as well as 100 age-matched control subjects) completed questionnaires. Compared with control subjects, quality of life was significantly decreased among patients with rEoE (P < .001) and patients with CE (P < .001). Rates of dysphagia (patients with rEoE, 49%; patients with CE, 37%; control subjects, 6%) and food impaction (patients with rEoE, 40%; patients with CE, 14%; control subjects, 3%) were significantly increased in the rEoE cohort compared with those seen in control subjects (P < .001 and P < .001, respectively). Increased esophageal eosinophil counts (odds ratio [OR], 1.6; 95% CI, 1.1-2.5; P < .05) during childhood were predictive of dysphagia during early adulthood. Food allergy (OR, 2.7; 95% CI, 1.2-6.0; P < .01), allergic rhinitis (OR, 3.5; 95% CI, 1.8-6.8; P < .001), and asthma (OR, 2.1; 95% CI, 1.04-4.3; P = .04) were associated with dysphagia. Food impaction was more common among patients with reported food allergy than among those without (OR, 3.1; 95% CI, 1.2-7.8; P = .02).

CONCLUSIONS

Esophageal eosinophilia is associated with reduced quality of life and persistent symptoms 15 years after presentation. Increased esophageal eosinophil counts and the occurrence of food allergy and atopy in childhood increase the rate of dysphagia in young adulthood.

Does impaired gallbladder function contribute to the development of Barrett's esophagus and esophageal adenocarcinoma?

INTRODUCTION

Esophageal adenocarcinoma is aetiologically associated with gastro-esophageal reflux, but the mechanisms responsible for the metaplasia-dysplasia sequence are unknown. Bile components are implicated. Impaired gallbladder function may contribute to duodenogastric reflux (DGR) and harmful GERD.

AIMS

This study aims to compare gallbladder function in patients with Barrett's esophagus, adenocarcinoma, and controls.

METHODS

Three groups of patients, all free of gallstone disease, were studied. Group 1: (n = 15) were normal controls. Group 2: (n = 15) were patients with >3-cm-long segment of Barrett's esophagus. Group 3: (n = 15) were patients with esophageal adenocarcinoma. Using real-time ultrasonography unit, gallbladder volume was measured in subjects following a 10-h fast. Ejection fraction was calculated before and after standard liquid meal and compared between the groups.

RESULTS

The mean percentage reduction in gallbladder volume was 50% at 40 min in the adenocarcinoma group compared with 72.4% in the control group (p < 0.001). At 60 min, gallbladder filling had recommenced in the control group to 64.1% of fasting volume while continuing to empty with further reduction to 63% in the Barrett's group and to 50.6% (p = 0.008) in the adenocarcinoma group. The mean gallbladder ejection fraction decreased progressively from controls to Barrett's to adenocarcinoma and was significantly lower in Barrett's group (60.9%; p = 0.019) and adenocarcinoma group (47.9%; p < 0.001) compared with normal controls (70.9%).

CONCLUSION

Gallbladder function is progressively impaired in Barrett's esophagus and adenocarcinoma. Gallbladder malfunction increases duodenogastric reflux, exposing the lower esophagus to an altered chemical milieu which, in turn, may have a role in promoting metaplasia-dysplasia-neoplasia sequence in the lower esophageal mucosa.

Barrett's esophagus: A historical perspective, an update on core practicalities and predictions on future evolutions of management

Interpretation of exploding knowledge about Barrett's esophagus is impaired by use of several conflicting definitions. Because any histological type of esophageal columnar metaplasia carries risk for esophageal adenocarcinoma, the diagnosis of Barrett's esophagus should no longer require demonstration of intestinal-type metaplasia. Endoscopic recognition and grading of Barrett's esophagus remains a significant source of ambiguity. Reflux disease is a key factor for development of Barrett's esophagus, but other factors must underlie its development, since it occurs in only a minority of reflux disease patients. Neither antireflux surgery nor proton pump inhibitor (PPI) therapy has major impacts on cancer risk. Within a year, a major trial should indicate whether low-dose aspirin usefully reduces cancer risk. The best referral centers have transformed the accuracy of screening and surveillance for early curable esophageal adenocarcinoma by use of enhanced and novel endoscopic imaging, visually-guided, rather than blind biopsies and by partnership with expert pathologists. General endoscopists now need to upgrade their skills and equipment so that they can rely mainly on visual targeting of biopsies on mucosal areas of concern in their surveillance practice. General pathologists need to greatly improve their interpretation of biopsies. Endoscopic therapy now achieves very high rates of cure of high-grade dysplasia and esophageal adenocarcinoma with minimal morbidity and risk. Such results will only be achieved by skilled interventional endoscopists. Esophagectomy should now be mainly restricted to patients whose cancer has extended into and beyond the submucosa. Weighing risks and benefits in the management of Barrett's esophagus is difficult, as is the process of adequately informing patients about their specific cancer risk.

Systematic review: persistent reflux symptoms on proton pump inhibitor therapy in primary care and community studies

BACKGROUND

Persistent gastro-oesophageal reflux disease (GERD) symptoms can occur despite proton pump inhibitor (PPI) therapy.

AIM

To assess the prevalence and potential determinants of persistent GERD symptoms in primary care and community-based studies.

METHODS

Studies were identified by systematic PubMed and Embase searches; pooled prevalence data are shown as sample-size weighted means and 95% confidence intervals.

RESULTS

Nineteen studies in individuals with GERD taking a PPI were included. In interventional, nonrandomized primary care trials, the prevalence of persistent troublesome heartburn and regurgitation was 17% (6-28%) and 28% (26-30%) respectively; in randomized trials, it was 32% (25-39%) and 28% (26-30%), respectively. In observational primary care and community-based studies, 45% (30-60%) of participants reported persistent GERD symptoms. Overall, persistent GERD symptoms despite PPI treatment were more likely in studies with a higher proportion of female participants [>60% vs. <50%, risk ratio (RR): 3.66; P < 0.001], but less likely in studies from Europe than in those from the USA (RR: 0.71; P < 0.001), and were associated with decreased psychological and physical well-being.

CONCLUSIONS

Persistent GERD symptoms despite PPI treatment are common in the primary care and community setting. Alternative approaches to management are required.

Systematic review: role of acid, weakly acidic and weakly alkaline reflux in gastro-oesophageal reflux disease

BACKGROUND

The importance of weakly acidic and weakly alkaline reflux in gastro-oesophageal reflux disease (GERD) is gaining recognition.

AIM

To quantify the proportions of reflux episodes that are acidic (pH <4), weakly acidic (pH 4-7) and weakly alkaline (pH >7) in adult patients with GERD, and to evaluate their correlation with symptoms.

METHODS

Studies were identified by systematic PubMed and Embase searches. Data are presented as sample-size weighted means and 95% confidence intervals.

RESULTS

In patients with GERD taking a proton pump inhibitor (PPI), 80% (76-84%) of reflux episodes were weakly acidic or weakly alkaline and 83% (78-88%) of reflux symptom episodes were associated with weakly acidic or weakly alkaline reflux episodes. In patients with GERD not taking a PPI, 63% (59-67%) of reflux episodes were acidic and 72% (57-87%) of reflux symptom episodes were associated with acid reflux episodes. Six studies presented data separately for weakly alkaline reflux, which accounted for <5% of all reflux episodes, both on and off PPI therapy.

CONCLUSIONS

Weakly acidic reflux underlies the majority of reflux episodes in patients with GERD on PPI therapy, and is the main cause of reflux symptoms occurring despite PPI therapy.

Landmarks in the understanding and treatment of reflux disease

The last 50 years have seen a transformation in the understanding and treatment of reflux disease. The development and wide use of flexible endoscopy and progressively more sophisticated approaches to measurement of pathophysiological factors have been major drivers of advances. The recognition and progressive elucidation of the mechanical events that comprise the transient lower esophageal sphincter relaxation and how they lead to reflux provide a novel and firm foundation for tailoring therapies that act directly to reduce occurrence of reflux episodes, either surgically or pharmacologically. Novel GABA(B) agonist drugs have been shown to inhibit transient relaxations and are currently being evaluated in clinical trials on patients with reflux disease. Better understanding has extended to recognition of the extraordinarily high prevalence of reflux disease and of the ability of proton pump inhibitor drugs to deliver major benefits to a high proportion of patients with reflux disease. The life of the Gastroenterological Society of Australia has spanned the period of these major advances. A large number of the members of the Society and their associates have contributed substantially to these advances.

[Gastro-esophageal reflux through gastric antisecretory drugs]

During the 20th century, gastro-esophageal reflux moved from the status of a rare and severe disease to that of a frequent disease occurring mostly, in the absence of any significant lesions. Proton pump inhibitors (PPIs) are the mainstay of its therapy and are prescribed mainly in an empirical way. Extradigestive manifestations require more accurate diagnostic tests and therapeutic management. The modalities of prescription of the PPIs quickly progressed toward the on-demand therapy and over-the-counter PPIs should become widespread. The relative failures of PPIs led to a profusion of new antisecretory agents but clinical improvements are presently disappointing and the rationale of this escalation is questionable. The concept of non acid gastro-esophageal reflux opens more innovative diagnostic and therapeutic perspectives which, however, must be validated. In this respect, endoscopic treatment needs more reliable techniques and more rigorous trials. Gastro-esophageal reflux refractory to PPIs corresponds mainly to functional esophageal disorders that need diagnostic and therapeutic improvements. Barrett's esophagus constitutes a major challenge for the next few years. Its screening and its prevention seem, for the moment, inaccessible. Its survey and the prevention of its complications should benefit from progress of diagnostic and interventional endoscopy.

Comorbidities are frequent in patients with gastroesophageal reflux disease in a tertiary health care hospital

INTRODUCTION

Several aspects of gastroesophageal reflux disease (GERD) have been studied, but the frequency of comorbidities is not yet fully understood.

OBJECTIVES

To study the prevalence of GERD comorbidities in a tertiary care hospital.

METHODS

We prospectively studied 670 consecutive adult patients from the outpatient department of our facility. A diagnosis was established using clinical, endoscopic and/or pHmetry-related findings. Each patient's medical file was reviewed with respect to the presence of other medical conditions and diagnoses.

RESULTS

Of the 670 patients, 459 (68.6%) were female, and the mean age was 55.94 (17-80 years). We registered 316 patients (47.1%) with the erosive form of GERD and 354 patients (52.9%) with the non-erosive form. A total of 1,664 instances of comorbidities were recorded in 586 patients (87.5%), with the most common being arterial hypertension (21%), hypercholesterolemia (9%), obesity (9%), type II diabetes mellitus (5%) and depression (4%). Two or more comorbidities were present in 437 individuals (64.8%). The occurrence of comorbidities increased with age and was higher in patients with the non-erosive form of GERD.

CONCLUSIONS

In a tertiary referral population, comorbidities were very common, and these may have worsened the already impaired health-related quality of life of these patients. Clinicians caring for GERD patients in this setting must be aware of the likelihood and nature of comorbid disorders and their impact on disease presentation and patient management.

Clinical practice. Gastroesophageal reflux disease

A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastrointestinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment?

Non-erosive and erosive gastroesophageal reflux diseases: No difference with regard to reflux pattern and motility abnormalities

OBJECTIVE

To investigate whether gastroesophageal reflux disease (GERD) with mild to moderate erosive esophagitis (ERD) is a more severe disease regarding the amount of acid reflux, motor abnormalities, and the presence/absence of hiatus hernia than non-erosive reflux disease (NERD).

MATERIAL AND METHODS

The study comprised a retrospective analysis of prospectively collected data on 313 consecutive subjects referred for endoscopy, pH-metry, and esophageal manometry. The patients were divided into four groups: Group I (n=92), subjects without GERD with normal pH-metry, without esophagitis and without reflux symptoms; Group II (n=111), patients with NERD (no esophagitis, abnormal pH-metry); Group III (n=77), patients with mild to moderate ERD (LA A, B; abnormal pH-metry); Group IV (n=33), patients with severe or complicated esophagitis (LA C, D; Barrett's esophagus). All data are expressed as medians with 5th-95th percentiles.

RESULTS

No difference was found in the amount of acid reflux between patients with mild to moderate ERD and those with NERD. The DeMeester score was 34.5 (17-105) in NERD patients and 31.6 (15-102) in ERD patients. No significant differences were found between NERD and ERD patients regarding lower esophageal sphincter (LES) basal pressure (11.6 mmHg; 3-25 in NERD versus 10.7 mmHg; 3-22 in ERD). Similar proportions of patients with NERD and ERD had low LES basal pressure (20.7% in NERD versus 24.7% in ERD; NS) and hiatus hernia (44% and 56%; NS). A relatively high proportion of patients without GERD (Group I) had ineffective esophageal motility (39%) and hiatus hernia (30%).

CONCLUSIONS

No difference was found between NERD and mild to moderate ERD in terms of acid exposure time and esophageal motor abnormalities. To a certain extent, ERD is a "more complicated" form of the disease. Host factors related to a particular patient (e.g. mucosal defense, genetics, acid clearance) might be responsible for the development of esophagitis.

Contribution of histology to the diagnosis of reflux disease

Histology in reflux disease is still regarded as having low sensitivity and specificity. During the last three decades several histological parameters have been developed, including thickness of basal cell layer, length of epithelial papillae, intraepithelial inflammatory cells and dilation of intercellular spaces. Unfortunately classification of these parameters was often not related to the clinical symptoms of the reflux affected individuals, proper control subjects were often missing and often no interobserver variation was given. Another reason for the proposed low value of biopsies is the fact that biopsies were often taken in a non-standardised way. Recent studies point towards an area of predominantly epithelial damage close to the lesser curvature or around the right oesophageal wall. In parallel, some large, careful studies carried out recently showed a good correlation with the clinical picture of reflux disease due to a standardised biopsy protocol and proper controls. But biopsies are not recommended in all routine classical cases of reflux disease since it is believed that little further information in addition to endoscopy can be obtained. However, histology can deliver much more information than the diagnosis of reflux induced lesions (e.g. the exclusion of malignancy or other oesophageal diseases).

Columnar-lined esophagus: time to drop the eponym of "Barrett": Historical review

There can be few medical conditions that have been surrounded by as much confusion about their definition or terminology as columnar-lined esophagus (CLE); approximately 30 different terms and eponyms have been used to describe this condition. The history of this condition can be divided into five stages: (i) descriptive stage, 1906-1950; (ii) "argument" stage, 1950-1963; (iii) "significant" stage, 1963-1973; (iv) surveillance stage, 1973-1990; and (v) refined research stage, 1990-present. The use of the eponym "Barrett's" to describe CLE is not justified from a historical point of view. Lining of the lower esophagus by columnar epithelium was termed "Barrett's esophagus" after the presentation by Barrett in 1957. Although this finding has been attributed to Barrett, the work of others, including Tileston, Lortat-Jacob, and Allison and Johnstone, preceded Barrett's description. The historical aspects of CLE were reviewed to show how little Norman Barrett had contributed to the core concept of this condition in comparison to the contributions of other investigators, particularly the contribution of Philip Allison. Based on many discussed historical facts, we are not in favor of retaining the term "Barrett's esophagus" and we propose that CLE be henceforth referred to as "columnar-lined esophagus".

Effect of esomeprazole on symptom relief and improvement of quality of life in gastroesophageal reflux disease patients

AIM: To compare the efficacy and safety of esomeprazole with omeprazole on symptom relief and improvement of quality of life in gastroesophageal reflux disease (GERD) patients.

METHODS: A prospective, randomized controlled study was designed. A total of 78 GERD patients diagnosed with endoscope and/or their 24 h esophageal pH monitored were randomized into esomeprazole treatment group and omeprazole treatment group (39 patients each group). Patients in the two groups received standard doses of esomeprazole (20 mg, twice a day, po) or double doses of omeprazole (20 mg, twice a day, po) for 8 wk. Symptom relief, efficiency, cure rate and quality of life were compared between the two groups.

RESULTS: Seven-six patients completed the 8-week therapy. One patient in each group was dropped out because of running counter to the RE testing procedure. Symptoms of the two groups at weeks 4 and 8 were significantly improved. Symptoms of patients in the esomeprazole group were much better improved than those in the omeprazole group (P < 0.01). There was a significant difference in remission of heartburn and chest pain between the two groups (78.3% vs 45.5%, 64.3% vs 37.5%, P < 0.05). However, there was no significant difference in remission of acid regurgitation and dysphagia between the two groups. There was a significant difference in the efficiency and cure rate at weeks 4 and 8 between the two groups (4 wk: 88.8% vs 59.3%, 80.0% vs 51.9%, P < 0.05; 8 wk: 96.0% vs 70.4%, 88.0% vs 63.1%, P < 0.05). The quality of life, cure rate, vitality (VT) and social function (SF) were much better improved in the esomeprazole group than in the omeprazole group (92.5 ± 5.7 vs 85.3 ± 7.1, 85.2 ± 4.6 vs 76.8 ± 6.5, P < 0.05).

CONCLUSION: Standard doses of esomeprazole have better effects on improving heartburn and chest pain, cure rate, VT and SF in GERD patients than double doses of omeprazole.

Environmental factors in the etiology of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is currently one of the most common health problems in the Western world, affecting up to 20% of the adult population weekly and 50% monthly. It generates substantial suffering among patients as well as significant costs to both patients and society in general. GERD can further result in serious complications such as esophageal strictures, Barrett's esophagus and esophageal adenocarcinoma. This review discusses the current knowledge on risk factors and potential protective factors in the development of GERD.

Contemplating the future without Helicobacter pylori and the dire consequences hypothesis

Helicobacter pylori is a serious chronic transmissible pathogen that causes gastric structural and functional damage and is a major cause of morbidity and mortality worldwide. H. pylori is one of the digestive tract pathogens that has traveled with mankind since before humans moved out of Africa. Some have suggested that the long association of H. pylori with humans means there must be a benefit and suggest dire consequences will follow its eradication. Fortunately, there are now sufficient experiences with the outcome of treatment and with populations where the infection disappeared long ago to support the conclusion that H. pylori is a serious chronic transmissible pathogen that no one needs, deserves, or desires. The dire consequence hypotheses have proven to be erroneous attempts to blame some of the problems facing the modern world on a pathogen that was and is responsible for much suffering, morbidity, and mortality. It is time to join together to eradicate it and to let H. pylori join smallpox and polio on the hit list of undesirables.