Gastroesophageal reflux disease in Asia: A historical perspective and present challenges

[Antireflux laparoscopic intervention]

OBJECTIVE

To study the safety and efficacy of laparoscopic fundoplication and hiatal hernia repair for gastroesophageal reflux disease following hiatal hernia.

MATERIAL AND METHODS

We retrospectively analyzed 56 patients with gastroesophageal reflux disease and hiatal hernia .They underwent laparoscopic fundoplication and hiatal hernia repair between January 2020 and January 2023.

RESULTS

All surgeries were successful without conversion to open surgery. Surgery time was 56-180 min (mean 68.4±3.6), blood loss 30-200 ml (mean 40.3±5.6). No mortality and severe complications occurred. All patients were followed-up for 6-24 months. The GERD-Q and De Meester scores were significantly lower after 6 months compared to baseline values (p <0.05), and resting pressure was lower. Tone of lower esophageal sphincter was significantly higher compared to preoperative level (p <0.05). In 1-2 years after surgery, symptoms completely disappeared in 48 patients and significantly improved in 6 patients. Two patients had no improvement. Contrast-enhanced examination found no recurrent hiatal hernia and digestive tract obstruction.

CONCLUSION. L

Aparoscopic fundoplication and hiatal hernia repair is safe and effective for gastroesophageal reflux disease with hiatal hernia.

Dietary and lifestyle factors associated with troublesome gastroesophageal reflux symptoms in Vietnamese adults

Background

Dietary and lifestyle habits related to troublesome gastroesophageal reflux symptoms (tGERS) differ significantly across populations. There have yet to be studies on the Vietnamese population.

Aims

To identify dietary and lifestyle habits associated with tGERS in Vietnamese adults.

Methods

A cross-sectional survey was conducted among Vietnamese adults aged 18 years and older from March 2023 to May 2023. Participants were recruited online through a widely read national newspaper and Facebook, one of Vietnam's most popular social media platforms. The survey questionnaire comprised 27 questions covering participants' basic demographic information, dietary and lifestyle habits, the presence and characteristics of tGERS, and inquiries about specific dietary and lifestyle patterns, foods, and beverages associated with tGERS.

Results

A total of 4,400 valid responses were collected, including 2050 participants without tGERS and 2,350 participants with tGERS. Multivariate analysis showed several factors associated with tGERS, including eating beyond fullness (OR 1.383, CI95% 1.127-1.698), tight clothing (OR 1.627, CI95% 1.256-2.107), stress (OR 1.566, CI95% 1.363-1.800), and insomnia (OR 1.321, CI95% 1.129-1.546). Among habits associated with tGERS, eating beyond fullness was the most frequently reported (64.6%). Interestingly, although a short meal-to-bed time and staying up late after midnight were not risk factors for tGERS, they were two common factors associated with tGERS in symptomatic participants, particularly those with nocturnal reflux symptoms. For food triggers, the three most common ones were greasy foods (71.9%), sour/spicy soups (64.7%), and citrus fruits (36.0%). In terms of beverages, carbonated soft drinks were at the top of triggering tGERS (40.3%), and beer and orange juice were the second and third most common triggers, accounting for 35.7 and 30.6%, respectively.

Conclusion

We reported the dietary and lifestyle habits associated with tGERS in Vietnamese adults for the first time. These findings will serve as a basis for future studies on the primary prevention and nondrug management of tGERS in Vietnam.

Esophageal Mucosal Admittance: A New Technique to Diagnose Gastroesophageal Reflux Disease - Is It Feasible?

Purpose

Esophageal mucosal admittance (MA) is a promising diagnostic method for gastroesophageal reflux disease (GERD). We conducted a study to describe the esophageal MA in patients with reflux symptoms and determine its diagnostic accuracy.

Patients and Methods

We recruited 92 patients with ambulatory pH-impedance monitoring, upper gastrointestinal endoscopy, and MA measured by the tissue conductance meter. MA was measured during endoscopy at 5cm (distal esophagus) and 15cm above the Z line (middle esophagus), repeated at least five times at each position, and median MA was obtained. Afterwards, two biopsies were taken 5cm above the Z line for histopathological evaluation using the Esohisto criteria. Patients were classified as GERD or non-GERD according to the 2018 Lyon consensus.

Results

The mean age was 43.2 years, and 42 patients were males. The most common symptoms were regurgitation (75.0%), belching (65.2%), and heartburn (46.7%). Twenty-three (32.3%) were diagnosed with GERD using the Lyon consensus, and 24 (26.1%) had esophagitis on histopathology. The median MA at the distal and middle esophagus was moderately correlated. The median MA at both positions was higher in the GERD group but only statistically significant in the middle esophagus. MA was not associated with pH-impedance parameters and esophagitis on histopathology. The diagnostic model developed using the logistic regression did not have good accuracy.

Conclusion

MA was not different between GERD and non-GERD patients.

Meta-analysis on the epidemiology of gastroesophageal reflux disease in China

BACKGROUND

No large-scale epidemiological survey on the prevalence of gastroesophageal reflux disease (GERD) in China has been conducted. China has a large population and a complex geographical environment. It is important to understand the prevalence and spatial distribution of GERD in China.

AIM

To explore the prevalence and the spatial, temporal, and population distributions of GERD in the natural Chinese population.

METHODS

We searched Chinese and English databases for literature on the prevalence of GERD in the natural Chinese population. The prevalence of GERD was pooled using a random-effects meta-analysis model. Subgroup analysis was performed according to time, region, and population. We used ArcGIS software to draw statistical maps and trend analysis charts. Spatial autocorrelation analysis was carried out using Geoda software. Spearman correlation analysis was used to assess the spatial distribution relationship between GERD and upper digestive tract tumours.

RESULTS

Altogether, 70 studies involving 276014 individuals from 24 provinces of China were included. The overall pooled prevalence of GERD was 8.7% (95%CI: 7.5%-9.9%) in mainland China. Over the past two decades, the prevalence of GERD in China has increased from 6.0% to 10.6%. GERD was more common in people aged 40-60, with body mass index ≥ 24, and of Uygur ethnicity. The prevalence was higher in the west and east than in the centre, and there may be a local spatial autocorrelation between the Qinghai-Tibet Plateau and the southeast. GERD was correlated with gastric (r = 0.421, P = 0.041) and oesophageal tumours (r = 0.511, P = 0.011) in spatial distribution.

CONCLUSION

GERD is becoming common in China. The prevalence differs by region and population. The development of appropriate strategies for the prevention and treatment of GERD is needed.

A deep learning based framework for the classification of multi- class capsule gastroscope image in gastroenterologic diagnosis

Purpose: The purpose of this paper is to develop a method to automatic classify capsule gastroscope image into three categories to prevent high-risk factors for carcinogenesis, such as atrophic gastritis (AG). The purpose of this research work is to develop a deep learning framework based on transfer learning to classify capsule gastroscope image into three categories: normal gastroscopic image, chronic erosive gastritis images, and ulcer gastric image. Method: In this research work, we proposed deep learning framework based on transfer learning to classify capsule gastroscope image into three categories: normal gastroscopic image, chronic erosive gastritis images, and ulcer gastric image. We used VGG- 16, ResNet-50, and Inception V3 pre-trained models, fine-tuned them and adjust hyperparameters according to our classification problem. Results: A dataset containing 380 images was collected for each capsule gastroscope image category, and divided into training set and test set in a ratio of 70%, and 30% respectively, and then based on the dataset, three methods, including as VGG- 16, ResNet-50, and Inception v3 are used. We achieved highest accuracy of 94.80% by using VGG- 16 to diagnose and classify capsule gastroscopic images into three categories: normal gastroscopic image, chronic erosive gastritis images, and ulcer gastric image. Our proposed approach classified capsule gastroscope image with respectable specificity and accuracy. Conclusion: The primary technique and industry standard for diagnosing and treating numerous stomach problems is gastroscopy. Capsule gastroscope is a new screening tool for gastric diseases. However, a number of elements, including image quality of capsule endoscopy, the doctors' experience and fatigue, limit its effectiveness. Early identification is necessary for high-risk factors for carcinogenesis, such as atrophic gastritis (AG). Our suggested framework will help prevent incorrect diagnoses brought on by low image quality, individual experience, and inadequate gastroscopy inspection coverage, among other factors. As a result, the suggested approach will raise the standard of gastroscopy. Deep learning has great potential in gastritis image classification for assisting with achieving accurate diagnoses after endoscopic procedures.

Influence of Alcohol Consumption on the Development of Erosive Esophagitis in Both Sexes: A Longitudinal Study

The influence of changes in alcohol consumption on erosive esophagitis (EE) development in both sexes is unclear. This observational study investigated sex differences in the influence of alcohol consumption on EE development, and included 2582 patients without EE at baseline from 13,448 patients who underwent >2 health check-ups over >1 year. The rates of non-drinkers who started drinking, and drinkers who abstained from drinking, who increased, and who decreased their weekly alcohol consumption were 7.2%, 9.7%, 14.7%, and 24.1% and 7.3%, 17.8%, 12.8%, and 39.0% in men and women, respectively. In the final cohort, 211/1405 (15.0%) men and 79/1177 (6.7%) women newly developed EE. The odds ratio (OR) for drinking in EE development was 1.252 (95% confidence interval (CI), 0.907−1.726) among men and 1.078 (95% CI, 0.666−1.747) among women. Among men aged <50 years, the OR for drinking ≥70 g/week in EE development was 2.825 (95% CI, 1.427−5.592), whereas among women, the OR for drinking ≥140 g/week in EE development was 3.248 (95% CI, 1.646−6.410). Among participants aged <50 years, the OR for daily drinking in EE development was 2.692 (95% CI, 1.298−5.586) among men and 4.030 (95% CI, 1.404−11.57) among women. The influence of alcohol consumption on EE development differed between the sexes. We recommend no alcohol consumption for individuals aged <50 years to avoid EE development. Daily drinkers should be assessed for EE development.

The Effect of the Preoperative Fasting Regimen on the Incidence of Gastro-Oesophageal Reflux in 90 Dogs

Simple Summary

Gastro-oesophageal reflux (GOR), a potential risk during anaesthesia, happens when the stomach contents move up into the oesophagus. The refluxed contents can damage the lining of the oesophagus or the respiratory tract. For many years it was believed that an increase in the stomach contents’ volume increases the risk of GOR. However, more recent studies have demonstrated this to be incorrect. The objective of this study was to compare the effects of three different pre-anaesthetic fasting regimens on the frequency of GOR in dogs under anaesthesia. Ninety dogs undergoing non-abdominal and non-thoracic elective surgery were included in the study and equally allocated to three groups. The results of this study suggest that the administration of a meal 3 h before anaesthesia does not have any beneficial effect in the reduction of GOR incidence in dogs compared to the administration of a meal 12 h before anaesthesia.

Abstract

This study aimed to investigate the effect of three different preoperative fasting regimens on the incidence of gastro-oesophageal reflux (GOR) in dogs under general anaesthesia. Ninety dogs undergoing non-abdominal and non-thoracic elective surgery were included in the study and equally allocated to three groups. Dogs received canned food providing half the daily resting energy requirements (RER) 3 h prior to premedication (group 3H), a quarter of the daily RER 3 h before premedication (group 3Q), and half the daily RER 12 h before premedication (group 12H). The animals were premedicated with acepromazine and pethidine, anaesthesia was induced with propofol and maintained with isoflurane vaporised in oxygen. Oesophageal pH was monitored throughout anaesthesia. Demographic and surgery-related parameters were not different among groups. The incidence of GOR was 11/30 in group 3H (36.7%), 9/30 in group 3Q (30.0%) and 5/30 in group 12H (16.7%), which was not statistically different (p = 0.262). Reduction of the amount of the preoperative meal from half to a quarter of the daily RER did not reduce the incidence of GOR but resulted in a lower oesophageal pH (p = 0.003). The results of this study suggest that the administration of a meal 3 h before anaesthesia does not have any beneficial effect in the reduction of GOR incidence in dogs compared to the administration of a meal 12 h before anaesthesia.

Esophageal Nocturnal Baseline Impedance and Post-reflux Swallow-induced Peristaltic Wave Index in Identifying Proton Pump Inhibitor-refractory Non-erosive Reflux Disease

Background/Aims

Esophageal mean nocturnal baseline impedance (MNBI) levels and post-reflux swallow-induced peristaltic wave (PSPW) index could increase the diagnostic value of 24-hour multichannel intraluminal impedance and pH monitoring in patients with gastroesophageal reflux disease. This study aims to compare the MNBI and PSPW index in patients with no evidence of erosive reflux disease.

Methods

Impedance-pH monitoring tracings from 70 patients, 50 with non-erosive reflux disease (NERD) and 20 with functional heartburn (FH), were reviewed. According to proton pump inhibitors (PPI) treatment response, NERD patients were divided into NERD/PPI responders and NERD/PPI nonresponders. MNBI, PSPW index, and intercellular spaces were measured and compared among each group.

Results

MNBI values and PSPW index were lower in NERD patients than in FH (P < 0.01 and P < 0.05, respectively). MNBI positively correlated with PSPW index (r = 0.525, P < 0.001). NERD/PPI responders had lower MNBI values and PSPW index compared to NERD/PPI nonresponders (both P < 0.01). MNBI and PSPW index distinguished NERD from FH patients with an area under the curve of 0.914 and 0.677, respectively. Wider intercellular space could be identified in patients with NERD (P < 0.01).

Conclusion

MNBI and PSPW index may differentiate NERD from FH patients and relate to PPI treatment efficacy in patients with NERD.

Management of Helicobacter pylori infection: The Bhubaneswar Consensus Report of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology (ISG) felt the need to organize a consensus on Helicobacter pylori (H. pylori) infection and to update the current management of H. pylori infection; hence, ISG constituted the ISG's Task Force on Helicobacter pylori. The Task Force on H. pylori undertook an exercise to produce consensus statements on H. pylori infection. Twenty-five experts from different parts of India, including gastroenterologists, pathologists, surgeons, epidemiologists, pediatricians, and microbiologists participated in the meeting. The participants were allocated to one of following sections for the meeting: Epidemiology of H. pylori infection in India and H. pylori associated conditions; diagnosis; treatment and retreatment; H. pylori and gastric cancer, and H. pylori prevention/public health. Each group reviewed all published literature on H. pylori infection with special reference to the Indian scenario and prepared appropriate statements on different aspects for voting and consensus development. This consensus, which was produced through a modified Delphi process including two rounds of face-to-face meetings, reflects our current understanding and recommendations for the diagnosis and management of H. pylori infection. These consensus should serve as a reference for not only guiding treatment of H. pylori infection but also to guide future research on the subject.

Consensus statements and recommendations on the management of mild-to-moderate gastroesophageal reflux disease in the Southeast Asian region

This paper reports the proceedings from the first consensus meeting on the management of mild-to-moderate gastroesophageal reflux disease (GERD) in the Southeast Asian (SEA) region. Seventeen statements were drawn up by a steering committee that focused on epidemiology, mechanism of action, diagnostic investigations, and treatment. Voting on the recommendations used the Delphi method with two rounds of voting among the 10 panel members. The consensus panel agreed that GERD is mostly a mild disease in the SEA region with predominantly non-erosive reflux disease (NERD). Complicated GERD and Barrett's esophagus are infrequently seen. The panel recommended endoscopy in patients with alarm or refractory symptoms but cautioned that the incidence of gastric cancer is higher in SEA. pH and impedance measurements were not recommended for routine assessment. The acid pocket is recognized as an important pathogenic factor in GERD. Lifestyle measures such as weight reduction, avoidance of smoking, reduction of alcohol intake, and elevation of the head of the bed were recommended but strict avoidance of specific foods or drinks was not. Alginates was recommended as the first-line treatment for patients with mild-to-moderate GERD while recognizing that proton-pump inhibitors (PPIs) remained the mainstay of treatment of GERD. The use of alginates was also recommended as adjunctive therapy when GERD symptoms were only partially responsive to PPIs.

Associations between Lifestyle Habits, Perceived Symptoms and Gastroesophageal Reflux Disease in Patients Seeking Health Check-Ups

Gastroesophageal reflux disease (GERD) is one of the most common diseases. It mainly causes the stomach contents to flow back to the esophagus, thereby stimulating the esophagus and causing discomfort. From the results of our research, we intend to provide the general public with information related to preventing gastroesophageal reflux disease and medical personnel with information on the treatment and care of patients with gastroesophageal reflux disease. This study aimed to investigate the association of lifestyle habits and perceived symptoms on GERD in patients who underwent routine health check-ups. This study was conducted as a retrospective cross-sectional design to collect GERD cases from the medical records containing the health questionnaires and the report of endoscopic findings on the day of the health check-up. A total of 5653 patients were enrolled between 1 January 2016, and 31 December 2018. About 60.2% (n = 3404) of patients with GERD were diagnosed based on endoscopic findings. Descriptive and multivariate logistic regression analyses were performed to identify the risk factors of the development of GERD. The results of the multivariate logistic regression analysis showed that age, sex, waist circumference, Areca catechu chewing habit, sleep disorders, otolaryngology symptoms, and hepatobiliary and gastrointestinal symptoms were significantly associated with GERD. In this study, our results can be used as a reference for public health care and clinicians. Because most GERD cases can be controlled and prevented by lifestyle modifications, health professionals should always obtain a detailed history regarding symptoms and lifestyle habits associated with GERD.

A Methodological and Reporting Quality Assessment of Systematic Reviews/Meta-Analyses about Chinese Medical Treatment for Gastroesophageal Reflux Disease

OBJECTIVE

To access the methodological and reporting quality of systematic reviews (SRs)/meta-analyses (MAs) about Chinese medical treatment for gastroesophageal reflux disease (GERD).

METHODS

The PubMed, Wanfang Data, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical Database (VIP), Chinese Biomedical (CBM), Web of Science, and Cochrane Library databases were searched from inception to June 2020. Two researchers independently screened the literature considering the eligibility criteria. Overview Quality Assessment Questionnaire (OQAQ), Assessment of Multiple Systematic Reviews 2 (AMSTAR 2), and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to assess the methodological and reporting quality of the included reports. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the level of evidence in each report.

RESULTS

Thirty-three SRs/MAs met the inclusion criteria. The OQAQ results showed that defects in the methodological quality of 17/32 reports were major, with scores of 3 points. Analyzing a single item as the object, search strategies (item 2), and risk of bias in individual studies (item 4) was considered poor. The AMSTAR 2 results showed that 25.4% of the items were not reported, and 7.8% of the items were only partially reported. The overall assessment of AMSTAR 2 showed the majority of systematic reviews and meta-analyses were of low/very low (31/33, 93.9%) methodological quality, with a lack of protocol registration and excluded study list. The PRISMA results showed that 19.9% of items were not reported, and 15.2% of items were only partially reported, due to a lack of protocol registration and study selection methods. The methodological and reporting quality of the included studies was generally poor. Evidence evaluation with GRADE showed that most (31/33) of the included studies had low or very low levels of evidence.

CONCLUSION

The methodological and reporting quality of SRs/MAs about Chinese medical treatment for GERD is generally poor. The main problems included incomplete search strategies, risk of bias in individual studies, the lack of protocol registration and excluded study list, and incorrect study selection methods.

Changing etiological frequency of chronic cough in a tertiary hospital in Shanghai, China

Background

The frequency distributions of the etiologies of chronic cough have changed over time. This study aimed to investigate the changing etiological frequency of chronic cough in a tertiary hospital in Shanghai, China, and to explore the clinical significance.

Methods

Medical records of 1,311 patients with chronic cough who visit our hospital between January 2009 and December 2016 were retrospectively reviewed. The etiologies of chronic cough were identified according to a standardized step-by-step diagnostic protocol and the changes in the etiological frequency of chronic cough over the years were using the Chi-squared (χ²) test.

Results

Cough variant asthma (CVA) (449/1,311, 34.2%), gastroesophageal reflux-related chronic cough (GERC) (374/1,311, 28.5%), upper airway cough syndrome/postnasal drip syndrome (UACS/PNDs) (241/1,311, 18.4%), atopic cough (AC) (188/1,311, 14.3%), and non-asthmatic eosinophilic bronchitis (NAEB) (147/1,311, 11.2%) were the common causes of chronic cough in descending order. The post-infectious cough (PIC) (39/1,311, 3.0%) and angiotensin-converting enzyme inhibitor (ACEI)-induced cough (25/1,311, 1.9%) were less common. During the 8-year period, the proportion of CVA (χ²=72.86, P<0.0001) and UACS/PNDs (χ²=68.80, P<0.0001) decreased, while those of NAEB (χ²=51.38, P<0.0001), GERC (χ²=55.95, P<0.0001) and AC (χ²=39.09, P<0.0001) increased.

Conclusions

The etiological frequency of chronic cough varies over time, and it may encourage the adjustment of the current diagnostic and therapeutic strategies for chronic cough.

Efficacy of the four weeks treatment of omeprazole plus mosapride combination therapy compared with that of omeprazole monotherapy in patients with proton pump inhibitor-refractory gastroesophageal reflux disease: a randomized controlled trial

Purpose

The aim of this study was to compare the effect of omeprazole plus mosapride combination therapy with that of omeprazole monotherapy in proton pump inhibitor (PPI) refractory gastroesophageal reflux disease (GERD) patients.

Patients and methods

Patients were eligible to participate in this study if they had experienced symptoms of heartburn and/or regurgitation more than twice weekly and were unresponsive to at least 8 weeks of a standard dose of PPI. A total of 44 consecutive patients were randomized to receive omeprazole 20 mg once daily plus either mosapride 5 mg or placebo three times daily for 4 weeks. We evaluated their clinical symptoms by means of frequency scale for symptoms of GERD (FSSG) questionnaires completed at the beginning and the end of the study. The primary outcome was to compare changes in FSSG scores between treatment groups during the study period.

Results

Most of the study population had non-erosive reflux disease (91.0% in the combination group and 81.8% in the control group). The minority of patients had Los Angeles grade A or B erosive esophagitis (9% in the combination group and 18.2% in the control group). None of the patients had Los Angeles grade C or D erosive esophagitis. FSSG total scores significantly decreased both in the combination group and the control group, with no significant differences in improvement between the groups (−8.00±7.18 for the combination group versus −5.68±6.29 for the control group, p=0.129). As a secondary outcome, our data showed that the effect of combination therapy on a number of symptom-free days (heartburn-free days, regurgitation-free days, and night-time heartburn-free days) was not superior to PPI monotherapy.

Conclusion

Combining mosapride for four weeks with a standard dose of PPI is not more effective than PPI alone in patients with PPI-refractory GERD.

Randomised phase 3 trial: tegoprazan, a novel potassium-competitive acid blocker, vs. esomeprazole in patients with erosive oesophagitis

BACKGROUND

Tegoprazan is a novel potassium-competitive acid blocker that has a fast onset of action and can control gastric pH for a prolonged period, which could offer clinical benefit in acid-related disorders.

AIM

To confirm the non-inferiority of tegoprazan to esomeprazole in patients with erosive oesophagitis (EE).

METHODS

In this multicentre, randomised, double-blind, parallel-group comparison study, 302 Korean patients with endoscopically confirmed EE (Los Angeles Classification Grades A-D) were randomly allocated to either tegoprazan (50 or 100 mg) or esomeprazole (40 mg) treatment groups for 4 or 8 weeks. The primary endpoint was the cumulative proportion of patients with healed EE confirmed by endoscopy up to 8 weeks from treatment initiation. Symptoms, safety and tolerability were also assessed.

RESULTS

The cumulative healing rates at week 8 were 98.9% (91/92), 98.9% (90/91) and 98.9% (87/88) for tegoprazan 50 mg, tegoprazan 100 mg and esomeprazole 40 mg, respectively. Both doses of tegoprazan were non-inferior to esomeprazole 40 mg. The incidence of adverse events was comparable among the groups, and tegoprazan was well-tolerated.

CONCLUSION

Once daily administration of tegoprazan 50 or 100 mg showed non-inferior efficacy in healing EE and tolerability to that of esomeprazole 40 mg.

What is the impact of metabolic syndrome and its components on reflux esophagitis? A cross-sectional study

Background

The prevalence rate of reflux esophagitis (RE) in Asia, including Taiwan, has increased dramatically in recent years. However, few studies have discussed on its relationship with metabolic syndrome (MetS). This study aimed to evaluate the correlation between RE and MetS and its components.

Methods

We conducted a cross-sectional study during 2013 to 2014 in Taiwan. A total of 4895 subjects who completed upper gastrointestinal endoscopy at the Health Examination Center of Changhua Christian Hospital were enrolled. RE was defined according to the upper gastrointestinal endoscopic findings and MetS was defined according to the Taiwanese criteria. Univariate and multivariate logistic regression analyses were applied to calculate odds ratios and 95% confidence intervals for each variable to assess the associated features for RE. We analyzed the relationship between the number of MetS components and the severity of RE using the chi-square test for trend.

Results

The prevalence rates of MetS and RE were respectively 28.5 and 59.6%. According to univariate logistic regression analysis, MetS was significantly associated with RE and remained a positive association in multivariate logistic regression analysis (adjusted OR^ß = 1.251; 95% CI = 1.071–1.462; p = 0.005). Furthermore, among the five MetS components, elevated blood pressure (adjusted OR^γ = 1.163; 95% CI = 1.023–1.323; p = 0.021), abdominal obesity (adjusted OR^γ = 1.173; 95% CI = 1.020–1.349; p = 0.026) and hyperglycemia (adjusted OR^γ = 1.306; 95% CI = 1.142–1.495; p < 0.001) were positively associated with the presence of RE. A weak association was also found between elevated triglycerides and RE after adjusting for age and gender (adjusted OR^α = 1.171; 95% CI = 1.022–1.343; p = 0.023). Reduced high-density lipoprotein cholesterol showed no significant difference between groups with and without RE. Older age (≥65 years), male gender, higher body mass index, higher uric acid, smoking, alcohol drinking, and hiatal hernia were found to be significant associated factors for RE. In addition, a dose-response relation between the number of MetS components and the presence of RE was demonstrated in the multivariate analysis. Furthermore, we performed a trend analysis and found the severity of RE got worse as the number of MetS components increased (p < 0.001).

Conclusion

This study suggests that MetS is significantly related to the presence and the severity of RE.

Weight Loss as a Nonpharmacologic Strategy for Erosive Esophagitis: A 5-Year Follow-up Study

Background/Aims

Obesity is a risk factor for gastroesophageal reflux disease (GERD), with several studies demonstrating positive associations between body mass index (BMI) and GERD symptoms. However, little is known about the effect of BMI changes on erosive esophagitis (EE). In this study, we investigated whether BMI reduction could resolve EE.

Methods

A retrospective cohort study was performed to assess the natural course of EE according to changes in BMI. Participants undergoing health check-ups from 2006 to 2012 were enrolled, and 1,126 subjects with EE were included. The degree of esophagitis was measured by upper endoscopy and serially checked over a 5-year follow-up. Logistic regression and Cox proportional hazards models were used to investigate the association between BMI reduction and EE resolution.

Results

Substantial weight loss is associated with EE resolution. The adjusted odds ratio for EE resolution was 1.44 (95% confidence interval [CI], 1.09 to 1.92) among participants with a decrease in BMI compared to those with no decrease in BMI. The EE resolution rate was related to the degree of BMI reduction. The effect of weight loss on EE resolution was higher among subjects who lost more weight. Compared with subjects with no decrease in BMI, the hazard ratios for EE resolution were 1.09 (95% CI, 0.89 to 1.35), 1.31 (95% CI, 1.01 to 1.72) and 2.12 (95% CI, 1.44 to 3.12) in subjects with BMI reductions of ≤1, 1–2, and >2 kg/m², respectively.

Conclusions

EE resolution is associated with a decrease in BMI, and weight loss is potentially an effective GERD treatment.

Antireflux surgery is equally beneficial in nonerosive and erosive gastroesophageal reflux disease

Purpose

Although nonerosive and erosive gastroesophageal reflux disease (GERD) have similar symptom severity, nonerosive reflux disease (NERD) is considered a milder type of GERD and gastroenterologists have hesitated to refer these patients for antireflux surgery. The aim of this study was to compare surgical outcomes of antireflux surgery between patients with NERD and erosive reflux disease (ERD).

Methods

Seventy patients met the inclusion criteria of this study among a total of 117 patients who underwent antireflux surgery from November 2012 to October 2017. According to preoperative endoscopy, patients were classified into NERD group (minimal changes or no esophagitis) and ERD group. Clinical characteristics and surgical outcomes were compared between NERD and ERD.

Results

There were 26 patients in NERD group and 44 patients in ERD group. The male:female ratio was higher in the ERD group than in the NERD group (P = 0.044). Preoperative symptoms, response to acid suppressive medication, acid exposure on pH monitoring study, and esophageal manometry results were similar in the 2 groups. Reflux on barium esophagography was more frequently observed in ERD (77.3%) than in NERD (50.0%, P = 0.019). At 6 months after surgery, complete resolution and partial improvement of GERD symptoms were similar in the 2 groups (80.8% and 15.4%, respectively, in NERD vs. 88.6% and 2.3%, respectively, in ERD; P = 0.363).

Conclusion

Laparoscopic Nissen fundoplication is equally beneficial to patients with NERD and ERD. Antireflux surgery should not be avoided for GERD patients without mucosal breaks on endoscopy as the evidence of erosive esophagitis.

Comparative effectiveness and acceptability of the FDA-licensed proton pump inhibitors for erosive esophagitis: A PRISMA-compliant network meta-analysis

BACKGROUND

This study compared the effectiveness and acceptability of all Food and Drug Administration (FDA)-recommended dose proton pump inhibitors (PPIs) in erosive esophagitis (EE): Dexlansoprazole 60 mg, Esomeprazole 40 mg, Esomeprazole 20 mg, Pantoprazole 40 mg, Lansoprazole 30 mg, Rabeprazole 20 mg, Omeprazole 20 mg.

METHODS

A systematic literature search was performed using PubMed, Embase, and Cochrane Library. Totally, 25 randomized controlled trials (RCTs) met study selection criteria and were incorporated in this network meta-analysis (NMA) study.

RESULTS

For the NMA, eligible RCTs of adults with EE verified by endoscopic examination were randomly assigned to the licensed PPIs at least 4 weeks of continuous therapy. The primary efficacy outcome was the endoscopic healing rates at 4 and 8 weeks. Heartburn relief rates were a secondary efficacy outcome. The rates of withdrawal were analyzed as a safety outcome. In comparison to the common comparator omeprazole 20 mg, esomeprazole 40 mg provided significantly healing rates at 4 weeks [odds ratio (OR), 1.46 (95% confidence interval, 95% CI, 1.24-1.71)] and 8 weeks [1.58 (1.29-1.92)], and improved the heartburn relief rates [1.29 (1.07-1.56)]. In comparison to lansoprazole 30 mg, esomeprazole 40 mg provided significantly healing rates at 4 weeks [1.30 (1.10-1.53)] and 8 weeks [1.37 (1.13-1.67)], and improved the heartburn relief rates [1.29 (1.03-1.62)]. In terms of acceptability, only dexlansoprazole 60 mg had significantly more all-cause discontinuation than omeprazole 20 mg [1.54 (1.03-2.29)], pantoprazole 40 mg [1.68 (1.08-2.63)], and lansoprazole 30 mg [1.38 (1.02-1.88)].

CONCLUSION

The standard-dose esomeprazole 40 mg had more superiority in mucosal erosion healing and heartburn relief. Esomeprazole 40 mg, pantoprazole 40 mg, esomeprazole 20 mg, and lansoprazole 30 mg showed more benefits in effectiveness and acceptability than other interventions.

Emerging Gastrointestinal and Liver Diseases in Asia Pacific: Implications to Health Care in the Region (World Gastroenterology Organization: Asian Pacific Association of Gastroenterology Distinguished Global Lecture 2015)

Colorectal cancer (CRC), gastroesophageal reflux disease (GERD), inflammatory bowel disease (IBD), and nonalcoholic fatty liver disease are considered important emerging diseases in the Asia Pacific (AP) region. The incidence rate of CRC is the highest among gastrointestinal cancers in the region surpassing that of gastric cancer. However, population CRC screening is limited by availability of adequate health resources and financing. GERD is a highly prevalent disease in AP with the prevalence of GERD symptoms and reflux esophagitis reported to be increasing. The usage of proton pump inhibitors has also been reported to be high. The incidence and prevalence of IBD is not as high as in the west but is now an increasingly recognizable disease in the AP region. Being a complicated disease, IBD will pose a huge financial burden with the increasing use of expensive biological drugs. In tandem with the exponential increase in obesity and diabetes mellitus in AP, nonalcoholic fatty liver disease will become the most important liver disease in the region in the coming years. These emerging diseases reflect the continued fast-paced socioeconomic development in the region with marked lifestyle changes and increasing affluence.

Alcohol and tea consumption are associated with asymptomatic erosive esophagitis in Taiwanese men

Objective

Asymptomatic erosive esophagitis (AEE) is commonly found in men, and might be a risk factor of developing esophageal adenocarcinoma. We aimed to determine if specific dietary habits increase the risk of AEE in asymptomatic Taiwanese men.

Methods

We recruited male adults undergoing upper gastrointestinal endoscopy for health check. We excluded subjects with reflux symptoms, or taking anti-reflux medications or drugs that potentially impair lower esophageal sphincter function or cause mucosal injury. The frequency of consuming reflux-provoking diets including alcohol, tea, coffee, tomato/citric juice, chocolate, sweet food, and spicy food was assessed. The erosive esophagitis was diagnosed based on the Los Angeles Classification after endoscopy. Frequent consumption of a specific diet was defined as ≥4 days/week of consuming that diet.

Results

A total of 1256 participants were recruited. After excluding 424 ineligible subjects, AEE was identified in 180 (22%) among 832 asymptomatic subjects. The risk of AEE increased with the number of days per week of consuming alcohol or tea: nondrinkers (19%, 17%), occasional drinkers (<1 day/week; 19%, 15%), regular drinkers (1–3 days/week; 26%, 21%), frequent drinkers (4–6 days/week; 32%, 22%), and daily drinkers (42%, 28%), respectively (trend test P < 0.001 for both). Multivariate analysis showed that hiatus hernia (adjusted odds ratio (aOR) 5.0, 95% confidence interval (CI) 2.6–9.6), drinking alcohol ≥4 days/week (aOR 2.3, 95% CI 1.3–4.0), and drinking tea ≥4 days/week (aOR 1.6, 95% CI 1.1–2.3) are independent risk factors of AEE. The risk of AEE was 3.8 times greater for those drinking both alcohol and tea ≥4 days/week than the non-drinkers.

Conclusions

Frequent alcohol and tea consumption increased the risk of AEE in Taiwanese men.

Operative Treatments for Reflux After Bariatric Surgery: Current and Emerging Management Options

Gastroesophageal reflux disease (GERD) is a common disorder that has a well-established connection with obesity. To ameliorate the morbidity associated with obesity, bariatric procedures have become an established pathway to accomplish sustained weight loss. In some procedures, such as with the Roux-en-Y gastric bypass surgery, weight loss is also accompanied by the resolution of GERD symptoms. However, other popular bariatric surgeries, such as the sleeve gastrectomy, have a controversial impact on their effect on reflux. Consequently, increased attention has been given to the development of strategies for the management of de novo or recurrent reflux after bariatric surgery. This article aims to discuss medical and surgical strategies for reflux after bariatric surgery, and their outcomes.

Gender differences in the association of non-alcoholic fatty liver disease and metabolic syndrome with erosive oesophagitis: a cross-sectional study in a Taiwanese population

OBJECTIVES

Although metabolic syndrome correlates with erosive oesophagitis, few studies have examined the association between non-alcoholic fatty liver disease (NAFLD), associated with obesity and insulin resistance as metabolic syndrome, and erosive oesophagitis. The possible gender differences in risk factors of erosive oesophagitis should be considered. This study aimed to determine the concomitant effects of NAFLD and metabolic syndrome on erosive oesophagitis with respect to gender.

DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES

This cross-sectional study, conducted between January 2000 and August 2009, included 12 090 participants from the health examination center of a tertiary hospital. NAFLD was diagnosed according to ultrasonographic findings after excluding participants with excessive alcohol consumption or other liver diseases. Metabolic syndrome was determined using the revised National Cholesterol Education Program Adult Treatment Panel III criteria. Erosive oesophagitis was defined according to the Los Angeles classification by oesophagogastroduodenoscopy.

RESULTS

On the basis of the oesophagogastroduodenoscopic findings, the prevalence of erosive oesophagitis was 20.1% (n=1427/7110) and 9.9% (n=477/4842) in males and females, respectively. After adjusting for other variables, metabolic syndrome (OR 1.26; 95% CI 1.09 to 1.45) but not NAFLD (OR 1.14; 95% CI 0.98 to 1.30) significantly correlated with erosive oesophagitis in males, while NAFLD (OR 1.50; 95% CI 1.21 to 1.86) but not metabolic syndrome (OR 1.24; 95% CI 0.94 to 1.63) positively correlated with erosive oesophagitis in females.

CONCLUSIONS

The detrimental effect on erosive oesophagitis is greater by metabolic syndrome than by NAFLD in males but greater by NAFLD than by metabolic syndrome in females.

Persistent gastro-oesophageal reflux symptoms despite proton pump inhibitor therapy

About one-third of patients with suspected gastro-oesophageal reflux disease (GERD) do not respond symptomatically to proton pump inhibitors (PPIs). Many of these patients do not suffer from GERD, but may have underlying functional heartburn or atypical chest pain. Other causes of failure to respond to PPIs include inadequate acid suppression, non-acid reflux, oesophageal hypersensitivity, oesophageal dysmotility and psychological comorbidities. Functional oesophageal tests can exclude cardiac and structural causes, as well as help to confi rm or exclude GERD. The use of PPIs should only be continued in the presence of acid reflux or oesophageal hypersensitivity for acid reflux-related events that is proven on functional oesophageal tests.

Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus

OBJECTIVE

Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus.

METHODS

A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations.

RESULTS

A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer.

CONCLUSIONS

These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region.

Pharmacological and Safety Profile of Dexlansoprazole: A New Proton Pump Inhibitor - Implications for Treatment of Gastroesophageal Reflux Disease in the Asia Pacific Region

Although gastroesophageal reflux disease is not as common in Asia as in western countries, the prevalence has increased substantially during the past decade. Gastroesophageal reflux disease is associated with considerable reductions in subjective well-being and work productivity, as well as increased healthcare use. Proton pump inhibitors (PPIs) are currently the most effective treatment for gastroesophageal reflux disease. However, there are limitations associated with these drugs in terms of partial and non-response. Dexlansoprazole is the first PPI with a dual delayed release formulation designed to provide 2 separate releases of medication to extend the duration of effective plasma drug concentration. Dexlansoprazole has been shown to be effective for healing of erosive esophagitis, and to improve subjective well-being by controlling 24-hour symptoms. Dexlansoprazole has also been shown to achieve good plasma concentration regardless of administration with food, providing flexible dosing. Studies in healthy volunteers showed no clinically important effects on exposure to the active metabolite of clopidogrel or clopidogrel-induced platelet inhibition, with no dose adjustment of clopidogrel necessary when coprescribed. This review discusses the role of the new generation PPI, dexlansoprazole, in the treatment of gastroesophageal reflux disease in Asia.

Risk factors for gastroesophageal reflux disease

Gastroesophageal reflux disease, a common disease of the digestive tract that can be caused by various factors, seriously harms the patients' life quality due to the repeated episodes. Here we discuss the risk factors for gastroesophageal reflux disease, in order to assist in the prevention and treatment of the disease.

Electroacupuncture to treat gastroesophageal reflux disease: study protocol for a randomized controlled trial

BACKGROUND

Gastroesophageal reflux disease lowers the quality of life and increases medical costs. Electroacupuncture has been used to ease symptoms and improve gastrointestinal motility in patients with gastroesophageal reflux disease. The main purposes of this study are to evaluate the efficacy and safety of this procedure.

METHODS/DESIGN

This is a protocol for a randomized, patient-blinded, assessor-blinded, sham-controlled trial. Sixty participants with symptoms of gastroesophageal reflux disease, who have previously undergone standard treatment, will be recruited from August 2015 at Kyung Hee University Korean Medicine Hospital. The participants will be allocated to either the electroacupuncture (n = 30) or the sham electroacupuncture group (n = 30); the allocation will be concealed from both the participants and the assessors. The EA group will undergo penetrating acupuncture at 18 fixed points and two optional points chosen using the pattern identification for gastroesophageal reflux disease. Electrical stimulation will be applied at some of the acupoints. The sham electroacupuncture group will undergo nonpenetrating acupuncture without electrical stimulation at 18 nonspecific points, each of which will be only 2 cm away from the true acupoints used in the electroacupuncture group. In both groups, the procedure will be performed using the Park device. The treatment will last for 6 weeks (with two sessions each week), and the outcome will be evaluated at baseline, 3 weeks, and 6 weeks. The primary outcome will be the proportion of responders with adequate symptom relief, whereas the secondary outcomes will comprise the results of the Nepean dyspepsia index; the Korean gastrointestinal symptom rating scale; the EQ-5D™; levels of gastrin, motilin, and inflammatory cytokines; the perceived stress scale; the qi-stagnation questionnaire; the patient global impression of change; and the spleen qi deficiency questionnaire.

DISCUSSION

The results of this trial will provide information about the efficacy and safety of electroacupuncture in the treatment of gastroesophageal reflux disease symptoms, as well as evidence regarding the use of electroacupuncture to treat gastroesophageal reflux disease in real clinical practice.

TRIAL REGISTRATION

Clinical Research Information Service Identifier, KCT0001653 . Registered on 12 October 2015.

Time trends in upper gastrointestinal diseases and Helicobacter pylori infection in a multiracial Asian population--a 20-year experience over three time periods

BACKGROUND

Marked epidemiological changes in upper gastrointestinal diseases and Helicobacter pylori infection have taken place in the Asian Pacific region. In particular, differences with respect to race in the multiracial Asian population in Malaysia have been important and interesting.

AIM

A time trend study of upper gastrointestinal disease and H. pylori infection in three time periods: 1989-1990, 1999-2000 and 2009-2010 spanning a period of 20 years was carried out.

METHODS

Consecutive first time gastroscopies carried out on patients attending the University of Malaya Medical Center were studied. Diagnoses and H. pylori infection status were carefully recorded.

RESULTS

A steady decline in prevalence of duodenal ulcer (DU) and gastric ulcer (GU) from 21.1% to 9.5% to 5.0% and from 11.9% to 9.4% to 9.9% while an increase in erosive oesophagitis (EO) from 2.0% to 8.4% to 9.5% (chi-square for trend; P < 0.001) for the periods 1989-1990, 1999-200 and 2009-2010 were observed. The overall prevalence of H. pylori had also decreased from 51.7% to 30.3% to 11.1% for the same periods of time. The proportion of H. pylori positive ulcers had also decreased: DU (90.1%-69.8%-28.9%) and GU (86.6-56.8%-18.9%) (P < 0.001). This was observed in Malays, Chinese and Indians but the difference over time was most marked in Malays. There was a steady decline in the proportion of patients with gastric and oesophageal cancers.

CONCLUSIONS

Peptic ulcers have declined significantly over a 20-year period together with a decline in H. pylori infection. In contrast, a steady increase in erosive oesophagitis was observed. Gastric and oesophageal squamous cell cancers have declined to low levels.

Outcome of Stretta radiofrequency and fundoplication for GERD-related severe asthmatic symptoms

This study aimed to investigate the outcome of treatment with Stretta radiofrequency (SRF) or laparoscopic Nissen fundoplication (LNF). A total of 137 gastroesophageal reflux disease (GERD) patients with severe asthmatic symptoms who responded inadequately to medical treatment for asthma were investigated. The patients were followed up 1 year and 5 years after SRF (n = 82) or LNF (n = 55) treatment. A questionnaire covering 29 related symptoms and medication use was employed. Digestive, respiratory, and ear-nose-throat (ENT) symptom scores significantly decreased after antireflux treatment. Symptom scores respectively changed from 17.2 ± 10.1, 31.9 ± 6.6, and 21.1 ± 11.8 to 5.0 ± 6.2, 11.5 ± 10.2, and 6.3 ± 6.8 at 1 year and to 5.6 ± 6.5, 13.1 ± 10.1, and 7.8 ± 7.2 at 5 years (P < 0.001). The outcome of LNF was significantly better than that of SRF in terms of digestive (P < 0.001, P = 0.001), respiratory (P = 0.006, P = 0.001), and ENT symptoms (P = 0.006, P = 0.003) at both 1 year and 5 years. SRF and LNF were both effective against the digestive symptoms of GERD as well as GERD-related severe asthmatic and ENT symptoms, with better outcomes exhibited by the LNF group. Severe asthmatic symptoms and GERD were closely associated, and this finding warrants further study.

Association between the body mass index and the risk of Barrett's esophagus in Japan

BACKGROUND

We investigated the association between long-segment Barrett's esophagus and obesity in the Japanese population in a multicenter case-control trial.

METHODS

One hundred thirteen patients with endoscopically detected Barrett's esophagus with a length of more than 2 cm and the same number of sex- and age-matched controls were prospectively enrolled. Barrett's esophagus was diagnosed based on the Prague C and M criteria. The body mass index (BMI) of the subjects was categorized into the following groups: normal, BMI <22.9; overweight, BMI 23.0-24.9, and obese, BMI >25.0. To determine the association between BMI and the risk of Barrett's esophagus, multivariate logistic regression analyses were performed.

RESULTS

The basically adjusted regression model adjusted for smoking and alcohol consumption revealed that overweight and obesity were significantly associated with an elevated risk of Barrett's esophagus (OR 2.4, 95% CI 1.2-4.7, and OR 2.5, 95% CI 1.3-4.6, respectively). The intensity of the association was not attenuated even after adjustment for gastroesophageal reflux disease-related parameters.

CONCLUSIONS

An increased BMI was associated with an increased risk for Barrett's esophagus through a gastroesophageal reflux-independent mechanism in the Japanese population. Further, unlike in Caucasian populations, being even slightly overweight with a BMI of 23.0-24.9 was an independent risk factor in the Japanese population.

Association between diabetes mellitus and gastroesophageal reflux disease: A meta-analysis

AIM: To investigate whether there is a link between diabetes mellitus (DM) and gastroesophageal reflux disease (GERD).

METHODS: We conducted a systematic search of PubMed and Web of Science databases, from their respective inceptions until December 31, 2013, for articles evaluating the relationship between DM and GERD. Studies were selected for analysis based on certain inclusion and exclusion criteria. Data were extracted from each study on the basis of predefined items. A meta-analysis was performed to compare the odds ratio (OR) in DM between individuals with and without GERD using a fixed effect or random effect model, depending on the absence or presence of significant heterogeneity. Subgroup analyses were used to identify sources of heterogeneity. Publication bias was assessed by Begg’s test. To evaluate the results, we also performed a sensitivity analysis.

RESULTS: When the electronic database and hand searches were combined, a total of nine eligible articles involving 9067 cases and 81 968 controls were included in our meta-analysis. Based on the random-effects model, these studies identified a significant association between DM and the risk of GERD (overall OR = 1.61; 95%CI: 1.36-1.91; P = 0.003). Subgroup analyses indicated that this result persisted in studies on populations from Eastern countries (OR = 1.71; 95%CI: 1.38-2.12; P = 0.003) and in younger patients (mean age < 50 years) (OR = 1.70; 95%CI: 1.22-2.37; P = 0.001). No significant publication bias was observed in this meta-analysis using Begg^’s test (P = 0.175). The sensitivity analysis also confirmed the stability of our results.

CONCLUSION: This meta-analysis suggests that patients with DM are at greater risk of GERD than those who do not have DM.

Gastroesophageal reflux disease and non-esophageal cancer

The association of gastroesophageal reflux disease (GERD) and esophageal cancer is well known. The carcinogenic properties of the gastroduodenal contents may also lead to cancer in target organs for GERD especially considering that they do not have intrinsic protective mechanisms as found in the esophagus. This review focuses on the putative relation between GERD and non-esophageal cancer. Most of the papers reviewed are far from ideal to prove the relationship of extra-esophageal cancer and GERD since a small number of patients is presented, most do not control cases based on tobacco usage and obesity, and the diagnosis of GERD is variable, not always from an objective measurement such as pH monitoring but relying on symptoms in most reports. Nevertheless, head and neck and lung cancer have a growing incidence parallel to GERD and a shift towards non-smoking, female gender and adenocarcinoma (compared to squamous cell carcinoma) is arising, similar to the example of esophageal cancer with the exception of the female gender.

Nonalcoholic fatty liver disease vs. obesity on the risk of erosive oesophagitis

BACKGROUND

Erosive oesophagitis (EE) may be complicated by oesophageal ulcers, peptic stricture, Barrett's oesophagus and oesophageal adenocarcinoma. There have been few studies examining the influence of nonalcoholic fatty liver disease (NAFLD) on EE, and even fewer exploring the simultaneous effects of NAFLD, general and central obesity on EE. We thus aim to clarify the relationship between NAFLD and EE when general and/or central obesity are considered simultaneously.

MATERIALS AND METHODS

In this cross-sectional study, we enrolled 12 090 subjects who underwent a health check-up at the Health Examination Center of a university hospital between January 2000 and August 2009 for analysis. NAFLD was diagnosed using liver ultrasound and EE was defined according to the Los Angeles classification by oesophagogastroduodenoscopy.

RESULTS

Subjects with EE (1922; 15·9%) had a higher proportion of NAFLD, general and central obesity. With adjustment for age, gender, hypertension, diabetes mellitus, hiatal hernia, hypertriglyceridemia, high-density lipoprotein cholesterol, alcohol consumption, tea drinking, smoking and habitual exercise, the results of the multivariate analyses showed that general obesity, central obesity and NAFLD were all significantly associated with EE in their separate models. When considering general obesity, central obesity and NAFLD simultaneously, NAFLD, but neither general nor central obesity, remained positively correlated to EE. In addition, male gender, hiatal hernia and hypertriglyceridemia were all significantly associated with EE.

CONCLUSION

In addition to general and central obesity, NAFLD is independently associated with increased risk of EE, and the detrimental effect of NAFLD on EE might be greater than those of general and central obesity.

Unmet treatment needs of gastroesophageal reflux disease in Asia: gastroesophageal reflux disease in Asia Pacific survey

BACKGROUND AND AIM

Data on patient satisfaction with proton pump inhibitor (PPI) therapy for gastroesophageal reflux disease (GERD) are scarce in Asia. The perspectives of Asian patients with GERD and their satisfaction with PPI therapy were investigated.

METHODS

The GERD in Asia Pacific Survey (GAPS) was conducted from December 2011 to March 2012. Patients aged 21-55 years with self-reported doctor-diagnosed GERD, who had experienced symptoms in the previous 12 months, and were currently taking PPIs were enrolled. After a pilot study, a questionnaire was completed by respondents from six Asian countries during face-to-face interviews.

RESULTS

A total of 450 patients with GERD participated in the GAPS. Although the respondents generally complied with treatment, response to therapy was only partially successful. Most respondents indicated that PPIs eliminated pain (72%), took effect within 30 min (76%), provided sustained relief (73%), and provided nocturnal relief (77%). However, 45% of respondents reported limited improvement in nocturnal symptoms, and 49% continued to take adjunctive therapy to manage their symptoms. After treatment, respondent's "well-being" had improved. However, GERD still had a negative impact on well-being for 76% of respondents after treatment, compared with 94% before treatment.

CONCLUSIONS

Asian patients reported a negative impact of GERD on their daily lives. Many respondents continued to experience symptoms despite reporting good compliance with PPI therapy, emphasizing the shortcomings of currently available therapy for GERD. This survey is the first to highlight Asian patients' perspectives of GERD and PPI therapy, and provides a platform for further evaluation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ClinicalTrial.gov identifier: NCT00312806.

Risk factors associated with Barrett’s epithelial dysplasia

AIM: To elucidate risk factors associated with dysplasia of short-segment Barrett’s esophagus (BE).

METHODS: A total of 151 BE patients who underwent endoscopic examination from 2004 to 2008 in Aoyama Hospital, Tokyo Women’s Medical University, Japan and whose diagnosis was confirmed from biopsy specimens were enrolled in the study. BE was diagnosed based on endoscopic findings of gastric-appearing mucosa or apparent columnar-lined esophagus proximal to the esophagogastric junction. Dysplasia was classified into three grades - mild, moderate and severe - according to the guidelines of the Vienna Classification System for gastrointestinal epithelial neoplasia. Anthropometric and biochemical data were analyzed to identify risk factors for BE dysplasia. The prevalence of Helicobacter pylori (H. pylori) infection and the expression of p53 by immunohistological staining were also investigated.

RESULTS: Histological examination classified patients into three types: specialized columnar epithelium (SCE) (n = 65); junctional (n = 38); and gastric fundic (n = 48). The incidence of dysplasia or adenocarcinoma from BE of the SCE type was significantly higher than that of the other two types (P < 0.01). The univariate analysis revealed that sex, H. pylori infection, body weight, p53 overexpression, and low diastolic blood pressure (BP) were associated with BE dysplasia. In contrast, body mass index, waist circumference, metabolic syndrome complications, and variables related to glucose or lipid metabolism were not associated with dysplasia. Multivariate logistic analysis showed that overexpression of p53 [odds ratio (OR) = 13.1, P = 0.004], H. pylori infection (OR = 0.19, P = 0.066), and diastolic BP (OR = 0.87, P = 0.021) were independent risk factors for epithelial dysplasia in BE patients with the SCE type.

CONCLUSION: Overexpression of p53 is a risk factor for dysplasia of BE, however, H. pylori infection and diastolic BP inversely associated with BE dysplasia might be protective.

Addition of prokinetics to PPI therapy in gastroesophageal reflux disease: A meta-analysis

AIM: To investigate the efficacy of adding prokinetics to proton pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD).

METHODS: PubMed, Cochrane Library, and Web of Knowledge databases (prior to October 2013) were systematically searched for randomized controlled trials (RCTs) that compared therapeutic efficacy of PPI alone (single therapy) or PPI plus prokinetics (combined therapy) for GERD. The primary outcome of those selected trials was complete or partial relief of non-erosive reflux disease symptoms or mucosal healing in erosive reflux esophagitis. Using the test of heterogeneity, we established a fixed or random effects model where the risk ratio was the primary readout for measuring efficacy.

RESULTS: Twelve RCTs including 2403 patients in total were enrolled in this study. Combined therapy was not associated with significant relief of symptoms or alterations in endoscopic response relative to single therapy (95%CI: 1.0-1.2, P = 0.05; 95%CI: 0.66-2.61, P = 0.44). However, combined therapy was associated with a greater symptom score change (95%CI: 2.14-3.02, P < 0.00001). Although there was a reduction in the number of reflux episodes in GERD [95%CI: -5.96-(-1.78), P = 0.0003] with the combined therapy, there was no significant effect on acid exposure time (95%CI: -0.37-0.60, P = 0.65). The proportion of patients with adverse effects undergoing combined therapy was significantly higher than for PPI therapy alone (95%CI: 1.06-1.36, P = 0.005) when the difference between 5-HT receptor agonist and PPI combined therapy and single therapy (95%CI: 0.84-1.39, P = 0.53) was excluded.

CONCLUSION: Combined therapy may partially improve patient quality of life, but has no significant effect on symptom or endoscopic response of GERD.

Addition of prokinetics to PPI therapy in gastroesophageal reflux disease: a meta-analysis

AIM

To investigate the efficacy of adding prokinetics to proton pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD).

METHODS

PubMed, Cochrane Library, and Web of Knowledge databases (prior to October 2013) were systematically searched for randomized controlled trials (RCTs) that compared therapeutic efficacy of PPI alone (single therapy) or PPI plus prokinetics (combined therapy) for GERD. The primary outcome of those selected trials was complete or partial relief of non-erosive reflux disease symptoms or mucosal healing in erosive reflux esophagitis. Using the test of heterogeneity, we established a fixed or random effects model where the risk ratio was the primary readout for measuring efficacy.

RESULTS

Twelve RCTs including 2403 patients in total were enrolled in this study. Combined therapy was not associated with significant relief of symptoms or alterations in endoscopic response relative to single therapy (95%CI: 1.0-1.2, P = 0.05; 95%CI: 0.66-2.61, P = 0.44). However, combined therapy was associated with a greater symptom score change (95%CI: 2.14-3.02, P < 0.00001). Although there was a reduction in the number of reflux episodes in GERD [95%CI: -5.96-(-1.78), P = 0.0003] with the combined therapy, there was no significant effect on acid exposure time (95%CI: -0.37-0.60, P = 0.65). The proportion of patients with adverse effects undergoing combined therapy was significantly higher than for PPI therapy alone (95%CI: 1.06-1.36, P = 0.005) when the difference between 5-HT receptor agonist and PPI combined therapy and single therapy (95%CI: 0.84-1.39, P = 0.53) was excluded.

CONCLUSION

Combined therapy may partially improve patient quality of life, but has no significant effect on symptom or endoscopic response of GERD.

Prevalence and determinants of gastroesophageal reflux symptoms in adolescents

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is common in adults, and there are increasing secular trends in adult GERD morbidity in many countries. However, population-based study on adolescent GERD was very limited. The specific aims of the study were to explore the prevalence and determinant of GERD symptoms in adolescents.

METHODS

A population-based association study was performed on 1828 students aged 13-16 years from four public junior high schools in Taiwan. The presences of symptoms of GERD, asthma and food allergy, demographic characteristics, and health behaviors were obtained by structured questionnaires.

RESULTS

Complete information of symptoms of GERD and asthma were available for 1745 (95.5%) students. The cumulative and 3-month prevalence rates of GERD symptoms were 20.5% and 8.9%, respectively. Multivariate-adjusted odds ratio of having experienced GERD symptoms were 1.53 (95% confidence interval [CI]: 1.18-1.98) for ever smoking, 1.52 (95% CI: 1.12-2.26) for bi-ethnicity, 1.70 (95% CI: 1.26-2.29) for food allergy, and 3.59 (95% CI: 2.69-4.82) and 2.43 (95% CI: 1.67-3.53) for having asthma attacks within or more than 1 year before, respectively. Similar results were found for 3-month prevalence.

CONCLUSIONS

The study showed that GERD symptoms were frequent in junior high school students in Taiwan. Food allergy, asthma, and cigarette smoking were independently correlated with the prevalence of GERD symptoms. Psychosocial factors associated with bi-ethnic family may contribute to its development.

Carcinogenesis of Barrett's esophagus: a review of the clinical literature

Barrett's esophagus (BE) is a premalignant condition of esophageal adenocarcinoma (EAC). Although the incidence of BE has risen rapidly in the West, it is rare in Asia despite a recent increase in the prevalence of gastroesophageal reflux disease. Controversies over the definition of BE are presented because most cases show short-segment BE, especially ultra-short BE, in Asia. Here we review possible risk factors for the development of EAC, particularly possible roles of ethnicity, specialized intestinal metaplasia (SIM), BE length, and environmental factors, such as Helicobacter pylori infection and obesity. Additionally, we summarize recent studies on the effect of chemoprevention including proton pump inhibitors, nonsteroidal anti-inflammatory drugs or aspirin in order to reduce the risk of neoplastic progression in BE patients. Although substantial knowledge of risk factors of dysplasia/EAC in BE is shown, the risk for neoplastic development may be influenced by geographic variation, study population, the presence or absence of SIM or dysplasia at baseline, and the small number of BE patients investigated. Recently, the efficiency of surveillance for BE patients has been discussed from the standpoint of cost-effectiveness. It may be too difficult to draw conclusions because no randomized clinical trials of BE surveillance have been performed.

Overweight associated with increased risk of erosive esophagitis in a non-obese Taiwanese population

Objective

To investigate the relationship between overweight and erosive esophagitis (EE) in a non-obese Taiwanese population.

Design and Methods

A total of 7,352 subjects (non-obese, 5,826; obese, 1,526) from a health examination center at National Cheng Kung University Hospital were enrolled. Central obesity was defined by a waist circumference (WC) ≥90 cm in male and 80 cm in female. Overweight was defined as body mass index (BMI) of 24–26.9 kg/m², and general obesity as BMI ≥27 kg/m². The Los Angeles classification was adopted to determine the presence of EE.

Results

There were significant differences in the prevalence of central obesity and different BMI status between subjects with and without EE in total and non-obese population. In total population, multivariate analyses revealed central obesity (OR, 1.17, 95% CI, 1.02–1.34, p = 0.021) and being obese (OR, 1.28, 95% CI, 1.07–1.52, p = 0.007)/overweight (OR, 1.25, 95% CI, 1.08–1.45, p = 0.003) had positive associations with EE in different model, respectively. When considering the joint effect of central obesity and BMI status, overweight (OR, 1.22; 95% CI, 1.04–1.44; p = 0.016) remained as an independent associated factor of EE but central obesity (OR, 1.06; 95% CI, 0.89–1.26; p = 0.549)/being obese (OR, 1.22; 95% CI, 0.98–1.53; p = 0.082) did not. As for non-obese group, separate model showed central obesity (OR, 1.19, 95% CI, 1.00–1.40, p = 0.046) and overweight (OR, 1.24; 95% CI, 1.07–1.44, p = 0.005) was positively associated with EE, respectively. However, being overweight (OR, 1.20; 95% CI, 1.02–1.42, p = 0.030) but not central obesity (OR, 1.08; 95% CI, 0.90–1.31; p = 0.398) was positively related to EE with considering the effect of overweight and central obesity simultaneously.

Conclusion

Overweight effect on EE was more detrimental than central obesity in non-obese subjects. In addition, male gender, hiatus hernia and alcohol use were also associated with increased risk of EE.

Background factors of reflux esophagitis and non-erosive reflux disease: a cross-sectional study of 10,837 subjects in Japan

Background

Despite the high prevalence of gastroesophageal reflux disease (GERD), its risk factors are still a subject of controversy. This is probably due to inadequate distinction between reflux esophagitis (RE) and non-erosive reflux disease (NERD), and is also due to inadequate evaluation of adjacent stomach. Our aim is therefore to define background factors of RE and NERD independently, based on the evaluation of Helicobacter pylori infection and gastric atrophy.

Methods

We analyzed 10,837 healthy Japanese subjects (6,332 men and 4,505 women, aged 20–87 years) who underwent upper gastrointestinal endoscopy. RE was diagnosed as the presence of mucosal break, and NERD was diagnosed as the presence of heartburn and/or acid regurgitation in RE-free subjects. Using GERD-free subjects as control, background factors for RE and NERD were separately analyzed using logistic regression to evaluate standardized coefficients (SC), odds ratio (OR), and p-value.

Results

Of the 10,837 study subjects, we diagnosed 733 (6.8%) as RE and 1,722 (15.9%) as NERD. For RE, male gender (SC = 0.557, OR = 1.75), HP non-infection (SC = 0.552, OR = 1.74), higher pepsinogen I/II ratio (SC = 0.496, OR = 1.64), higher BMI (SC = 0.464, OR = 1.60), alcohol drinking (SC = 0.161, OR = 1.17), older age (SC = 0.148, OR = 1.16), and smoking (SC = 0.129, OR = 1.14) are positively correlated factors. For NERD, HP infection (SC = 0.106, OR = 1.11), female gender (SC = 0.099, OR = 1.10), younger age (SC = 0.099, OR = 1.10), higher pepsinogen I/II ratio (SC = 0.099, OR = 1.10), smoking (SC = 0.080, OR = 1.08), higher BMI (SC = 0.078, OR = 1.08), and alcohol drinking (SC = 0.076, OR = 1.08) are positively correlated factors. Prevalence of RE in subjects with chronic HP infection and successful HP eradication denotes significant difference (2.3% and 8.8%; p<0.0001), whereas that of NERD shows no difference (18.2% and 20.8%; p = 0.064).

Conclusions

Significantly associated factors of NERD are considerably different from those of RE, indicating that these two disorders are pathophysiologically distinct. Eradication of Helicobacter pylori may have disadvantageous effects on RE but not on NERD.

The clinical characteristics of gastroesophageal reflux disease in patients with laryngeal symptoms who are referred to gastroenterology

The prevalence of gastroesophageal reflux disease (GERD) has increased recently in Asia-Pacific countries. However, little is known about its prevalence and clinical characteristics in GERD patients with atypical symptoms in Asia. The aim of this study was to investigate the clinical characteristics of GERD in patients who had laryngeal symptoms in Korea. Data were gathered retrospectively from patients who presented with atypical symptoms, such as throat discomfort, globus pharyngeus, hoarseness, and chronic cough. They underwent a 24-hour ambulatory intraesophageal pH monitoring and filled in a validated reflux questionnaire. Overall, 128 patients (36 men and 92 women) with laryngeal symptoms were included. Of these 128, 43 patients (34%) had erosive esophagitis or pathological reflux from 24-hour ambulatory pH monitoring, and 24 (19%) had a positive Bernstein test or positive symptom index from 24-hour pH monitoring. Sixty-one patients (48%) had no evidence of reflux esophagitis on upper endoscopy and pathological acid reflux on 24-hour pH monitoring. Fifty-six patients (44%) had weekly heartburn or regurgitation. Typical symptoms and dyspepsia were significantly more common in patients with GERD who had laryngeal symptoms than non-GERD. Fifty-two percent of patients had laryngeal symptoms that were associated with GERD. The presence of typical reflux symptoms and dyspepsia are risk factors for GERD in patients who present with laryngeal symptoms.

The Prevalence of Erosive Esophagitis Is Not Significantly Increased in a Healthy Korean Population - Could It Be Explained?: A Multi-center Prospective Study

Background/Aims

Researches on the potential risk factors for the development of erosive esophagitis have been conducted extensively, however, the results are conflicting. The aim of this multicenter study was to identify the prevalence rate and risk factors of erosive esophagitis and their interactions with residency status.

Methods

A total of 4,023 eligible subjects at 8 tertiary health care centers were evaluated using questionnaires, laboratory tests and endoscopy. Univariate and multivariate analyses were conducted to identify independent risk factors for erosive esophagitis.

Results

The prevalence rate of reflux esophagitis was 8.8%. Los Angeles grade A was common type of erosive esophagitis. Residence in a large urban areas was negatively associated with the development of erosive esophagitis (OR, 0.60; 95% CI, 0.40-0.90). The high body mass index (≥ 25 kg/m²) was more frequent in residents of small and medium-sized cities than those in big cities (38.8% and 26.9%, respectively; P < 0.001). Seronegativity of Helicobacter pylori was associated with increased erosive esophagitis (OR, 1.91; 95% CI, 1.48-2.46). Triglyceride ≥ 150 mg/dL (OR, 1.65; 95% CI, 1.08-2.07), fasting glucose level ≥ 126 mg/dL (OR, 1.73; 95% CI, 1.06-2.81), and hiatal hernia (OR, 3.11; 95% CI, 1.87-5.16) were also associated with erosive esophagitis.

Conclusions

The prevalence rate of erosive esophagitis and its risk factors in this study were similar to the result of 8.0% of nationwide study in 2006. Residency and obesity are more important independent risk factors than H. pylori infection status for development of erosive esophagitis in Korea. These results suggest that the prevalence rate of erosive esophagitis in Korea might not increase as in the Western countries.

Increasing insulin resistance is associated with increased severity and prevalence of gastro-oesophageal reflux disease

BACKGROUND

The diagnosis of gastro-oesophageal reflux disease (GERD) is based on reflux symptoms. Although metabolic syndrome has been linked to erosive oesophagitis (EO), the impact of insulin resistance, the core of the metabolic syndrome, on reflux symptoms remains to be elucidated.

AIM

To assess the effects of insulin resistance on GERD, including both endoscopic findings and symptoms.

METHODS

A total of 743 sonographic noncirrhotic adult subjects, who underwent an upper gastrointestinal endoscopic examination, completed a gastro-oesophageal reflux questionnaire and had available fasting insulin data were included. Endoscopic findings were classified according to the Los Angeles classification. Homeostatic model assessment-insulin resistance (HOMA-IR) index was used to evaluate the status of insulin resistance. Univariate and multivariate approaches were used to evaluate the associations between insulin resistance and GERD.

RESULTS

Older age, male gender, smoking and alcohol consumption increased the prevalence of EO, but not GERD symptoms. A large waist circumference, high fasting blood glucose levels and high number of metabolic syndrome components were associated with increased prevalence of both EO and GERD symptoms, while high blood pressure was associated with increased prevalence of EO only. Moreover, higher scores in the gastro-oesophageal reflux questionnaire were associated with higher HOMA-IR index, and higher HOMA-IR index was associated with increased prevalence of EO (adjusted odds ratio 1.14, 95% CI 1.03-1.26, P = 0.012).

CONCLUSIONS

Our findings demonstrate clear associations between insulin resistance, metabolic syndrome and GERD. Whether reducing insulin resistance may improve GERD symptoms or EO deserves prospective study.