Prevalence of gastroesophageal reflux disease in Korea and associated health-care utilization: a national population-based study

Nationwide Study of the Epidemiology, Diagnosis, and Treatment of Hypersensitivity Pneumonitis in Korea

BACKGROUND

Hypersensitivity pneumonitis (HP) is a condition with an uncertain global incidence, and information on its diagnosis and management is limited. This study aimed to address these knowledge gaps.

METHODS

This study utilized customized claims data from the Health Insurance Review and Assessment Service (HIRA) in South Korea from January 2010, to December 2021. Patients with HP were identified based on the diagnosis code (International Classification of Diseases, 10th Revision, J67) between 2011 and 2020. Incident HP cases were defined as new HP claims, excluding those with claims in the previous year. The study examined various factors such as age, sex, comorbidities, diagnostic methods, and treatment patterns. Additionally, multivariate logistic regression analysis was performed to identify risk factors associated with treatment initiation.

RESULTS

A total of 8,678 HP incident cases were confirmed, with age- and sex-adjusted annual incidence rates ranging from 1.14/100,000 in 2020 to 2.16/100,000 in 2012. The mean age of patients with incident HP was 52 years, with a higher incidence observed among males. Additionally, the most common comorbidity was asthma. Bronchoscopy was performed on 16.9% of patients, and 25.4% of patients did not receive treatment within 1 year of diagnosis. Among those who received treatment, prednisone was the most used systemic steroid, and azathioprine was the most commonly used second-line immunosuppressant. Factors associated with treatment initiation included the female sex, having asthma or gastroesophageal reflux disease (GERD), and undergoing bronchoscopy.

CONCLUSION

This study provides valuable insights into the incidence, diagnosis, and treatment patterns of HP in South Korea using nationwide medical claims data.

Gastroesophageal reflux disease and risk of cancer: Findings from the Korean National Health Screening Cohort

AIM

Little is known about the association of cancers other than esophageal adenocarcinoma with gastroesophageal reflux disease (GERD). This study aimed to examine the association between GERD and the risk of different types of cancer.

METHODS

A cohort study was conducted using data from the National Health Screening Cohort. We included 10,261 GERD patients and 30,783 non-GERD individuals who were matched in a 1:3 ratio by age and sex. All participants were followed-up until cancer diagnosis, death, or end of the study (December 31, 2015). Hazard ratios were calculated using the Cox proportional hazards model, adjusting for smoking and alcohol consumption, physical activity, body mass index, income, area, and Charlson Comorbidity Index.

RESULTS

The median follow-up time was 9.9 years. GERD was associated with an increased risk of esophageal (adjusted hazard ratios [aHR] = 3.20 [1.89-5.41]), laryngeal (aHR = 5.42 [2.68-10.96]), and thyroid cancers (aHR = 1.91 [1.55-2.34]) after controlling for all covariates. The results were consistent when examining GERD with esophagitis (K210) and without esophagitis (K219) separately. For thyroid cancer, the results were insignificant after controlling for having ever-received thyroid biopsy procedures. A dose-response relationship was found between GERD and esophageal cancer as well as laryngeal cancer, with patients with a longer duration of GERD treatment showing a stronger effect. In contrast, GERD was associated with a reduced risk of colorectal (aHR = 0.73 [0.59-0.90]), liver (aHR = 0.67 [0.51-0.89]), and pancreatic cancers (aHR = 0.43 [0.24-0.76]), which might have resulted from differences in healthcare utilization between GERD and non-GERD groups.

CONCLUSION

GERD was associated with an increased risk of esophageal and laryngeal cancers. Additionally, early detection and treatment of precancerous lesions among the GERD group could lead to a lower risk of colorectal, liver, and pancreatic cancers.

Carcinogenicity assessment of tegoprazan in Sprague-Dawley (Crl:CD) rats and ICR (Crl:CD1) mice

Tegoprazan is a novel potassium-competitive acid blocker (P-CAB) that reversibly inhibits the proton pump in gastric parietal cells and has been approved for the treatment of acid-related diseases in Korea. This study aimed to evaluate the carcinogenic potential of tegoprazan in Sprague-Dawley rats and CD-1 mice. Tegoprazan was administered daily by oral gavage to rats for up to 94 weeks and mice for up to 104 weeks. Evidence of carcinogenic potential of tegoprazan was identified in rats only and was limited to benign and/or malignant neuroendocrine cell tumors at exposures >7-fold of the recommended human dose. Glandular stomach findings were considered secondary to the expected pharmacology of tegoprazan, characterized by their location in the fundic and body regions of the stomach. Overall, tegoprazan induced gastric enterochromaffin-like (ECL) cell tumors in SD rats, but did not produce any treatment-related statistically significant increase in the incidence of neoplasms relevant to humans when administered to SD rats and CD-1 mice by gavage at doses up to 300 and 150 mg/kg/day, respectively. Gastric ECL cell tumors are thought to be induced by the exaggerated indirect pharmacological effect of tegoprazan, similar to that reported for proton pump inhibitors (PPIs) and other P-CABs.

Feasibility Study on Endoscopic Balloon-Assisted Laser Treatment (EBLT) of Gastroesophageal Reflux Disease (GERD) in In Vivo Porcine Model

Gastroesophageal reflux disease (GERD) has been growing globally, with an increasing burden on the healthcare system due to multiple factors, such as aging and obesity. The current study evaluated the feasibility of endoscopic balloon-assisted laser treatment (EBLT) in a porcine model. GERD was initially developed in three animals via botulinum toxin injection into lower esophageal sphincter (LES). A week after the injection, the EBLT was performed on the GERD-developed models (control = 1 vs. treated = 2). A dose of 30 W of 980 nm laser light was endoscopically applied for 90 s to the LES. Both endoscopic ultrasound and manometry were performed before and after the EBLT. After 12 weeks, esophageal tissues were extracted and prepared for histological analysis. The maximum mucosa temperature was below 50 °C during the EBLT. Compared to control, the treated group yielded thicker and shorter LES muscle layers and maintained LES pressure. Through histology, the EBLT reinforced the muscularis layer with preserved mucosa and mild remodeling of the intermuscular collagen in the LES. The current study demonstrated the feasibility of EBLT as a new endoscopic approach for GERD. Further studies will examine the EBLT in a larger number of animals to warrant efficacy and safety for clinical translations.

Risk Factors of Pertussis Among Older Adults in South Korea: A Nationwide Health Data-Based Case-Control Study

INTRODUCTION

To better understand the conditions associated with pertussis diagnosis among older adults in South Korea, a matched case-control study was conducted of individuals ≥ 50 years diagnosed with pertussis between 2009 and 2018.

METHODS

Pertussis cases were identified using the nationwide Health Insurance Review and Assessment service (HIRA) database. Each case was then matched to up to 10 controls identified using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) by age, sex, and geographic region at index date. In the 12 months and 30 days prior to index date, the presence of clinical characteristics previously reported to be related to pertussis and pertussis-like conditions were assessed, respectively. A conditional multivariate logistic regression model was then used to calculate odds ratios (ORs) of pertussis diagnosis, adjusted for each of the characteristics.

RESULTS

Pertussis cases (n = 1004) generally demonstrated a higher prevalence of comorbidities compared to controls (n = 9710). Pre-existing asthma and chronic obstructive pulmonary disease (COPD) within 12 months of index date were associated with a two-fold increased risk of pertussis with adjusted ORs (95% confidence interval) of 2.08 (1.68-2.58) and 2.32 (1.59-3.39), respectively. Gastroesophageal reflux disease [GERD; 2.67 (2.23-3.19)], cancer [1.68 (1.23-2.31)], cardiovascular disease [1.62 (1.31-2.00)], renal disease [1.56 (1.12-2.16)], autoimmune disease [1.50 (1.25-1.79)], and hyperlipidemia [1.43 (1.16-1.77)] were also associated with pertussis diagnosis. Finally, acute respiratory events within 30 days prior to index date, such as pneumonia, acute bronchitis, and upper respiratory tract infection (URTI), were highly associated with increased odds of pertussis diagnosis [adjusted ORs of 8.28 (5.10-13.44), 4.86 (3.84-6.14), and 2.90 (2.30-3.67), respectively].

CONCLUSIONS

This study's findings complement and expand upon previous studies on the adult pertussis population, generating real-world data to describe underlying clinical characteristics of those diagnosed with pertussis in South Korea.

Global, regional and national burden of gastroesophageal reflux disease, 1990-2019: update from the GBD 2019 study

BACKGROUND

Because trends in the epidemiology and burden of gastroesophageal reflux disease (GERD) are changing, reinvestigating the geographical differences and trend changes is essential. Here we evaluated the latest epidemiologic patterns and trends for GERD, using data from Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

Annual case numbers, age-standardized rates of prevalence, incidence, and years of life lived with disability (YLDs), and their estimated annual percentage changes (EAPCs) for GERD between 1990 and 2019 were derived from the GBD 2019 study. Association between GERD burden and socio-demographic index (SDI) was also investigated.

RESULTS

In 2019, there were 783.95 million cases of GERD globally. Between 1990 and 2019, the total number of prevalent cases, incident cases, and YLDs increased by 77.53%, 74.79%, and 77.19%, respectively. The global age-standardized incidence rate (ASIR) and age-standardized YLD rate (ASYR) increased during this period (EAPC = 0.06 and 0.05, respectively). Tropical Latin America and East Asia had the highest and lowest age-standardiZed prevalence rate (ASPR), ASIR, and ASYR in 2019, respectively. From 1990 to 2019, prevalent cases, incident cases, YLDs, and their corresponding age-standardized rates of GERD were higher in females than males in all years. Higher SDI was associated with lower ASPR, ASIR, and ASYR of GERD in 2019.

CONCLUSIONS

GERD will continue to be a major public health burden due to increasing numbers of prevalent cases, incident cases, and YLDs. In order to tackle this troublesome disease, it is crucial to understand the changes in both global and regional trends in epidemiology and the burden for policymakers and other stakeholders. Key messagesThis is the most updated estimate on GERD epidemiology globally, including 204 countries, some of which were not assessed before.The overall burden of GERD continued to worsen with the prevalent cases increasing by 77.53% from 441.57 million in 1990 to 783.95 million in 2019.GERD is likely to remain a common reason for consultation in primary care, and our data may allow for health service provision planning.

Clinical Implications of the Gastroesophageal Reflux Disease Questionnaire and Reflux Symptom Index in Patients With Suspected Laryngopharyngeal Reflux Symptoms

Background/Aims

To evaluate the usefulness of gastroesophageal reflux disease questionnaire (GerdQ) and reflux symptom index (RSI) for diagnosis of gastroesophageal reflux disease (GERD) in patients with suspected laryngopharyngeal reflux (LPR) symptoms (cough, hoarseness, globus, and throat pain).

Methods

A total of 98 patients with LPR symptoms were incorporated from either gastroenterology or otorhinolaryngology clinic. Patient’s laryngoscopic findings were graded by reflux finding score (RFS), and RFS ≥ 7 was considered as positive LPR. Erosive esophagitis on endoscopy or abnormal results on ambulatory impedance-pH monitoring were used as diagnostic criteria for GERD. Esophageal motor function was evaluated using high-resolution esophageal manometry.

Results

Ninety-three (94.9%) of the 98 subjects were diagnosed as LPR by RFS, but only 15 (15.3%) had GERD. For GerdQ, the cutoff value of 9 showed the highest area under curve (AUC) to diagnose GERD by receiver operating curve analysis (AUC = 0.565); the sensitivity, specificity, positive predictive value, and negative predictive value were unsatisfactory (50.0%, 70.7%, 22.6%, and 89.2%, respectively.) RSI also showed poor performance in diagnosing GERD; the cutoff value of 25 showed the highest yield (AUC = 0.581); the sensitivity, specificity, positive predictive value, and negative predictive value were 42.9%, 79.3%, 26.1%, and 89.0%, respectively. Ineffective esophageal motility was frequently observed (69 of 98, 70.4%), but there was no difference in esophageal motility parameters between GERD and non-GERD patients.

Conclusions

In patients with LPR symptoms, significant discrepancies are observed between laryngoscopic diagnosis and GERD. In this population, neither GerdQ nor RSI is useful in diagnosing GERD.

The association between chronic rhinosinusitis and proton pump inhibitor use: a nested case-control study using a health screening cohort

This study aimed to evaluate the relationship between chronic rhinosinusitis (CRS) and proton pump inhibitor (PPI) use in a Korean population. The Korea National Health Insurance Service-National Sample Cohort was assessed from 2002 to 2013. Patients with CRS (n = 7194) and control participants (n = 28,776) were matched by random order at a 1:4 ratio for age, sex, income group, region of residence, and index date. We analyzed PPI use by patients with and without CRS. ICD-10 codes defined CRS, and claim codes defined previous PPI use. Conditional logistic regression analyzed the crude and adjusted odds ratios (ORs) with 95% confidence intervals (CI). Subgroup analyses were performed according to age and sex. There was a difference in PPI prescription history and prescription duration between the CRS and control groups. The rate of CRS was higher in current (33.8% [263/778]) and past (26.3% [713/2708]) PPI users than PPI non-users (19.1% [6218/32,484], P < 0.001). The adjusted OR (aOR) of CRS with/without nasal polyps was 1.71 (95% CI 1.46–2.02, P < 0.001) and 1.28 (95% CI 1.16–1.41, P < 0.001) in current and past PPI users, respectively. Irrespective of PPI prescription days, PPI use was associated with higher CRS occurrence (aOR 1.46; 95% CI 1.26–1.69, P < 0.001) in the 30–89-day PPI user group. The subgroup analyses results were consistent. The ORs of CRS were higher in PPI users than in the controls, and consistently so in all age and sex groups.

Association between sitting-time at work and incidence of erosive esophagitis diagnosed by esophagogastroduodenoscopy: a Korean cohort study

Background

Most previous longitudinal studies on lifestyle and gastroesophageal reflux disease (GERD) have focused on physical activity rather than sitting time. The main purpose of this study was to investigate the relationship between prolonged sitting time and the development of erosive esophagitis (EE).

Methods

A self-report questionnaire was used for measuring sitting time in the Kangbuk Samsung Health Study. Sitting time was categorized into four groups: ≤ 6, 7–8, 9–10, and ≥ 11 hours/day. Esophagogastroduodenoscopy (EGD) was performed by experienced endoscopists who were unawared of the aims of this study. Hazard ratios (HRs) and 95% confidence intervals (CIs) for the development of EE were estimated using Cox proportional hazards analyses with ≤ 6 hours/day sitting time as the reference.

Results

There were 6,524 participants included in the study. During a mean follow-up of 3.14 years, 2,048 incident cases developed EE. In age- and sex-adjusted models, the HR in the group sitting ≥ 11 hours per day compared ≤ 6 hours per day was 0.88 (95% CI: 0.76–0.99). After further adjusting for alcohol intake, smoking status, educational level, history of diabetes, and history of dyslipidemia, sitting time was still significantly related to the risk of EE (HR, 0.87; 95% CI: 0.76–0.98). After further adjustment for exercise frequency, this association persisted (HR, 0.86; 95% CI: 0.76–0.98). In subgroup analysis by obesity, the relationship between sitting time and EE was only significant among participants with body mass index < 25 kg/m² (HR, 0.82; 95% CI: 0.71–0.95).

Conclusions

Generally, prolonged sitting time is harmful to health, but with regard to EE, it is difficult to conclude that this is the case.

[Esophageal pH-impedance monitoring of reflux patterns in non-erosive reflux disease, reflux hypersensitivity and functional heartburn]

OBJECTIVE

To analyze the differences in reflux patterns in 24-hour esophageal pH-impedance monitoring in patients with non-erosive reflux disease (NERD), reflux hypersensitivity (RH) and functional heartburn (FH) and explore the possible mechanism of symptoms in patients with heartburn and negative endoscopic findings.

METHODS

Seventy-nine patients with heartburn as the main symptoms but negative endoscopic findings, including 35 with NERD, 16 with RH and 28 with FH, were enrolled in this study.All the patients underwent 24-h esophageal pH-impedance monitoring and esophagogastroscopy, and the results were compared among the 3 groups.

RESULTS

Acid reflux episode was significantly increased and weakly alkaline reflux episode was significantly decreased in NERD group in comparison with RH group and FH group (P < 0.05).The patients in NERD group showed significantly increased total reflux episode, mixed reflux episode, proximal acid reflux episode, proximal weak acid reflux episode, total proximal reflux episode, percentage of proximal acid reflux, percentage of proximal weak acid reflux, and percentage of total proximal reflux as compared with the other two groups (all P < 0.05).Bolus clear time was significantly prolonged in NERD group compared with that in the other two groups (P < 0.05).Analysis of the reflux acidity showed that the percentages of different reflux episodes differed significantly among the 3 groups (P < 0.05);acid reflux was the main reflux in NERD, while weak acid reflux was the main reflux in RH and FH groups, which had also significantly increased weakly alkaline reflux episodes compared with NERD group.

CONCLUSIONS

Patients with NERD, RH and FH had different reflux patterns.Acid reflux is predominant in the NERD, while weakly alkaline reflux is significantly increased RH and FH.In patients with normal esophageal acid exposure but without symptoms or without recorded symptoms during esophageal pH-impedance monitoring, analysis of the total reflux episode, mixed reflux episode, proximal acid reflux episode and percentage can help in the differential diagnosis between RH and FH.

Trends in laparoscopic anti-reflux surgery: a Korea nationwide study

BACKGROUND

In 2014, the results derived from the nationwide data of the Korean Anti-reflux Surgery Study (KARS) demonstrated short-term feasibility and safety of anti-reflux surgery. This study aimed to update the longer-term safety and feasibility of laparoscopic anti-reflux surgery up to 1-year follow-up with the KARS nationwide cohort.

METHODS

The data of 310 patients with GERD who received anti-reflux surgery up to 2018 were analyzed. Baseline patient characteristics, postoperative symptom resolution, and postoperative complications were evaluated at postoperative 3 months and 1 year using the questionnaire designed by KARS. We divided the patients into two groups according to the operation period (up to and after 2014) to identify changes in the trends of the characteristics of surgical patients and operative qualities.

RESULTS

The typical preoperative symptoms were present in 275 patients (91.7%), and atypical symptoms were present in 208 patients (71.0%). Ninety-seven (35.5%) and 124 patients (46.1%) had inadequate PPI responses and hiatal hernia, respectively. At postoperative 1 year, typical and atypical symptoms were either completely or partially controlled in 90.3% and 73.5.0% of patients, respectively. Moderate-to-severe dysphagia, inability to belch, gas bloating, and flatulence at postoperative 1 year were identified in 23.5%, 29.4%, 23.2%, and 22.0% of patients, respectively. The number of surgical patients continuously increased from 2011 to 2018 in Korea. The proportion of patients with hiatal hernia and comorbidities increased (p < 0.01, p = 0.053), and the operation time decreased significantly (p < 0.01) in the late period (2015-2018) as compared with the early period (2011-2014). Symptom control and complication rate were equivalent between the two periods.

CONCLUSIONS

Anti-reflux surgery was effective with > 90% of typical symptom resolution and posed a comparable postoperative complication rate with those in Western studies with mid-term to long-term follow-up. This result supports the feasibility and safety of anti-reflux surgery as a treatment for GERD in the Korean population.

The first case of tegoprazan-induced urticaria

WHAT IS KNOWN AND OBJECTIVE

Tegoprazan induces adverse drug reactions during clinical trials; however, tegoprazan-induced urticaria has not been reported. Here, we describe the first case of this.

CASE DESCRIPTION

A 55-year-old woman presented with acute urticaria with pruritus after taking the gastro-oesophageal reflux disease medication, tegoprazan. Urticaria disappeared after tegoprazan discontinuation. In an oral provocation test, after taking 10% of tegoprazan, she developed pruritus, and after taking 30%, she developed urticaria on her back.

WHAT IS NEW AND CONCLUSION

This is the first case of urticaria induced by tegoprazan. Physicians should understand the possibility of a tegoprazan-induced hypersensitivity reactions.

The characteristics of antireflux surgery compared to proton pump inhibitor treatment in Korea: a nationwide study using claim data from 2007 to 2016

Purpose

Laparoscopic antireflux surgery is not widely used in Korea, but published data suggest that its results are comparable to those of Western countries. The purpose of this study was to compare the clinical characteristics, medical utilization, and medical costs of antireflux surgery and proton pump inhibitor (PPI) treatments.

Methods

We used Korean patients who underwent fundoplication (n = 342, surgery group) and a 25% random sample of all patients diagnosed with gastroesophageal reflux disease (GERD) who were prescribed PPIs for more than 12 weeks (n = 130,987, medication group) between 2007 to 2016. We compared medical costs and utilization between the 2 groups.

Results

The average cost of fundoplication was $4,631. The costs of GERD treatment in the first year after surgery and during the follow-up period were $78.1 and $50.1 per month, respectively. In the surgery group, the average monthly medical expenses decreased as the year progressed, but the average monthly medical expenses ($137.5 per month) did not decrease in the medication group. After stratifying by age group, the medical costs of the surgery group were lower than those of the medication group for all ages except for patients between the ages of 70 and 79. The cost difference between the 2 groups was prominent between the ages of 20 and 49.

Conclusion

This study showed that a significant decrease in cost was observed 1 year after surgery, and it was more apparent in younger patients. Further research is needed to determine the appropriateness of antireflux surgery for each group of patients.

Treatment Pattern and Economic Burden of Refractory Gastroesophageal Reflux Disease Patients in Korea

Background/Aims

The prevalence of gastroesophageal reflux disease (GERD) has increased in Korea, and the economic burden of this chronic disease is substantial. We aim to investigate the treatment pattern and economic burden in Korea of refractory GERD requiring long-term use of proton pump inhibitors (PPIs).

Methods

We conducted a cross-sectional analysis of nationally representative sample data obtained from 2012 to 2016 and provided by the Health Insurance Review and Assessment Service. The participants were 86 936 in the medication group and 40 in the surgery group. Age- and sex-standardized prevalence of refractory GERD requiring PPIs medication for more than 12 weeks were analyzed. Generalized linear models were used to estimate cost ratios for comparing the medical costs of the surgery and medication groups after adjustment for demographics and comorbidity.

Results

The prevalence of refractory GERD increased from 1.2% in 2012 to 1.9% in 2016, and the estimated total number of GERD patients increased from 402 000 to 736 000 during this time period. The medical expenditures of the surgery group within 90 days of antireflux surgery (ARS) were 16.9-fold higher compared to those of the medication group; the significant difference in medical costs between the 2 groups disappeared after 90 days post-surgery.

Conclusions

The prevalence of refractory GERD requiring long-term use of PPIs has been trending upwards recently. Nevertheless, ARS is very rarely performed. Considering the increasing medical costs of long-term PPI use, further cost-effectiveness analysis is needed to compare ARS and PPI therapy for the treatment of GERD in Korea.

Anti-reflux Surgery Versus Proton Pump Inhibitors for Severe Gastroesophageal Reflux Disease: A Cost-Effectiveness Study in Korea

Background/Aims

The economic burden for gastroesophageal reflux disease (GERD) has recently increased in Asian countries. This study investigates the cost-effectiveness between anti-reflux surgery and medication, with proton pump inhibitors (PPIs) for GERD in Korea.

Methods

We used a decision tree and Markov model to obtain the costs and quality-adjusted life years (QALYs) of the surgical and medical strategies. Our target cohort was the severe GERD patients aged 50 years old who required a continuous double dose of PPIs. The time horizon was 10 years and all estimates were discounted at 5% per year. The incremental cost-effectiveness ratio of the anti-reflux surgery compared with medication with PPIs was calculated. Sensitivity analyses were performed on all relevant variables.

Results

The cost-utility analysis indicated anti-reflux surgery was more cost-effective than medication among severe GERD patients over a 10-year period. The model predicted that the surgical strategy had a cost savings of $551 and the QALYs had a gain of 1.18 as compared with the medical strategy. The break-even point in costs of the anti-reflux surgery over the medication was estimated to be 9 years. Sensitivity analyses using the varying parameter assumptions demonstrated the robustness of the study results.

Conclusions

This study showed anti-reflux surgery was less expensive and more effective therapy over the PPI medication after 9 years of follow-up. This suggests the surgical strategy is a cost-effective alternative to PPI medication among patients who need long-term management for GERD in Korea.

Phase III, randomised, double-blind, multicentre study to evaluate the efficacy and safety of vonoprazan compared with lansoprazole in Asian patients with erosive oesophagitis

OBJECTIVE

To establish the non-inferior efficacy of vonoprazan versus lansoprazole in the treatment of Asian patients with erosive oesophagitis (EO).

DESIGN

In this phase III, double-blind, multicentre study, patients with endoscopically confirmed EO were randomised 1:1 to receive vonoprazan 20 mg or lansoprazole 30 mg, once daily for up to 8 weeks. The primary endpoint was EO healing rate at 8 weeks. The secondary endpoints were EO healing rates at 2 and 4 weeks. Safety endpoints included treatment-emergent adverse events (TEAEs).

RESULTS

In the vonoprazan (n=238) and lansoprazole (n=230) arms, 8-week EO healing rates were 92.4% and 91.3%, respectively (difference 1.1% (95% CI -3.822% to 6.087%)). The respective 2-week EO healing rates were 75.0% and 67.8% (difference 7.2% (95% CI -1.054% to 15.371%)), and the respective 4-week EO healing rates were 85.3% and 83.5% (difference 1.8% (95% CI -4.763% to 8.395%)). In patients with baseline Los Angeles classification grade C/D, 2-week, 4-week and 8-week EO healing rates were higher with vonoprazan versus lansoprazole (2 weeks: 62.2% vs 51.5%, difference 10.6% (95% CI -5.708% to 27.002%); 4 weeks: 73.3% vs 67.2%, difference 6.2% (95% CI -8.884 to 21.223); and 8 weeks: 84.0% vs 80.6%, difference 3.4% (95% CI -9.187% to 15.993%)). Overall, EO healing rates appeared higher with vonoprazan versus lansoprazole. TEAE rates were 38.1% and 36.6% in the vonoprazan and lansoprazole group, respectively.

CONCLUSION

Our findings demonstrate the non-inferior efficacy of vonoprazan versus lansoprazole in terms of EO healing rate at 8 weeks in this population. Safety outcomes were similar in the two treatment arms.

TRIAL REGISTRATION NUMBER

NCT02388724.

Laparoscopic repair of hiatal hernia

Background

Laparoscopic hiatal hernia repair is a complex surgery typically performed by general abdominal surgeons because it typically involves an abdominal approach. Here, we report our experiences on laparoscopic repair of hiatal hernia as thoracic surgeons.

Methods

Based on our experience of minimally invasive esophageal surgery (MIES) for esophageal cancer, we began performing laparoscopic repair of hiatal hernia in 2009. We analyzed the surgery-related data and postoperative outcomes of 18 consecutive patients we operated on from 2009 to 2017.

Results

There were 1 male and 17 female patients with a median age of 73 years (range, 37-81 years). Ten of 14 symptomatic patients experienced reflux symptoms, such as heartburn. Four patients had a history of prior abdominal surgery. Hiatal hernia types I, II, III, and IV were observed in 3, 9, 5, and 1 patients, respectively. Two (11.1%) laparoscopic procedures required conversion. Modified Collis gastroplasty was used as an esophageal lengthening procedure in 5 patients (27.8%). Mean operation time was 213.8±70.1 minutes and mean hospital stay was 6.2±1.5 days. There were no postoperative complications. At the last follow-up, 15 patients (83.3%) were asymptomatic; however, 3 (16.7%) complained of reflux or dysphagia. Recurrent hiatal hernia was detected on an esophagogram in only 1 patient at 3.5 years after laparoscopic surgery.

Conclusions

Laparoscopic repair of hiatal hernia is a feasible technique with a satisfactory surgical outcome. Importantly, it can be performed by thoracic surgeons who are experienced in the laparoscopic approach.

Personal, academic and stress correlates of gastroesophageal reflux disease among college students in southwestern Saudi Arabia: A cross-section study

Background

Gastroesophageal reflux disease (GERD) is a worldwide prevalent gastrointestinal disorder which has negative impacts on quality of life, health and economy. The aims of this study were to assess the prevalence of GERD among college students in southwestern Saudi Arabia and to evaluate its personal, academic and stress correlates.

Materials and methods

Through a cross-sectional study design, a self-reported questionnaire was distributed between a representative sample of students in health and non-health care colleges in southwestern Saudi Arabia. The questionnaire included data for personal characteristics, academic study, and Arabic versions of GERD questionnaire (GerdQ) and Cohen's Perceived Stress Scale.

Results

Out of 2878 studied students, GERD was reported by 28.6% and 36.6% of students in health and non-health care colleges respectively with an overall prevalence rate of 33.18%. It was associated with impacts on daily life in 17.2% of students. By multivariable regression analysis, GERD was significantly higher among males (aOR = 1.44, 95% CI:117–1.65), ex-smokers (aOR = 1.87), current smokers (aOR = 1.71), non-health care students (aOR = 1.36) and those exposed to high perceived stress (aOR = 1.30).

Conclusion

GERD is a prevalent problem among college students in southwestern Saudi Arabia as it affects about one third of the students. Considering high prevalence of GERD, associated daily life impacts, young age of the studied subject and the risk of future complications, this condition could represent a challenging health and economic problem. The risk of GERD is higher among; males, smokers, former smokers, non-health care colleges students and subjects exposed to high perceived stress.

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GERD affects about one third of college students in southwestern Saudi Arabia.

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GERD is associated with daily life impacts in about one fifth of the students.

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GERD could represent a challenging health and economic problem.

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GERD is significantly associated with high perceived stress.

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Risk of GERD is higher among male students, smokers and non-health care students.

Natural history of gastroesophageal reflux: A prospective cohort study in a stratified, randomized population in Beijing

OBJECTIVE

To explore the natural history of and risk factors for gastroesophageal reflux (GER) in a prospective cohort in Beijing, China.

METHODS

We selected adult participants using a stratified randomized method and performed initial surveys in 1996 and the current survey in 2008. Well-trained investigators administered the survey questionnaire using face-to-face interviews. Reflux symptoms were evaluated by their intensity and frequency. GER was defined as heartburn, acid reflux, and food regurgitation at least once a week, and monthly reflux was defined as at least one of the above symptoms occurring 1-3 days per month.

RESULTS

The resurvey response rate was 47.8% (1189/2486). Over 12 years, 66.9% of the respondents remained unchanged, and one-third changed, with a GER new onset rate of 7.0 per 1000 person-years and a GER disappearance rate of 64.6 per 1000 person-years. This kept the GER prevalence stable at 8.2% to 9.5% (P = 0.28). GER and monthly reflux exhibited significant differences in their tendency to persist or become aggravated to GER (22.4% vs 11.9%, P = 0.02). Participants who initially had single, mild to moderate, daily GER were more likely to recover from reflux over time. Participants with persistent and aggravated GER had more severe heartburn and acid reflux than those with new-onset GER in the current survey. Multiple logistic regression analysis showed that emotional depression is a risk factor for GER aggravation (odds ratio 3.52, 95% confidence interval 1.43-8.67, P = 0.006).

CONCLUSION

The initial symptom profile of reflux determines the outcome of GER over time.

Correlates of gastroenterology health-services utilization among patients with gastroesophageal reflux disease: a large database analysis

Background

Gastroesophageal reflux disease (GERD) is associated with high utilization of health care services. Diagnostic tests usually are not required to establish GERD diagnosis, but endoscopy is recommended for patients with alarm symptoms such as dysphagia and unintentional weight loss, and those whose symptoms are not relieved by proton pump inhibitors (PPIs) therapy. Evidence on the correlates of utilization of gastroenterology health services among GERD patients is limited. The study aim was to examine associations of patient and physician’s characteristics with high utilization of gastroenterology services.

Methods

In a cross-sectional study using the database of the second largest integrated care organization in Israel, data of all adult GERD patients (N = 75,219) in 2012–2015 were analyzed. High utilization of services was assessed using two dependent variables analyzed separately: undergoing two or more gastroscopies or having six or more visits to a gastroenterology consultant during the study-period.

Results

Overall, 11,261 (15.0%) patients had two or more gastroscopies and 23,703 (31.5%) had six or more visits to a gastroenterology consultant. The likelihood of high utilization of gastroscopy increased with age; in immigrants from the Former Soviet Union versus patients who were born in Israel; residents of Jerusalem, the south, the north and Haifa districts versus the center district; in patients with high PPI purchases, and in patients who belonged to clinics in which the physician-manger had no board certification. The correlates were similar for visits to a gastroenterology consultant.

Conclusions

Patient and physician’s characteristics were related to high utilization of gastroenterology services among GERD patients. The associations with age and country of birth might reflect more severe disease. The regional differences warrant further research and interventions at the district level. Training in gastroenterology of primary care physicians without a board certification is warranted.

Electronic supplementary material

The online version of this article (10.1186/s13584-019-0335-3) contains supplementary material, which is available to authorized users.

Barretts's carcinogenesis

Barrett's esophagus is considered a precancerous lesion of esophageal adenocarcinoma (EAC). Long‐segment Barrett's esophagus, which is generally associated with intestinal metaplasia, has a higher rate of carcinogenesis than short‐segment Barrett's esophagus, which is mainly composed of cardiac‐type mucosa. However, a large number of cases reportedly develop EAC from the cardiac‐type mucosa which has the potential to involve intestinal phenotypes. There is no consensus regarding whether the definition of Barrett's epithelium should include intestinal metaplasia. Basic researches using rodent models have provided information regarding the origins of Barrett's epithelium. Nevertheless, it remains unclear whether differentiated gastric columnar epithelium or stratified esophageal squamous epithelium undergo transdifferentiation into the intestinal‐type columnar epithelium, transcommittment into the columnar epithelium, or whether the other pathways exist. Reflux of duodenal fluid including bile acids into the stomach may occur when an individual lies down after eating, which could cause the digestive juices to collect in the fornix of the stomach. N‐nitroso‐bile acids are produced with nitrites that are secreted from the salivary glands, and bile acids can drive expression of pro‐inflammatory cytokines via EGFR or the NF‐κB pathway. These steps may contribute significantly to carcinogenesis.

Association Between Erosive Esophagitis and the Anthropometric Index in the General Korean Population

Background:

An association between obesity and gastroesophageal reflux disease has been reported. However, previous studies have focused on obesity or central obesity.

Aims:

To investigate the association of the anthropometric index and endoscopic erosive esophagitis in health checkups of Koreans.

Study Design:

Case-control study.

Methods:

A total of 1.207 consecutive subjects (aged 40-80 years) during health checkups underwent upper endoscopy and bioelectrical impedance analysis. We collected anthropometric data by bioelectrical impedance analysis, which consisted of body mass index, percent body fat, muscle mass, and fat mass.

Results:

Of 1.207 subjects who underwent upper gastrointestinal endoscopy (mean age, 50.55±9 years), 239 (19.8%) had endoscopic erosive esophagitis. In a univariate analysis, the endoscopic erosive esophagitis group was more likely to be a male and had a higher body mass index, muscle mass and fat mass. In logistic regression analysis, only muscle mass remained an independent risk factor for EE after adjustment for both age and gender. Higher muscle mass was associated with increased EE risk (rate ratio: 1.354, 95% confidence interval: 1.206-1.405, p= 0.027).

Conclusion:

High muscle mass, but body mass index, is an independent risk factor for erosive esophagitis in a population over 40 years of age.

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.

The association between proton pump inhibitor use and the risk of tuberculosis: A case-control study

PURPOSE

Few studies have reported an association between proton pump inhibitor (PPI) use and tuberculosis. Tuberculosis incidence is relatively high in Asian people, and an increase in PPI prescriptions has been reported in South Korea. Thus, we investigated the association between PPI use and tuberculosis development.

METHODS

We conducted a case-control study on 25 672 newly diagnosed tuberculosis patients using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database (2002-2013). We selected a control group without tuberculosis using 1:1 exact matching based on age, sex, index year, insurance type, and income level. We investigated PPI exposure 2 years prior to the index date and classified the subjects into nonuser, continuous user, recent user, and former user groups. Odds ratios (ORs) and 95% confidence intervals (CIs) for tuberculosis development were calculated using conditional logistic regression.

RESULTS

A total of 51 344 cases and controls were analyzed. Recent PPI use (adjusted odds ratio [aOR], 1.28; 95% CI, 1.18-1.39) and continuous PPI use (aOR, 1.13; 95% CI 1.10-1.28) were significantly associated with tuberculosis development, compared with nonuse of PPIs. An increased tuberculosis incidence was not observed in the former use group compared with the nonuse group (aOR 1.05, 95% CI 0.95-1.17).

CONCLUSIONS

In this case-control study, we found that recent PPI use and continuous PPI use were associated with increased tuberculosis development. Although further investigation is needed, the tuberculosis risk accompanying PPI treatment should be considered.

The Influences of Visceral Fat Area on the Sites of Esophageal Mucosal Breaks in Subjects with Gastroesophageal Reflux Diseases

Background

Central obesity is suggested as a risk factor for gastroesophageal reflux diseases. The aim of this study was to evaluate the influences of a visceral fat area on the site of mucosal breaks in the esophagogastric junction (EGJ).

Methods

Subjects who underwent abdomen-computerized tomography and esophagogastroduodenoscopy for screening on the same day were evaluated between 2007 and 2016. We enrolled 178 subjects who had erosive esophagitis (LA classifications A-D). Abdominal obesity was evaluated by measuring visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), VAT-to-SAT ratio, total adipose tissue (TAT), body mass index (BMI), and waist circumference (WC).

Results

The lesser curvature (LC) of EGJ was the most frequent site of mucosal breaks (104 cases, 58.4%). BMI, WC, VAT, the VAT-to-SAT ratio, and TAT were higher in the LC group. In multivariate analysis, higher VAT (odds ratio (OR) 2.90, 95% confidence interval (CI) 1.18 to 7.13, 3rd vs. 1st quartile, P = 0.021; OR 3.63, 95% CI 1.44 to 9.10, 4th vs. 1st quartile, P = 0.006) and the VAT/SAT ratio (OR 2.91, 95% CI 1.11 to 7.61, 3rd vs. 1st quartile, P = 0.03; OR 3.02, 95% CI 1.17 to 7.83, 4th vs. 1st quartile, P = 0.023) were significantly associated with mucosal breaks in the LC group. However, BMI, WC, and TAT were not significant in the multivariate analysis.

Conclusion

The VAT and the VAT/SAT ratio were significantly associated with the mucosal breaks in the LC of EGJ. Visceral obesity could influence the location of the mucosal breaks on EGJ.

Prevalence and factors associated with gastroesophageal reflux disease in southern India: A community-based study

BACKGROUND AND AIM

Gastroesophageal reflux disease (GERD) is common worldwide with significant expenditure for health care. Community-based data on the prevalence of GERD in India remains scarce. This study was conducted to determine the prevalence of GERD and to identify potential associations.

METHODS

A community-based survey of adults (aged ≥18 years) was done through population proportionate to size sampling in urban and rural areas of Vellore district, Tamil Nadu, India. GERD was defined as heartburn and regurgitation occurring at least twice per week. Associations between GERD and gender, age, anthropometric measures, and consumption of tobacco, alcohol, meat, and milk were evaluated. Odds ratios (OR) with 95% confidence intervals were derived from logistic regression models.

RESULTS

Of 6174 participants (3157 urban, 2599 male), 8.2% had GERD. The prevalence was higher in urban (11.1%) compared to rural areas (5.1%) (p < 0.001). Among patients with GERD, 34.3% used medications daily for symptom relief. On univariate analysis, GERD was associated with female gender, living in an urban area, age >30, BMI >25, and infrequent milk consumption. On multivariate analysis, female gender (OR 1.3; 95% CI 1.1-1.6), living in urban area (OR 2.3; 95% CI 1.9-2.8), age >30 years (OR 1.9; 95% CI 1.4-2.5), BMI ≥ 25 kg/m² (OR 1.3; 95% CI 1.1-1.6), and infrequent milk intake (OR 1.6; 95% CI 1.3-1.9) were independently associated with GERD.

CONCLUSION

Symptomatic GERD was found in 8.2% of respondents in this representative southern Indian community, being more prevalent in urban residents, women, older, and obese individuals.

Validation of the Korean Version of the Gastroesophageal Reflux Disease Questionnaire for the Diagnosis of Gastroesophageal Reflux Disease

Background/Aims

The Gastroesophageal Reflux Disease Questionnaire (GerdQ) has been developed and validated as a tool for the diagnosis of gastroesophageal reflux disease (GERD) in patients with gastrointestinal symptoms. However, the GerdQ and the cutoff value for determining GERD has not been validated in Korea.

Methods

Patients with symptoms suggestive of GERD were consecutively recruited. The Korean version of GerdQ was developed through a forward-backward translation process according to the cross-cultural adaptation method. Endoscopically documented esophagitis, abnormal results on 24-hour ambulatory pH recording with symptom association monitoring, or response to proton pump inhibitor treatment were used as diagnostic references for GERD. The reproducibility and test characteristics of the Korean version of GerdQ were assessed.

Results

A total of 149 patients with a median age of 55 years were analyzed. The intra-class correlation coefficient of 2 subsequently measured GerdQ scores was 0.651 (95% CI, 0.518-0.748). The cutoff value of 8 was found to have the highest sensitivity (64.9%; 95% CI, 56.2-73.7) and specificity (71.4%; 95% CI, 56.5-86.4) for the diagnosis of GERD. The questionnaire had a high positive predictive value (88.1%; 95% CI, 81.2-95.0), but a low negative predictive value (38.5%; 95% CI, 26.2-50.3) for GERD. Any symptom improvement on proton pump inhibitor treatment showed a sensitivity of 93.0% (95% CI, 88.3-97.7) and a specificity of 48.6% (95% CI, 32.0-65.1) for GERD.

Conclusion

The Korean version of GerdQ is a useful complementary tool in the diagnosis of GERD.

Fatty liver disease and the risk of erosive oesophagitis in the Korean population: a cross-sectional study

OBJECTIVES

To investigate an association between fatty liver disease (FLD) and erosive oesophagitis.

DESIGN AND SETTING

This was a cross-sectional study of subjects selected from examinees who underwent health check-up, including oesophagogastroduodenoscopy in one hospital between 2004 and 2011. Erosive oesophagitis was classified according to the Los Angeles classification and FLD was diagnosed with ultrasonography. The anthropometric and laboratory data of the subjects were analysed using χ² test and multivariate logistic regression. Additionally, we have analysed our data with two-stage least square estimation using the Baltagi-Chang one-way model to clarify unobserved confounding variable.

PRIMARY OUTCOME MEASURE

The effect of FLD on erosive oesophagitis.

RESULTS

Among the 14 723 eligible subjects, 4232 (28.7%) subjects diagnosed with FLD were classified into the fatty liver group and 10 491 (71.3%) subjects without FLD were classified into the non-fatty liver group. The incidence rate of erosive oesophagitis was significantly higher in the fatty liver group than in the non-fatty liver group (10.4%vs6.1%, p<0.0001). The multivariate analysis revealed that the fatty liver group was significantly associated with erosive oesophagitis (OR 1.19, 95% CI 1.03 to 1.37, p=0.016).

CONCLUSION

FLD diagnosed by ultrasonography is an independent risk factor of erosive oesophagitis. It suggests that FLD-related metabolic abnormality may be associated with erosive oesophagitis.

Evidence-Based Practice Guideline for Surgical Treatment of Gastroesophageal Reflux Disease 2018

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea, and physicians, including surgeons, have been focusing on its treatment. Indeed, in Korea, medical treatment using a proton pump inhibitor is the mainstream treatment for GERD, while awareness of surgical treatment is limited. Accordingly, to promote the understanding of surgical treatment for GERD, the Korean Anti-Reflux Surgery Study Group published the Evidence-Based Practice Guideline for the Surgical Treatment of GERD. The guideline consists of 2 sections: fundamental information such as the definition, symptoms, and diagnostic tools of GERD and a recommendation statement about its surgical treatment. The recommendations presented 5 debates regarding fundoplication: 1) comparison of the effectiveness of medical and surgical treatments, 2) effectiveness of surgical treatment in cases of refractory GERD, 3) effectiveness of surgical treatment of extraesophageal symptoms, 4) comparison of effectiveness between total and partial fundoplication, and 5) effectiveness of fundoplication in cases of hiatal hernia. The present guideline is the first to demonstrate the efficacy of the surgical treatment GERD in Korea.

Epidemiology of Gastroesophageal Junction Adenocarcinoma in Korea

The incidence of gastroesophageal junction adenocarcinoma (GEJAC) in Western countries has increased in recent decades, in addition to a rise in the incidence of esophageal adenocarcinoma (EAC). Gastroesophageal reflux disease (GERD), obesity, smoking, alcohol consumption, and low Helicobacter pylori (HP) infection rate have been nominated as risk factors for such cancers. Among these risk factors, the increased prevalence of GERD and obesity and the decreased prevalence of HP infection are of special interest owing to the currently increasing prevalence of GEJAC in Western countries. Although similar trends in the prevalence of GERD, obesity, and HP infection are observed in Asian countries after a time lag from Western countries, it is still uncertain if the prevalence of GEJAC in Asian countries is increasing, especially in Korea. The incidence of GERD in Korea is currently increasing; it was below 3% in the 1990s. The incidence of obesity in the Korean population is increasing owing to the adoption of westernized lifestyles, including food preferences, and the HP infection rate in Korea is known to be decreasing. Therefore, based on logical extrapolation of observations of Western countries, the incidence of GEJAC will increase in Korea. However, the proportion of GEJAC among other upper gastrointestinal malignancies in Korea appears to be currently unchanged compared with that in the 1990s. Presently, there is a lack of epidemiologic studies on this issue in this region; therefore, more studies are needed to clarify the characteristics of these tumors and to improve clinical outcomes for patients with these tumors.

Gastroesophageal reflux disease increases the risk of chronic rhinosinusitis: a nested case-control study using a national sample cohort

BACKGROUND

The purpose of this study was to evaluate the relations between gastroesophageal reflux disease (GERD) and chronic rhinosinusitus (CRS) in a Korean population.

METHODS

Subjects from the Korean National Health Insurance Service-National Sample Cohort, all ≥20 years old, were assessed from 2002 to 2013. In total, 23,489 CRS participants were matched with 93,956 controls at a ratio of 1:4 with respect to age, group, sex, income group, region of residence, hypertension, diabetes, and dyslipidemia. We analyzed previous history of GERD in the CRS and control groups. The CRS group included patients identified using International Classification of Diseases 10th edition (ICD-10) codes (J32) who had treated their CRS ≥2 times and had undergone head and neck computed tomography (CT). The GERD group included patients identified using the ICD-10 (K21) code who had treated their GERD ≥2 times and had taken a proton pump inhibitor (PPI) for ≥2 weeks. Crude and adjusted odds ratios (ORs) were analyzed using unconditional logistic regression analyses. The 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed according to age and sex.

RESULTS

The rate of GERD was higher in the CRS group (17.1% [4020 of 23,489]) than in the control group (9.1% [8522 of 93,956]; p < 0.001). The adjusted OR of GERD was 2.04 (95% CI, 1.96-2.13; p < 0.001) in the CRS group. The results of the subgroup analyses were consistent.

CONCLUSION

The ORs of GERD were increased in CRS participants. This relationship was consistent in all age and sex groups.

Increased risk of appendectomy in patients with gastroesophageal reflux disease: A nested case-control study using a national sample cohort

The purpose of this study is to confirm and complement previous data regarding an association between gastroesophageal reflux disease and appendectomy.The Korean National Health Insurance Service-National Sample Cohort includes data from people ≥ 20 years old collected from 2002 to 2013. A total of 13,484 participants who received an appendectomy were matched with 53,936 controls at a 1:4 ratio. We analyzed the previous histories of gastroesophageal reflux disease (GERD) in the appendectomy and control groups. Appendectomies were identified using operation codes (Q2860-Q2863) exclusive for appendicitis (International Classification of Disease-10 (ICD-10): K35). GERD was defined using the ICD-10 (K21), and patients who were treated ≥ 2 times and were prescribed a proton pump inhibitor (PPI) for ≥ 2 weeks were included. Crude (simple) and adjusted odds ratios (ORs) for GERD and appendectomy were analyzed using conditional logistic regression analyses.A higher GERD rate was detected in the appendectomy group (11.4% [1,713/15,062]) than in the control group (8.2% [4,947/60,248], P < .001). Adjusted ORs for GERD were 1.37 (95% confidence interval [CI] = 1.30-1.45) (P < .001). Subgroup analyses stratified according to age and sex revealed consistent findings. The adjusted OR for GERD in participants prescribed PPIs for ≥ 30 days was 1.31 (95% CI = 1.20-1.43), and the adjusted OR for GERD in participants prescribed PPIs for ≥ 60 days was 1.30 (95% CI = 1.15-1.48).The Odds for GERD were higher in the appendectomy group than in the control group.

Surgical outcomes and over one-year follow-up results of laparoscopic Nissen fundoplication for gastroesophageal reflux disease: Single-center experiences

BACKGROUND

Laparoscopic antireflux surgery is a standard surgical treatment method for gastroesophageal reflux disease (GERD) in Western countries. However, the procedure has not been actively carried out in Korea because of concerns regarding surgical complications. Here, we conducted this study to evaluate short-term surgical outcomes of laparoscopic Nissen fundoplication (LNF) performed at a single institution.

METHODS

From January 2010 to August 2016, totally 29 patients underwent LNF for GERD performed by three surgeons at Asan Medical Center, Korea. All patients participated in a telephonic survey including the presence of symptoms and the status of quality of life (QOL).

RESULTS

The median age at operation and BMI were 54 years and 23.8 kg/m², respectively. Preoperatively, 27 patients (93.1%) underwent PPI therapy. All patients had typical or atypical GERD symptoms. One patient (3.4%) required reoperation because of total gastroesophageal junction obstruction. 24 patients (82.8%) reported complete or partial resolution of symptoms, whereas 21 (72.4%) reported partial or complete improvement in quality of life. In patients with reflux esophagitis, GERD symptoms were significantly relieved after LNF (P = 0.005). LNF responders tended to perceive an improvement in quality of life post operation (P < 0.001).

CONCLUSION

LNF is a feasible, safe, and effective treatment option for controlling GERD symptoms as well as improving the quality of life. Presence of reflux esophagitis was a predictor of successful outcomes.

Gastroesophageal reflux disease and its related factors among women of reproductive age: Korea Nurses' Health Study

Background

Recently, the number of patients diagnosed with gastroesophageal reflux disease (GERD) has increased in Korea. Risk factors of GERD include age, sex, medication use, lack of physical exercise, increased psychological stress, low or high body mass index (BMI), unhealthy eating habits, increased alcohol consumption, and cigarette smoking. However, few studies examined the major factors affecting GERD in women of childbearing age. Therefore, this study assessed the risk factors of GERD among 20,613 female nurses of reproductive age using data from the Korea Nurses’ Health Study.

Methods

Participants were recruited from July 2013 to November 2014. They provided their history of GERD 1 year prior to data collection, along with information on their demographic characteristics, health-related behaviors, diet, medical history, and physical and psychological factors. Of the total sample, 1184 individuals with GERD diagnosed in the year prior to the study were identified. Propensity score matching was used for analysis.

Results

Cigarette smoking, increased alcohol consumption, low or high BMI, depression, and increased psychosocial stress were associated with the prevalence of GERD among Korean young women. Multivariate ordinal logistic regression analysis revealed significant positive relationships between GERD and being a former smoker; having a low (< 18.5 kg/m²) or high BMI (> 23 kg/m²); and having mild, moderate, moderately severe, and severe depression.

Conclusions

Smoking, BMI, and depression were associated with GERD. To reduce this risk among female nurses, intervention strategies are required to help nurses maintain a normal weight and manage their depression.

Bidirectional association between gastroesophageal reflux disease and depression: Two different nested case-control studies using a national sample cohort

The purpose of this study is to evaluate the associations between gastroesophageal reflux disease (GERD) and depression using a national sample cohort of the Korean population. Data were collected from individuals ≥20 years old in the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013. We designed two different nested case-control studies. In study I, 60,957 participants with depression were matched at a 1:4 ratio with 243,828 controls, and their previous histories of GERD were analyzed. In study II, 133,089 participants with GERD were matched at a 1:2 ratio with 266,178 controls, and their previous histories of depression were analyzed. Crude and adjusted odds ratios (ORs) were analyzed using unconditional logistic regression analyses, and 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed according to age and sex. The adjusted OR for GERD was 2.01 (95% CI = 1.96–2.07) in the patients with depression (study I). The adjusted OR for depression was 1.48 (95% CI = 1.43–1.52) in the patients with GERD (study II). The results of the subgroup analyses were consistent. GERD and depression displayed bidirectional associations.

Potentially inappropriate medication and hospitalization/emergency department visits among the elderly in Korea

Objective

To investigate the association between potentially inappropriate medicine (PIM) use, defined using the American Geriatric Society (AGS) 2012 Beers criteria, and the risk of hospitalization or emergency department (ED) visits in elderly patients, and to examine the most frequently used PIMs among patients with adverse outcomes.

Design/Setting

This was a retrospective study using National Health Insurance claims data from 2010 to 2012.

Intervention(s)

Elderly patients who took PIMs are compared to those who were not taking PIMs.

Study participants

Elderly patients (n = 79 552) who visited medical institutions in Jeju Island during 2011.

Main outcome measure

Hospitalization and ED visits were evaluated according to whether the patients took PIMs during the study period. The most frequent medications used by the PIM group were also investigated.

Results

The likelihood of hospitalization was higher in older patients who took at least one PIM than in those who were not taking PIMs during the study period (odds ratio 2.25, 95% confidence interval 2.09-2.44). Patients taking PIMs were more likely to visit EDs (odds ratio 1.59, 95% confidence interval 1.50-1.67). Among patients who were hospitalized or visited EDs, 45.5% had taken at least one PIM on that day. The most commonly used PIMs included chlorpheniramine maleate, diazepam, metoclopramide HCl and diclofenac sodium.

Conclusion

Our findings indicate that PIM use can lead to negative health consequences, providing further evidence of the inappropriateness of these medications. Thus, pharmaceutical policies regarding PIM use may need to be implemented for elderly adults in Korea.

Nationwide survey of partial fundoplication in Korea: comparison with total fundoplication

Purpose

Laparoscopic total fundoplication is the standard surgery for gastroesophageal reflux disease. However, partial fundoplication may be a viable alternative. Here, we conducted a nationwide survey of partial fundoplication in Korea.

Methods

The Korean Anti-Reflux Surgery study group recorded 32 cases of partial fundoplication at eight hospitals between September 2009 and January 2016. The surgical outcomes and postoperative adverse symptoms in these cases were evaluated and compared with 86 cases of total fundoplication.

Results

Anterior partial fundoplication was performed in 20 cases (62.5%) and posterior in 12 (37.5%). In most cases, partial fundoplication was a secondary procedure after operations for other conditions. Half of patients who underwent partial fundoplication had typical symptoms at the time of initial diagnosis, and most of them showed excellent (68.8%), good (25.0%), or fair (6.3%) symptom resolution at discharge. Compared to total fundoplication, partial fundoplication showed no difference in the resolution rate of typical and atypical symptoms. However, adverse symptoms such as dysphagia, difficult belching, gas bloating and flatulence were less common after partial fundoplication.

Conclusion

Although antireflux surgery is not popular in Korea and total fundoplication is the primary surgical choice for gastroesophageal reflux disease, partial fundoplication may be useful in certain conditions because it has less postoperative adverse symptoms but similar efficacy to total fundoplication.

Insulin Resistance is Associated with Chronic Laryngitis in Korean Women

OBJECTIVES

The aim of this study was to investigate the association between chronic laryngitis (CL) and insulin resistance (IR) in South Korea using data from the 2010 Korea National Health and Nutrition Examination Surveys (KNHANES).

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional data of 4,261 adults who completed KNHANES were analyzed. CL was considered when participants experienced a voice change and demonstrated flexible laryngoscopic findings of diffuse laryngeal inflammation. All participants were assessed for IR using the homeostasis model assessment of insulin resistance (HOMA-IR).

RESULTS

Among the Korean population older than 19 years, the prevalence of chronic laryngitis was 3.8±0.7%. Univariate analysis demonstrated that CL was significantly associated with smoking and systolic and diastolic blood pressure in men and with age, diastolic blood pressure, HDL cholesterol, insulin, and HOMA-IR in women. Multiple regression analysis demonstrated that the mean value of HOMA-IR was significantly associated with CL in women only. In addition, CL was more prevalent in the highest compared with the lowest HOMA-IR quartile (OR [95% CI]: 2.268 [1.053-4.884] after adjusting for age, OR [95% CI]: 2.235 [1.040-6.181] after adjusting for confounding factors of age, body mass index, smoking status, alcohol intake, regular exercise, education, and income).

CONCLUSIONS

These findings indicate that IR characterized by HOMA-IR is significantly associated with CL in Korean women only. Our results suggest that HOMA-IR could be an early predictive factor of increased risk of CL in Korean women.

Identification of target risk groups for population-based Clostridium difficile infection prevention strategies using a population attributable risk approach

OBJECTIVES

We aimed to determine risk factors associated with Clostridium difficile infection (CDI) and assess the contributions of these factors on CDI burden.

METHODS

We conducted a 1:4 matched case-control study using a national claims dataset. Cases were incident CDI without a history of CDI in the previous 84 days, and were age- and sex-matched with control patients. We ascertained exposure, defined as a history of morbidities and drug use within 90 days. The population attributable risk (PAR) percent for risk factors was estimated using odds ratios (ORs) obtained from the case-control study.

RESULTS

Overall, the strongest CDI-associated risk factors, which have significant contributions to the CDI burden as well, were the experience of gastroenteritis (OR=5.08, PAR%=17.09%) and use of antibiotics (OR=1.69, PAR%=19.00%), followed by the experiences of female pelvic infection, irritable bowel syndrome, inflammatory bowel disease, and pneumonia, and use of proton-pump inhibitors (OR=1.52-2.37, PAR%=1.95-2.90).

CONCLUSIONS

The control of risk factors that had strong association with CDI and affected large proportions of total CDI cases would be beneficial for CDI prevention. We suggest performing CDI testing for symptomatic patients with gastroenteritis and implementing antibiotics stewardship.

Effects of estrogen on esophageal function through regulation of Ca2+-related proteins

BACKGROUND

The calcium ion is important for physiological functions in all tissues and organs and essential to many vital functions, including hormone secretion and muscle contraction. The intracellular concentration of calcium is regulated by calcium related proteins such as CaBP-9k, PMCA1, and NCX1. In this study, we investigated the relationship between calcium regulation and esophageal functions such as mucin secretion and smooth muscle contraction.

METHODS

To evaluate the influence of sex steroid hormones, immature rats were treated for 3 days with estradiol (E2), progesterone (P4), and their antagonists (ICI 182,780, and RU486). Esophageal function, transcription level, and localization of CaBP-9k, PMCA1, NCX1, ERα, and MUC2 were examined in the esophagus.

RESULTS

Transcriptional level of Cabp-9k and Muc2 was increased by E2, but not by P4. CaBP-9k, PMCA1, and MUC2 were mainly localized in the mucosal layer. Acidic mucosubstances in the esophagus were increased by E2 and recovered by ICI treatment. Unlike the expression of Cabp-9k, mRNA levels of Pmca1, Ncx1, and Erα were only decreased in response to E2, and recovered by ICI co-treatment group. The contraction of the esophagus and mRNA level of Mylk were reduced by E2. Overall, E2 upregulated mucus secretion, but downregulated muscle contraction in the esophagus through regulation of the expression of calcium related genes and the resultant intracellular calcium level.

CONCLUSIONS

The regulation of E2 in the function of esophagus may be applied to treat esophageal diseases such as reflux esophagitis, achalasia, and esophageal cancer.

Central Obesity as a Risk Factor for Non-Erosive Reflux Disease

PURPOSE

Although central obesity is a risk factor for erosive esophagitis, information regarding the association between central obesity and non-erosive reflux disease (NERD) is still scarce. The purpose of this study was to investigate the risk factors for NERD by comparing NERD patients and healthy controls.

MATERIALS AND METHODS

Comprehensive clinical data from 378 patients who underwent esophagogastroduodenoscopy from December 2012 to May 2013 and had no visible esophageal mucosal breakage were analyzed. The Korean version of GerdQ questionnaire was used to diagnose NERD. The association between central obesity and NERD was assessed after matching subjects according to propensity scores.

RESULTS

There were 119 NERD patients and 259 controls. In multivariate analysis, central obesity, female gender, and younger age were significantly associated with NERD [odds ratio (OR)=2.55, 1.93, and 1.80; p=0.001, 0.005, and 0.011, respectively]. After adjusting for 12 clinical variables using propensity score matching, 114 NERD patients were matched to 114 controls. All variables were well balanced between the two groups (average D before matching: 0.248, after matching: 0.066). Patients with NERD were more likely to have central obesity than healthy controls (28.1% vs. 7.9%). After adjusting for propensity scores and all covariates in multivariable logistic regression analyses, central obesity was still found to be a significant risk factor for NERD (OR=4.55, p<0.001).

CONCLUSION

Central obesity appears to be an independent risk factor for NERD. This result supports the presence of an association between GERD and central obesity, even in the absence of esophageal erosion (NERD).

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.

Rationale and Design for a Randomized Comparison of Efficacy and Safety between Aspirin and Clopidogrel in Atrial Fibrillation Patients with Low Stroke Risk: CESAC-AF trial

BACKGROUND

Atrial fibrillation (AF) increases the risk of thromboembolic stroke. An oral anticoagulant should be administrated to prevent stroke in patients with moderate stroke risk (ie, CHA₂DS₂-VASc score>2). If the stroke risk is low (i.e. the score=1), however, antiplatelet agent such as aspirin is widely used. Aspirin can cause peptic ulcer disease (PUD) while its alternative, clopidogrel, theoretically does not.

OBJECTIVE

To elucidate the efficacy and safety between aspirin and clopidogrel, a multicenter randomized controlled trial was designed in AF patients with low stroke risk.

METHODS

According to sample size estimation based on previous literature, a total of 1560 AF patients with low stroke risk will be randomly assigned into 4 different groups dependent upon initial esophagogastroduodenoscopy (EGD) results: two mono-antiplatelet treatment groups with either aspirin 100mg or clopidogrel 75mg for 1year; two antiplatelet agent and proton pump inhibitor (PPI) combination groups. Follow-up EGD will be performed at 1year.

RESULTS

The clinical follow-up will be performed for 1year after enrollment. The primary efficacy endpoint is to compare the annual stroke rate between aspirin and clopidogrel treatment groups. The primary safety endpoint is to compare the prevalence of drug-induced gastrointestinal (GI) and intracranial hemorrhage and upper-GI response including PUD based on EGD after 1year.

CONCLUSIONS

This trial will determine whether clopidogrel is noninferior in stroke prevention and superior in reduction of GI events including PUD to aspirin in AF patients with low stroke risk. (ClinicalTrials.gov: NCT02960126).

Endoscopic Accessories Used for More Advanced Endoluminal Therapeutic Procedures

Endoscopic accessories describe an extensive variety of auxiliary instruments used for diagnostic and therapeutic endoscopy. Various endoscopic accessories have been developed over the previous few decades and are mostly used for treating neoplastic lesions, such as early gastrointestinal (GI) carcinomas and premalignant lesions. Because of extensive research on natural orifice endoluminal surgery (NOTES) in the early 2000s and recent technological developments, new devices have been developed for various advanced endoluminal therapeutic procedures. In particular, a remarkable development of endoscopic management was achieved in the field of gastroesophageal reflux disease (GERD) and obesity. In both conditions, there is treatment gap between medical and surgical therapy. A large proportion of the patients who do not respond to medical treatment and lifestyle modification, still hesitate to directly undergo surgical treatment. To bridge this gap, endoscopic management has been receiving increasing attention. In this article, I review endoscopic and/or endoluminal devices used for the treatment of GERD and obesity with proposed mechanisms of their function.

Factors predicting outcomes of laparoscopic Nissen fundoplication for gastroesophageal reflux disease: experience at a single institution in Korea

Purpose

Laparoscopic fundoplication is considered the standard surgical treatment for gastroesophageal reflux disease (GERD) in Western countries. However, some patients experience poor surgical outcomes with this procedure. The study aimed to identify the predictive factors of the surgical outcomes of laparoscopic Nissen fundoplication for the treatment of Korean GERD patients.

Methods

Sixty-one patients with GERD were treated using laparoscopic Nissen fundoplication between November 2012 and February 2015. Symptom control rates were compared according to clinical and surgical factors to identify predictive factors of successful surgical outcomes.

Results

Thirty-five men and 26 women were enrolled. Preoperatively, typical symptoms were present in 60 patients (98%), while atypical symptoms were present in 40 patients (66%). Postoperatively, typical symptoms were controlled in 51 of 60 patients (85.0%), while atypical symptoms were controlled in 33 of 40 patients (82.5%). Overall, at 6 months postsurgery, 54 (88.5%) reported some resolution of GERD symptoms, with 48 (78.7%) achieving complete control. Patients who exhibited a good response to proton pump inhibitor therapy had a significantly greater rate of complete symptom control (P = 0.035).

Conclusion

Laparoscopic fundoplication is effective for controlling GERD symptoms. Response to preoperative proton pump inhibitor was a predictor of successful outcome.

Chronic cough in Korean adults: a literature review on common comorbidity

Chronic cough is a significant medical condition with high prevalence and a strong negative impact on the quality of life. Cough hypersensitivity is thought to underlie chronic cough, with several environmental and host factors interacting to cause neuronal sensitization and chronicity. Comorbid conditions affecting cough reflex pathways, such as upper airway diseases, asthma, and gastroesophageal reflux, play important roles in chronic cough. However, their prevalence may vary in patients living in different geographical regions or with different ethnicities. We conducted a literature review to examine common comorbidities in Korean adult patients with chronic cough, their clinical implications, and the issues that still need to be addressed in the development of clinical evidence of chronic cough in Korean adult patients.

Antireflux Surgery in Korea: A Nationwide Study from 2011 to 2014

Background/Aims

Although laparoscopic fundoplication is a well-established therapy for gastroesophageal reflux disease (GERD) in Western countries, the mainstay of GERD treatment in Korea is long-term proton pump inhibitor (PPI) use. The aim of the present study was to evaluate nationwide data regarding antireflux surgery in Korea.

Methods

Data from 2011 to 2014 were collected from the Korean Antireflux Surgery Study Group and then analyzed.

Results

A total of 87 patients underwent laparoscopic fundoplication for the treatment of GERD. Preoperatively, typical symptoms were present in 81 patients (93%) and atypical symptoms were present in 51 patients (59%). Twenty-seven patients (31%) had poor PPI responses. The average surgical time and postoperative hospital stay were 116.3±42.3 minutes and 4.3±3.1 days, respectively. At 3 months after surgery, typical symptoms were completely controlled in 86.3% of patients and partially controlled in 11.7%, whereas atypical symptoms were completely controlled in 63.3% of patients and partially controlled in 23.3%.

Conclusions

This study showed that although atypical symptoms and PPI nonresponders are common, the complete control rates of typical and atypical symptoms were 86.3% and 63.3%, respectively. Laparoscopic fundoplication is an efficacious method of controlling the symptoms of GERD and has an acceptable rate of postoperative morbidity and adverse symptoms.

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.

A Comparison Study of Esophageal Findings on (18)F-FDG PET/CT and Esophagogastroduodenoscopy

PURPOSE

The aim of this study was to compare the esophageal findings of 2-deoxy-2-[(18)F]fluoro-d-glucose positron emission tomography-computed tomography ((18)F-FDG PET/CT) and esophagogastroduodenoscopy (EGD).

METHODS

We retrospectively reviewed (18)F-FDG PET/CT and EGD findings of 369 subjects who underwent medical examination between January 2014 and December 2014. The range and intensity of esophageal (18)F-FDG uptake were visually analyzed. The maximum standardized uptake value (SUVmax) of the esophagus and around the esophagogastric (EG) junction was measured. EGD results were provided by the gastroenterologist. We compared the esophageal findings obtained using (18)F-FDG PET/CT and EGD.

RESULTS

There were typical linear FDG uptakes in (18)F-FDG PET/CT patients who underwent EGD the same day. In visual analysis of the range and intensity of the (18)F-FDG uptake, the patients who underwent (18)F-FDG PET/CT and EGD on the same day showed relatively diffuse and discernible (18)F-FDG uptake in the esophagus. Reflux esophagitis was diagnosed in 59 subjects, and 27 of these were classified as higher than Los Angeles classification A. With an increasing degree of reflux esophagitis observed on EGD, the SUVmax in the esophagus and around the EG junction was also increased.

CONCLUSION

Our study showed that FDG uptake at the esophagus or the EG junction might be clinically significantly related to esophagitis. However, EGD performed before (18)F-FDG PET/CT on the same day may affect the esophageal (18)F-FDG uptake.