Gastroesophageal reflux disease: a typical spectrum disease (a new conceptual framework is not needed)

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis.

Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Invention and Pilot Study of the Efficacy and Safety of the SUPRAtube Device in Continuous Supraglottic Aspiration for Intubated and Mechanically Ventilated Patients

Background

Bronchoaspiration of content that accumulates in the supraglottic area (eg, saliva, gastroesophageal reflux) is a risk factor for ventilator-associated pneumonia. A continuous supraglottic suction system may decrease the risk of bronchoaspiration in these patients.

Objective

(1) Constructing a conceptual model and functional prototype of a continuous supraglottic suction device for use in humans; (2) defining functional characteristics in ex vivo swine head models; and (3) evaluating its efficacy and safety in mechanically ventilated patients.

Methods

Study conducted in three phases. First phase: definition of distances and diameters of the triangle determined by dental arch, posterior oropharynx and vallecula, and diameter of the oropharynx in axial projection; and identification of the declining area of supraglottic suction. Second phase: design engineering and functional prototype evaluated in ex vivo models. Third phase: evaluation of device use in terms of safety and efficacy in ventilated patients.

Results

We obtained a final functional model of the SUPRAtube device injected into PVC for medical use. Device effectiveness in in vitro simulation showed a high and fast suction capacity of liquid and thick volumes. Study of swine heads allowed to validate the shape, size and functional fenestration of the device. Study in intubated and mechanically ventilated patients showed a high supraglottic suction capacity and the absence of local adverse events during 72 (7-240) hours of continuous operation.

Conclusion

Our study describes the process of conceptualization, design and production of a practical, safe, low-cost continuous supraglottic suction device without representing antibiotic pressure, which appears to be a new complementary preventive strategy for the standard management of intubated and mechanically ventilated patients.

Severity of GERD and disease progression

BACKGROUND

Many factors may play a role in the severity and progression of gastroesophageal reflux disease (GERD) since pathophysiology is multifactorial. Data regarding the progression of GERD are controversial: some reports of increased esophageal acid exposure (EAE) and mucosal damage were considered as evidence for a stable disease course, while others interprete these findings as disease progression. The aim of this study is to analyze a large patient-population with persisting symptoms indicative of GERD under protonpumpinhibitor-therapy and identify components characterizing disease severity and progression.

METHODS

Patients with symptoms indicative of GERD were included in the study in a tertiary referral center (Frankfurt, Germany). All selected patients were under long-term protonpumpinhibitor-therapy with persistant symptoms. All patients underwent investigations to collect data on their physical status, EAE, severity of esophagitis, anatomical changes, and esophageal functional defects as well as their relation to the duration of the disease. Incidence over time was plotted as survival curves and tested with Log-rank tests for the four main disease markers. Multivariate modeling with COX-regression model was used to estimate the general impact of the four main disease markers on the time course of the disease. In order to elucidate possible causal relationships over time, a path analysis (structural equation model) was calculated.

RESULTS

From the database with 1480 data sets, 972 patients were evaluated (542 males, 430 females). The mean age was 50.5 years (range18-89). The mean body mass index was 27.2(19-48). The mean time between the onset of symptoms and the diagnostic investigations was 8.2 years (1-50). A longer disease history for GERD was significantly associated with a higher risk for LES-incompetence. The mean duration from symptom onset to the time of clinical investigation was 9 years for patients with LES-incompetence (n = 563), compared to a mean of 6 years for those with mechanically intact LES (n = 95). A longer period from symptom onset to diagnostics was significantly associated with higher acid exposure. The pathway analysis was significant for the following model: 'history' (P < 0.001➔LES-incompetence & Hiatal Hernia➔(p < 0,001)➔pH-score (P < 0.001).Conclusion: LES-incompetence, the functional deterioration of the LES, and the anatomical alteration at the esophagogastric junction (Hiatal Hernia) as well as an increased EAE were associated with a long history of suffering from GERD. Path modeling suggests a causal sequence overtime of the main disease-parameters, tentatively allowing for a prediction of the course of the disease.

The Natural Course of Gastroesophageal Reflux Disease: A Critical Appraisal of the Literature

Interpreting natural course studies have been very difficult due to their retrospective design, lack of standardization, reliability of reported mucosal findings, liberal use of antireflux medications and accuracy of chart documentation. Studies provided a wide range of progression rates of patients from nonerosive reflux disease (NERD) to erosive esophagitis (EE). However, direct progression from NERD to Barrett's esophagus appears to be an uncommon phenomenon. Importantly, progression of NERD patients was commonly reported to low grades of EE, which are currently considered inconclusive of gastroesophageal reflux disease. Reports of progression rates from low grades to high grades EE also vary considerably. Progression of patients with EE, without metaplastic epithelium underneath the inflammation, to Barrett's esophagus is relatively uncommon. Recently, it was also recognized that regression from high grades to low grades EE and from EE to NERD is a common phenomenon affecting up to 25% of the patients from each group.

A novel ex vivo porcine model of acid-induced esophageal damage for preliminary functional evaluations of anti-gastroesophageal reflux disease medical devices

Aim

The aim of the study was to set up a porcine ex vivo model of acid-induced damage and to evaluate its performance by means of multichannel intraluminal impedance and pH (MII-pH) live recording, histology, and Evans blue (EB) permeability assay.

Materials and Methods

Thirteen esophagi, collected at a slaughterhouse, were ablated of their sphincters, pinned upright on a support, and placed in a thermostatic hood at 37°C with two infusion tubes and an MII-pH probe inserted in the top end. Three esophagi (histology controls) were only left in the hood for 3.5 h before sampling, while the remaining organs underwent the experimental protocol including saline infusion and recovery recording, and acid solution infusion and recovery recording.

Results

MII-pH analysis highlighted a significantly stronger decrease during acid infusion when compared to saline, but a better post-infusion recovery for saline solution. At the end of the protocol, MII was still statistically lower than baseline. The acid-damaged esophagi significantly absorbed more EB dye, and histology revealed strong mucosal exfoliation.

Conclusion

The proposed model of esophageal acid damage seems to be repeatable, reliable, and achievable using organs collected at the slaughterhouse. MII recording proved to have good sensitivity in detecting mucosal alterations also in ex vivo trials.

Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients

In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.

New classifications of gastroesophageal reflux disease: an improvement for patient management?

Introduction: Gastroesophageal reflux disease (GERD) is a very common and often debilitating disease. In the broad spectrum of GERD phenotypes, three main groups may be traditionally distinguished: 1) patients only affected by esophageal and/or extra-esophageal symptoms; 2) patients with erosive esophagitis and 3) patients with further complications. Areas covered: This review provides an overview on the current classifications of GERD patients, and their impact on their management. Expert opinion: In 2017, the GERD Consensus Working Group focused the attention on patients unresponsive to PPIs. In this scenario, a diagnosis of GERD might be confirmed by evident signs of erosive esophagitis and the finding of pH or multichannel intraluminal impedance-pH tests, such as more than 6%. The 'Lyon Consensus' panel of experts confirmed that positive indices of reflux-symptom association, without other altered parameters, represent reflux hypersensitivity. GERD requires a customized management; it is crucial to assess frequency and severity of symptoms and their response to an optimal course of therapy as well as to explore the endoscopic alterations and consider other diagnoses responsible for persistent symptoms.

Management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) continues to be one of the most prevalent gastrointestinal tract disorders. Management of GERD is individualized for each patient depending on severity of symptoms, complications of GERD and patient/physician preference. The different management options include life style modification, pharmacological therapy, minimally invasive procedures and surgery. The final decision regarding management should be made based on an individualized patient centered approach on a case-by-case basis in consultation with a multidisciplinary team including primary care physician, gastroenterologist and surgeon. We provide a comprehensive review for the management of GERD.

Proposed approach to the challenging management of progressive gastroesophageal reflux disease

The progression of gastroesophageal reflux disease (GERD) in patients who are taking proton pump inhibitors (PPIs) has been reported by several investigators, leading to concerns that PPI therapy does not address all aspects of the disease. Patients who are at risk of progression need to be identified early in the course of their disease in order to receive preventive treatment. A review of the literature on GERD progression to Barrett’s esophagus and the associated physiological and pathological changes was performed and risk factors for progression were identified. In addition, a potential approach to the prevention of progression is discussed. Current evidence shows that GERD can progress; however, patients at risk of progression may not be identified early enough for it to be prevented. Biopsies of the squamocolumnar junction that show microscopic intestinalization of metaplastic cardiac mucosa in endoscopically normal patients are predictive of future visible Barrett’s esophagus, and an indicator of GERD progression. Such changes can be identified only through biopsy, which is not currently recommended for endoscopically normal patients. GERD treatment should aim to prevent progression. We propose that endoscopically normal patients who partially respond or do not respond to PPI therapy undergo routine biopsies at the squamocolumnar junction to identify histological changes that may predict future progression. This will allow earlier intervention, aimed at preventing Barrett’s esophagus.

On-Demand Therapy with Proton Pump Inhibitors for Maintenance Treatment of Nonerosive Reflux Disease or Mild Erosive Esophagitis: A Systematic Review and Meta-Analysis

Background

Proton pump inhibitors (PPIs) are widely used for the long-term management of gastroesophageal reflux disease (GERD). However, concerns about the cost and/or inconvenience of continuous maintenance PPI treatment have led to the evaluation of various alternative approaches.

Aim

To assess the effectiveness of on-demand PPI therapy in the maintenance treatment of nonerosive reflux disease (NERD) or mild erosive esophagitis (EE).

Methods

We searched MEDLINE, EMBASE, Web of Science, and Cochrane Library from inception until October 2, 2017, for randomized controlled trials (RCTs) comparing on-demand PPI versus placebo or daily PPI in the management of NERD or mild EE (Savary-Miller grade 1). Discontinuation of therapy during the trial was used as a surrogate for patient dissatisfaction and failure of symptomatic control. We calculated pooled odds ratios (OR) to evaluate the efficacy of on-demand PPI treatment. Separate analyses were conducted for studies comparing on-demand PPI with daily PPI and with placebo. Subgroup analysis was done based on NERD studies alone and on studies of both NERD and mild EE. These were analyzed using a random effects model.

Results

We included 10 RCTs with 4574 patients. On-demand PPI was superior to daily PPI (pooled OR = 0.50; 95% confidence interval (CI) = 0.35, 0.72). On subgroup analysis in NERD patients only, pooled OR was 0.44 (0.29, 0.66). In studies including patients with NERD and mild EE, pooled OR was 0.76 (0.36, 1.60). For studies comparing on-demand PPI with placebo, pooled OR was 0.21 (0.15, 0.29); subgroup analyses of studies evaluating NERD only and studies conducted in NERD and mild EE showed similar results (pooled OR was 0.22 (0.13, 0.36) and 0.18 (0.11, 0.31), resp.).

Conclusions

On-demand PPI treatment is effective for many patients with NERD or mild EE. Although not FDA-approved, it may be adequate for those patients whose symptoms are controlled to their satisfaction.

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.

Intake of Dietary One-Carbon Metabolism-Related B Vitamins and the Risk of Esophageal Cancer: A Dose-Response Meta-Analysis

Several B vitamins are essential in the one-carbon metabolism pathway, which is central to DNA methylation, synthesis, and repair. Moreover, an imbalance in this pathway has been linked to certain types of cancers. Here, we performed a meta-analysis in order to investigate the relationship between the intake of four dietary one-carbon metabolism-related B vitamins (B2, B6, folate, and B12) and the risk of esophageal cancer (EC). We searched PubMed, Web of Science, and Embase for relevant studies published through 1 March 2018. The odds ratio (OR) with 95% confidence interval (CI) for the highest versus the lowest level of each dietary B vitamin was then calculated. From 21 articles reporting 26 studies including 6404 EC cases and 504,550 controls, we found an inverse correlation between the consumption of vitamin B6 and folate and the risk of EC; this association was specific to the US, Europe, and Australia, but was not found in Asia. A dose-response analysis revealed that each 100 μg/day increase in folate intake reduced the risk of EC by 12%. Moreover, each 1 mg/day increase in vitamin B6 intake decreased the risk of EC by 16%. Surprisingly, we found that each 1 μg/day increase in vitamin B12 intake increased the risk of esophageal adenocarcinoma by 2%, particularly in the US and Europe, suggesting both geographic and histological differences. Together, our results suggest that an increased intake of one-carbon metabolism-related B vitamins may protect against EC, with the exception of vitamin B12, which should be consumed in moderation.

Relevance between GerdQ score and the severity of reflux esophagitis in Uygur and Han Chinese

Gastroesophageal reflux disease questionnaire (GerdQ) was used to investigate the inpatients with typical reflux related symptoms in Gastroenterology. According to heartburn, regurgitation, abdominal pain, nausea, sleep disorders, whether taking over the counter (OTC) drugs 6 points to score. Using endoscopy as the gold standard for the diagnosis of reflux esophagitis (RE), and the results were compared with GerdQ score to determine the threshold value for RE, to analyze the distribution of GerdQ score for patients with RE, to assess the relationship between the GerdQ score and the severity of RE. A total of 1233 patients were enrolled in this study, including 538 patients had RE and 695 had not. There was statistical significance in the GerdQ score of RE group and non-RE group (P <0.05), showing that significant correlation between the score and the occurrence of RE. GerdQ score and the severity of RE were positively correlated. Further research also showed that there was a direct correlation between GerdQ score and the severity of RE in the Uygur and Han. GerdQ seems to be an useful screening tool in initial diagnosis of RE, and positively correlated with the severity of RE.

Necrotizing sialometaplasia-like change of the esophageal submucosal glands is associated with Barrett's esophagus

The esophageal submucosal glands (SMG) protect the squamous epithelium from insults such as gastroesophageal reflux disease by secreting mucins and bicarbonate. We have observed metaplastic changes within the SMG acini that we have termed oncocytic glandular metaplasia (OGM), and necrotizing sialometaplasia-like change (NSMLC). The aim of this study is to evaluate the associated clinicopathological parameters of, and to phenotypically characterize the SMG metaplasias. Esophagectomy specimens were retrospectively assessed on hematoxylin and eosin sections and assigned to either a Barrett's esophagus (BE) or non-BE control group. Clinicopathologic data was collected, and univariate analysis and multivariate logistic regression models were performed to assess the adjusted associations with NSMLC and OGM. Selected cases of SMG metaplasia were characterized. SMG were present in 82 esophagi that met inclusion criteria. On univariate analysis, NSMLC was associated with BE (p = 0.002). There was no relationship between NSMLC and patient age, sex, tumor size, or treatment history. OGM was associated with BE (p = 0.031). No relationship was found between OGM and patient age, sex, or tumor size. On multivariate analysis, BE was independently associated with NSMLC (odds ratio [OR] 4.95, p = 0.003). Treatment history was also independently associated with OGM (p = 0.029), but not NSMLC. Both NSMLC and OGM were non-mucinous ductal type epithelia retaining a p63-smooth muscle actin co-positive myoepithelial cell layer. NSMLC and OGM were present in endoscopic mucosal resection specimens. Our study suggests that SMG metaplasia is primarily a reflux-induced pathology. NSMLC may pose diagnostic dilemmas in resection specimens or when only partially represented in mucosal biopsies or endoscopic resection specimens.

Investigation of relationships among gastroesophageal reflux disease subtypes using narrow band imaging magnifying endoscopy

AIM: To investigate the relationships among subtypes of gastroesophageal reflux disease (GERD) using narrow band imaging (NBI) magnifying endoscopy.

METHODS: A reflux disease questionnaire was used to screen 120 patients representing the three subtypes of GERD (n = 40 for each subtypes): nonerosive reflux disease (NERD), reflux esophagitis (RE) and Barrett’s esophagus (BE). NBI magnifying endoscopic procedure was performed on the patients as well as on 40 healthy controls. The demographic and clinical characteristics, and NBI magnifying endoscopic features, were recorded and compared among the groups. Targeted biopsy and histopathological examination were conducted if there were any abnormalities. SPSS 18.0 software was used for all statistical analysis.

RESULTS: Compared with healthy controls, a significantly higher proportion of GERD patients had increased number of intrapapillary capillary loops (IPCLs) (78.3% vs 20%, P < 0.05), presence of microerosions (41.7% vs 0%, P < 0.05), and a non-round pit pattern below the squamocolumnar junction (88.3% vs 30%, P < 0.05). The maximum (228 ± 4.8 vs 144 ± 4.7, P < 0.05), minimum (171 ± 3.8 vs 103 ± 4.4, P < 0.05), and average (199 ± 3.9 vs 119 ± 3.9, P < 0.05) numbers of IPCLs/field were also significantly greater in GERD patients. However, comparison among groups of the three subtypes showed no significant differences or any linear trend, except that microerosions were present in 60% of the RE patients, but in only 35% and 30% of the NERD and BE patients, respectively (P < 0.05).

CONCLUSION: Patients with GERD, irrespective of subtype, have similar micro changes in the distal esophagus. The three forms of the disease are probably independent of each other.

Intakes of dietary folate and other B vitamins are associated with risks of esophageal adenocarcinoma, Barrett's esophagus, and reflux esophagitis

Folate is implicated in carcinogenesis via effects on DNA synthesis, repair, and methylation. Efficient folate metabolism requires other B vitamins and is adversely affected by smoking and alcohol. Esophageal adenocarcinoma (EAC) may develop through a process involving inflammation [reflux esophagitis (RE)] leading to metaplasia [Barrett's esophagus (BE)] and carcinoma. Within a population-based, case-control study, we investigated associations between dietary folate and related factors and risks of EAC, BE, and RE. EAC and BE cases had histologically confirmed disease; RE cases had endoscopically visible inflammation. Controls, age-sex frequency matched to EAC cases, were selected through population and general practice registers. Participants underwent structured interviews and completed food-frequency questionnaires. Multivariate ORs and 95% CIs were computed using logistic regression. A total of 256 controls and 223 EAC, 220 BE, and 219 RE cases participated. EAC risk decreased with increasing folate intake (OR highest vs. lowest = 0.56; 95% CI: 0.31, 1.00; P-trend < 0.01). Similar trends were found for BE (P-trend < 0.01) and RE (P-trend = 0.01). Vitamin B-6 intake was significantly inversely related to risks of all 3 lesions. Riboflavin intake was inversely associated with RE. Vitamin B-12 intake was positively associated with EAC. For EAC, there was a borderline significant interaction between folate intake and smoking (P-interaction = 0.053); compared with nonsmokers with high (≥ median) folate intake, current smokers with low intakes (<median) had an 8-fold increased risk (OR: 8.15; 95% CI: 3.61, 18.40). The same group had increased BE risk (OR: 2.93; 95% CI: 1.24, 6.92; P-interaction = 0.12). Folate and other dietary methyl-group factors are implicated in the etiology of EAC and its precursors.

Evaluation of the gastro-oesophageal junction: defining the incompetent cardio-oeosophageal angle non-invasively with ultrasound and computerized tomography

This study aimed to demonstrate the presence of gastro-oesophageal reflux disease (GORD) non-invasively using ultrasound (US) and computerized tomography (CT). Intra-abdominal oesophageal length (IAOL) and cardio-oesophageal angle (COA) were measured by US in 25 patients with known reflux and in 25 healthy subjects (control group). CT images of 42 patients with reflux disease and 44 controls were reviewed retrospectively, and IAOL and COA were measured on curved multiplanar format images. Using a cut-off value for IAOL of 20.5 mm, the sensitivity to detect GORD with US was 96% and the specificity was 80% and, with CT, the sensitivity was 95% and the specificity was 78%. A cut-off value of 138.5° for COA yielded sensitivity and specificity values for GORD detection of 76% and 72% with US and 83% and 80% with CT, respectively. In conclusion, with equivocal diagnostic findings, IAOL and COA are useful parameters that can be determined non-invasively by US or CT and may aid diagnosis and treatment choices for patients with suspected GORD.

Evolution of gastro-oesophageal reflux disease over 5 years under routine medical care--the ProGERD study

BACKGROUND

The evolution of gastro-oesophageal reflux disease (GERD) under current management options remains uncertain.

AIM

To examine whether, depending on the initial presentation, non-erosive (NERD) and erosive reflux disease (ERD) without Barrett's oesophagus will progress to more severe disease under current routine care following the resolution of the initial condition.

METHODS

Patients with the primary symptom of heartburn were included at baseline, and stratified into non-erosive (NERD) and erosive reflux disease (ERD), LA grades A-D (Los Angeles classification). After a 2- to 8-week course with esomeprazole therapy to achieve endoscopic healing in ERD and symptom relief in NERD, patients were treated routinely at the discretion of their physician. We report oesophagitis status and the presence of endoscopic and confirmed Barrett's oesophagus after 5 years.

RESULTS

A total of 6215 patients were enrolled in the study of whom 2721 patients completed the 5-year follow-up. Progression, regression and stability of GERD severity were followed from baseline to 5 years. Only a few patients with NERD and mild/moderate ERD progressed to severe forms of ERD and even Barrett's oesophagus. Most patients remained stable or showed improvement in their oesophagitis; 5.9% of the NERD patients, 12.1% of LA grade A/B patients and 19.7% of LA grade C/D patients in whom no Barrett's oesophagus was recorded at baseline progressed to endoscopic or confirmed Barrett's oesophagus at 5 years.

CONCLUSION

Most GERD patients remain stable or improve over a 5-year observation period under current routine clinical care.

Efficacy of leukotriene receptor antagonist for erosive esophagitis: a preliminary retrospective comparative study

While diagnostic overlap exists between gastroesophageal reflux disease and eosinophilic esophagitis especially on histological findings, therapeutic approaches for the two disease entities are very different. Recently, anti-inflammatory treatment, in addition to acid suppressants, has been investigated for gastroesophageal reflux disease. This study investigated whether the incidence of endoscopic erosive esophagitis was lower in recipients of long-term leukotriene receptor antagonist (LTRA) treatment. This retrospective comparative study included 207 recipients of an LTRA and an equal number of controls who underwent screening upper endoscopic examination. Twenty-two (10.6%) and 51 (24.6%) cases of erosive esophagitis were detected in the LTRA and control groups, respectively (P < 0.001). A significantly higher incidence of minimal change esophagitis was also found in the controls compared with the LTRA group (14.5% vs. 2.4%, P < 0.001). On multivariate analysis, LTRA treatment was significantly and inversely associated with erosive esophagitis (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.13 to 0.46). Within the LTRA treatment group, an increased risk of erosive esophagitis was strongly associated with the presence of hiatal hernia (OR, 5.89; 95% CI, 2.20-15.73, P < 0.001) and short duration of LTRA treatment (OR, 0.64; 95% CI, 0.37-0.89, P= 0.022). In conclusion, this preliminary retrospective analysis demonstrated that patients who underwent long-term treatment with a LTRA had low incidence of endoscopic minimal change esophagitis.

Erosive esophagitis is a risk factor for Barrett's esophagus: a community-based endoscopic follow-up study

OBJECTIVES

Symptomatic gastroesophageal reflux disease (GERD) is associated with a significantly increased risk of esophageal adenocarcinoma, but its natural history in the general population is poorly understood. Whether nonerosive reflux disease (NERD) is a risk factor for Barrett's esophagus (BE), the precursor of esophageal adenocarcinoma, is unknown. Furthermore, quantifying the risk of incident BE in those with untreated reflux esophagitis has not been possible. We aimed, in a prospective follow-up study with endoscopy, to evaluate the risk of BE in a cohort from the Swedish general population (the Kalixanda Study).

METHODS

Those with endoscopic or histological findings suggestive of GERD and randomly half of those with NERD (n=481) were invited for follow-up investigation including endoscopy and a validated symptom questionnaire 5 years after the initial study. Multinomial logistic regression was used to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) for change in presentation of GERD.

RESULTS

Of the 405 subjects available for inclusion, endoscopy was performed in 284 (response rate 70.1%). The incidence of BE was 9.9/1,000 person-years. Of those with NERD at baseline (n=113), progression to erosive esophagitis was found in 11; 2 developed BE. Erosive esophagitis (n=90) progressed to a more severe grade in 12 and to BE in 8 cases. Erosive esophagitis at baseline was independently associated with BE at follow-up (RRR 5.2; 95% CI 1.2-22.9).

CONCLUSIONS

Compared with being free of GERD at follow-up, erosive esophagitis is a major risk factor for BE (with a fivefold increased risk) after 5 years in the general population.

Dietary antioxidant and mineral intake in humans is associated with reduced risk of esophageal adenocarcinoma but not reflux esophagitis or Barrett's esophagus

The role of antioxidants in the pathogenesis of reflux esophagitis (RE), Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC) remains unknown. We evaluated the associations among dietary antioxidant intake and these diseases. We performed an assessment of dietary antioxidant intake in a case control study of RE (n = 219), BE (n = 220), EAC (n = 224), and matched population controls (n = 256) (the Factors Influencing the Barrett's Adenocarcinoma Relationship study) using a modification of a validated FFQ. We found that overall antioxidant index, a measure of the combined intake of vitamin C, vitamin E, total carotenoids, and selenium, was associated with a reduced risk of EAC [odds ratio (OR) = 0.57; 95% CI = 0.33-0.98], but not BE (OR = 0.95; 95% CI = 0.53-1.71) or RE (OR = 1.60; 95% CI = 0.86-2.98), for those in the highest compared with lowest category of intake. Those in the highest category of vitamin C intake had a lower risk of EAC (OR = 0.37; 95% CI = 0.21-0.66; P-trend = 0.001) and RE (OR = 0.46; 95% CI = 0.24-0.90; P-trend = 0.03) compared with those in the lowest category. Vitamin C intake was not associated with BE, and intake of vitamin E, total carotenoids, zinc, copper, or selenium was not associated with EAC, BE, or RE. In conclusion, the overall antioxidant index was associated with a reduced risk of EAC. Higher dietary intake of vitamin C was associated with a reduced risk of EAC and RE. These results suggest that antioxidants may play a role in the pathogenesis of RE and EAC and may be more important in terms of progression rather than initiation of the disease process.

Comparison of Direct Medical Care Costs Between Erosive Reflux Disease and Non-erosive Reflux Disease in Korean Tertiary Medical Center

Background/Aims

Gastroesophageal reflux disease is one of the most common and frequent chronic disease requiring considerable cost. We investigated the medical care costs in the erosive reflux disease (ERD) and non-erosive reflux disease (NERD).

Methods

The risk factors and the direct medical care costs were analyzed retrospectively in the ERD (178 patients) and NERD (183 patients) groups for a follow up period of 2 years.

Results

Logistic regression analysis showed that the ERD was more frequent in the groups of male gender, alcohol consumption, higher body mass index (≥25 kg/m²), hiatal hernia, and higher triglyceride levels (≥150 mg/dL). The direct medical care costs per person for 2 years were found to be $384.8 (ERD) and $412.9 (NERD) without statistically significant differences (p = 0.364). However, 9.3% (17/183) of the NERD patients had visited the emergency room compared to 3.4% (6/178) of the ERD patients (p = 0.029). In addition, more NERD patients were hospitalized than ERD patients (p = 0.006), and because of the longer hospitalization period, the medical costs in NERD patients were higher than ERD patients (p = 0.038).

Conclusions

In spite of the different risk factors for ERD and NERD, total direct medical care costs were similar between the ERD and NERD group. However, more visits to emergency room and longer hospitalization period with more hospitalization costs in NERD patients account for the differences in medical service and usage distribution between the 2 groups.

Do eosinophil numbers differentiate eosinophilic esophagitis from gastroesophageal reflux disease?

CONTEXT

Although the healthy esophageal mucosa contains no eosinophils, eosinophilic infiltration is observed in 2 major clinicopathologic settings: gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EE). The prevalence of EE is increasing in many countries, and this increase seems only partly to be due to a better awareness of the pathology, following the relatively recent description of EE. Gastroesophageal reflux disease and EE represent 2 entities that do not respond to the same treatment modalities and, thus, need to be distinguished. However, diagnostic criteria of EE have been defined arbitrarily, and the more recent articles tend to prove that the overlap with GERD is probably greater than initially believed, leading the authors to advise strict exclusion of GERD before considering the diagnosis of EE.

OBJECTIVES

To provide pathologists with the currently proposed histologic criteria of GERD and EE, to stress the need to combine these criteria with clinical data and endoscopic findings, and to outline the remaining controversies.

DATA SOURCES

This review is based on selected articles identified by a PubMed (US National Library of Medicine, Bethesda, Maryland) search of the literature in English for GERD and EE, a recent review by the American Gastroenterological Association (Bethesda), the Proceedings of the First International Gastrointestinal Eosinophil Research Symposium, and the authors' experience.

CONCLUSION

Proper identification of the etiology of eosinophilic infiltration of the esophagus allows accurate medical or surgical treatment and follow-up. Eosinophilic esophagitis and GERD diagnoses require integration of the histologic findings with the clinical and endoscopic data.

[Is there a relationship between leptin and the phenotype of gastroesophageal reflux disease?]

BACKGROUND/AIMS

Obesity is associated with gastroesophageal reflux disease (GERD). Leptin is a hormone which controls appetite and energy homeostasis. Alterations of its level in humans have been linked with obesity and related carcinogenesis. We postulated that the leptin level in plasma or tissues might be different according to the phenotype of GERD. We evaluated this hormone in patients with non-erosive reflux disease (NERD) and reflux esophagitis (RE) with demographic characteristics to confirm the postulation.

METHODS

The patients with typical GERD symptoms such as acid regurgitation and heartburn were prospectively enrolled and evaluated. The demographic data included body mass index, waist circumference, smoking, and the consumption of coffee. Rapid urease test was done to evaluate the status of Helicobacter pylori infection. We measured plasma leptin level along with the tissue level, which was obtained from the fundus of stomach.

RESULTS

A total of 44 patients were evaluated (RE 20 cases, NERD 24 cases). No demographic data was different between the two groups, except waist circumference (mean 88.6 cm in RE, 80.9 cm in NERD, p=0.006), smoking (45% in RE, 12.5% in NERD, p=0.021) and coffee consumption (85% in RE, 50% in NERD, p=0.025). The level of plasma leptin was not different between the two groups. The level of tissue leptin was also not different between the two groups with an increasing tendency in RE (mean 32.5 ng/mL vs. 28.0 ng/mL in NERD).

CONCLUSIONS

We could not find any association between plasma and tissue leptin levels and the phenotype of GERD. However, increasing tendency in RE could afford to further studies in near future.

Nonerosive Reflux Disease (NERD) - An Update

Recognizing nonerosive reflux disease (NERD) as a distinct presentation of gastroesophageal reflux disease (GERD) was one of the most important developments in the field of GERD in the last decade. Whilst the definition of NERD has not changed significantly over the years, the disorder accounts for the majority of the GERD patients and those who failed proton pump inhibitor (PPI) treatment. Recent developments in NERD focused primarily on understanding the pathophysiology and natural history. The introduction of esophageal impedance + pH has led to the assessment of other forms of gastroesophageal reflux in causing NERD. Therapeutic modalities still focus on acid suppression, but there is growing recognition that other therapeutic strategies should be considered in NERD.

Gastroesophageal reflux disease: medical or surgical treatment?

Background. Gastroesophageal reflux disease is a common condition with increasing prevalence worldwide. The disease encompasses a broad spectrum of clinical symptoms and disorders from simple heartburn without esophagitis to erosive esophagitis with severe complications, such as esophageal strictures and intestinal metaplasia. Diagnosis is based mainly on ambulatory esophageal pH testing and endoscopy. There has been a long-standing debate about the best treatment approach for this troublesome disease. Methods and Results. Medical treatment with PPIs has an excellent efficacy in reversing the symptoms of GERD, but they should be taken for life, and long-term side effects do exist. However, patients who desire a permanent cure and have severe complications or cannot tolerate long-term treatment with PPIs are candidates for surgical treatment. Laparoscopic antireflux surgery achieves a significant symptom control, increased patient satisfaction, and complete withdrawal of antireflux medications, in the majority of patients. Conclusion. Surgical treatment should be reserved mainly for young patients seeking permanent results. However, the choice of the treatment schedule should be individualized for every patient. It is up to the patient, the physician and the surgeon to decide the best treatment option for individual cases.

Nondigestive symptoms in non-erosive reflux disease: nature, prevalence and relation to acid reflux

BACKGROUND

Nondigestive symptoms are frequent in the irritable bowel syndrome (IBS).

AIM

To characterize nondigestive symptoms in non-erosive gastro-oesophageal reflux disease (NERD) patients, as features of IBS are common in patients with NERD.

METHODS

A prospective, case-control study. NERD was defined in patients with reflux symptoms, a normal oesophageal mucosa and oesophageal pH < 4 for > or = 5% of the time during 24-h pH monitoring. Nondigestive symptoms were scored on validated scales of somatic pain, urinary, sleep and neurasthenia. IBS was defined by the Rome I criteria.

RESULTS

pH-positive NERD patients (n = 326) scored significantly higher than controls (nonpatient hospital visitors; n = 174) on all scales. The scores of pain, sleep and neurasthenia were highly specific in the discrimination of NERD patients from controls. In patients, nondigestive symptoms were independently associated with age, reflux symptoms severity and IBS status, but not with oesophageal acid exposure. NERD patients who met diagnostic criteria for IBS (49%) scored significantly higher on all the nondigestive symptoms scales than those had not met [IBS(-)]. Yet, IBS(-) patients scored significantly higher than controls on all scales.

CONCLUSIONS

Nondigestive symptoms were highly prevalent in NERD patients and were specific in their discrimination from controls. Nondigestive symptoms correlated with reflux symptoms and were predicted by IBS status.

Systematic review: persistence and severity in gastro-oesophageal reflux disease

BACKGROUND

Management strategies for gastro-oesophageal reflux disease (GERD) are often inconsistent with the proposition that it is a persistent or chronic disease.

AIM

To determine the persistence of reflux symptoms and complications associated with GERD.

METHODS

Systematic searches of Medline and EMBASE.

RESULTS

In longitudinal studies, 65% (95% CI 54-75%) of patients with complicated GERD and 70% (95% CI 57-83%) of patients with 'defined' GERD had persistent disease at follow-up, whereas 34% (95% CI 27-40%) with infrequent or mild reflux symptoms at baseline had persistent symptoms. Clinical trials of maintenance treatment for at least 6 months after healing of oesophagitis reported mean relapse rates of 75% (95% CI 68-82%) in patients taking placebo and 28% (95% CI 21-35%) in those taking proton pump inhibitors. Retrospective studies reported that 34-41% of individuals with GERD recalled experiencing their symptoms for >10 years. The prevalence of GERD is high (10-20%), whereas the incidence is low (4.5-19.6 cases per 1000 person-years), suggesting that GERD is likely to persist for at least 18 years.

CONCLUSIONS

Individuals with GERD have persistent reflux symptoms that merit management as a chronic disease; infrequent reflux symptoms are less likely to be chronic and may respond to different management strategies.

Mortality associated with gastroesophageal reflux disease and its non-malignant complications: a systematic review

OBJECTIVE

The mortality associated with malignant complications of gastroesophageal reflux disease (GERD) is well recognized. The aim of this systematic review was to assess the less well-examined mortality associated with GERD and its non-malignant complications, including esophageal erosions, ulcers, bleeding, perforation and strictures.

MATERIAL AND METHODS

Studies reporting mortality in GERD and its non-malignant complications were identified via systematic PubMed searches, and previously unpublished population mortality statistics from public access databases. RESULTS. Three countries were examined (USA, UK, Finland). Cohort studies (n=3) in the UK showed a 1.16- to 1.6-fold increase in risk of death in individuals with GERD compared with the general population, the majority of deaths being due to cardiac disease. Population data indicate that GERD and its likely esophageal complications were the cause of death in 685 and 521 cases, respectively, in the USA (year: 2003) (age-adjusted mortality: 2.3/million and 1.8/million, respectively), and in 36 and 349 cases, respectively, in England and Wales (2004) (0.6/million and 5.4/million, respectively). In Finland (2000), GERD-related mortality was 4.6/million. Mortality from GERD and its likely esophageal complications increased with age, and was between 1.2-fold and 1.8-fold higher in men than in women. Cohort studies in the USA are inconsistent on mortality risk associated with surgical therapy. Time-trend data suggest that mortality from GERD and its non-malignant complications has been increasing.

CONCLUSIONS

Data from Europe and the USA show that GERD and its non-malignant complications can on rare occasions cause death.

Proton pump inhibitor therapy in gastro-oesophageal reflux disease decreases the oesophageal immune response but does not reduce the formation of DNA adducts

BACKGROUND

Chronic oesophageal inflammation and related oxidative stress are important in the pathogenesis of erosive oesophagitis (EO) and its malignant progression.

AIM

To study the effect of proton pump inhibitors (PPIs) on oesophageal cellular immune response and oxidative damage in EO patients.

METHODS

Forty gastro-oesophageal reflux disease (GERD) patients [non-erosive reflux disease (NERD): 15, EO: 25] were included, after 7 days off antisuppressive drugs. EO patients were randomized to 20-mg rabeprazole once daily for either 4 or 8 weeks with baseline and follow-up endoscopy with distal oesophageal biopsies. T lymphocytes, macrophages and mast cells were quantified by immunohistochemistry. DNA adducts were measured by analysis of 8-oxo-deoxyguanosine levels.

RESULTS

Erosive oesophagitis patients had more T lymphocytes and CD8(+) T lymphocytes in squamous epithelium than NERD patients (P = 0.001, P = 0.002, respectively). Levels of DNA adducts between both groups were, however, not different (P = 0.99). Four- and eight-week rabeprazole treatment in EO patients resulted in a significant decrease in number of T lymphocytes and CD8(+) T lymphocytes (all P < 0.05). PPIs did not, however, affect levels of DNA adducts.

CONCLUSIONS

Short-term PPI therapy in EO patients reduces the oesophageal cellular immune response, but does not change oxidative damage. PPI therapy may therefore not be effective in reducing the risk of oesophageal cancer in GERD patients.

Clinical significance of minimal change lesions of the esophagus in a healthy Korean population: a nationwide multi-center prospective study

BACKGROUND AND AIM

At least half of the patients with typical reflux symptoms have non-erosive reflux disease (NERD). Minimal change lesions are commonly seen in the screening endoscopic examinations for individuals without clinically significant symptoms. We evaluated the correlation between minimal changes and symptoms in individuals visiting the hospital for routine health check-up by a nationwide survey in 2006.

METHODS

Upper gastrointestinal endoscopic examinations as a health check-up were performed for 25,536 patients. Among them, symptom questionnaires were given in 23,350 patients without mucosal break or Barrett's esophagus. Endoscopic findings of the lower esophagus were divided into normal or minimal changes. Minimal changes in the present study included white turbid discoloration and Z-line blurring.

RESULTS

Among a total of 25,536 subjects, reflux esophagitis was found in 2019 subjects (7.91%) and 3043 patients (11.9%) were classified as having minimal changes. History of gastroesophageal reflux disease (GERD) was more commonly found in individuals with minimal changes. Among the reflux-related symptoms, heartburn, acid regurgitation, globus sensation, and epigastric soreness were related to the minimal changes of the esophagus. Especially, individuals with globus sensation or epigastric soreness were more likely to have minimal changes compared to individuals without respective symptoms. Male gender, current smoker, history of H. pylori eradication, frequent stooping at work, hiatal hernia, and atrophic/metaplastic gastritis were found to be risk factors for minimal changes.

CONCLUSION

The minimal changes were closely related with upper gastrointestinal symptoms and had similar risk factors for GERD, suggesting that minimal changes could be considered as early endoscopic findings of GERD.

Cyclooxygenase-2 and inducible nitric oxide synthase gene polymorphisms and risk of reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma has increased in recent years, and Barrett's esophagus is a recognized risk factor. Gastroesophageal reflux of acid and/or bile is linked to these conditions and to reflux esophagitis. Inflammatory disorders can lead to carcinogenesis through activation of "prosurvival genes," including cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS). Increased expression of these enzymes has been found in esophageal adenocarcinoma, Barrett's esophagus, and reflux esophagitis. Polymorphic variants in COX-2 and iNOS genes may be modifiers of risk of these conditions. In a population-based case-control study, we examined associations of the COX-2 8473 T>C and iNOS Ser(608) Leu (C>T) polymorphisms with risk of esophageal adenocarcinoma, Barrett's esophagus, and reflux esophagitis. Genomic DNA was extracted from blood samples collected from cases of esophageal adenocarcinoma (n = 210), Barrett's esophagus (n = 212), and reflux esophagitis (n = 230) and normal population controls frequency matched for age and sex (n = 248). Polymorphisms were genotyped using TaqMan allelic discrimination assays. Odds ratios and 95% confidence intervals were obtained from logistic regression models adjusted for potential confounding factors. The presence of at least one COX-2 8473 C allele was associated with a significantly increased risk of esophageal adenocarcinoma (adjusted odds ratio, 1.58; 95% confidence interval, 1.04-2.40). There was no significant association between this polymorphism and risk of Barrett's esophagus or reflux esophagitis or between the iNOS Ser 608 Leu polymorphism and risk of these esophageal conditions. Our study suggests that the COX-2 8473 C allele is a potential genetic marker for susceptibility to esophageal adenocarcinoma.

Functional heartburn, nonerosive reflux disease, and reflux esophagitis are all distinct conditions—A debate: Pro

Gastroesophageal reflux disease (GERD) traditionally has been approached as a spectrum-continuum, suggesting that patients may progress over time and develop a more severe esophageal mucosal involvement. The spectrum-continuum conceptual model had a profound impact on the research priorities in GERD, as well as on proposed diagnostic algorithms and therapeutic strategies. Natural course studies in GERD are almost always retrospective and commonly afflicted with a plethora of shortcomings. Factors that affect quality of natural course studies in GERD include the following: index endoscopy results are taken at face value; antireflux treatment is consumed until index endoscopy and/or offered during the follow-up phase; pathophysiologic, anatomic, and genetic factors are overlooked; and lack of confirmation of the durability of the new esophageal mucosal finding. Functional heartburn is common and likely to affect a large subset of patients presenting with heartburn. Evidence to support progression of functional heartburn to nonerosive reflux disease (NERD), erosive esophagitis, or Barrett's esophagus is very scarce. The largest population-based or longest-duration natural course studies report that only 10% of patients progress from NERD to erosive esophagitis over time. The other GERD patients remained within their respective phenotypic presentations of GERD.

Epidemiology of gastroesophageal reflux disease in Tehran, Iran

BACKGROUND AND AIM

Epidemiological studies have indicated an increase in the prevalence of gastroesophageal reflux disease in Western countries; however, there is a lack of information about its prevalence in Iran. The aim of this study was to measure gastroesophageal reflux disease prevalence in a representative sample of the Tehran population in 1999.

METHODS

In a cross-sectional study, 700 people, with a male : female ratio of 1:1, were selected by stratified randomization based on the probability of 20% prevalence of gastroesophageal reflux disease and 3% error. They were divided equally into seven age groups. Heartburn and acid regurgitation were considered as the most common symptoms of gastroesophageal reflux disease. The severity and frequency of heartburn and the role of personal habits in the appearance of this symptom were determined. The prevalence of gastroesophageal reflux disease in samples was measured, and its actual prevalence in society was estimated.

RESULTS

Of 700 people, 350 were male and 350 were female. The major symptoms of gastroesophageal reflux disease were observed in 278 (39.7%) people. The prevalence of gastroesophageal reflux disease of smokers was twice that of non-smokers.

CONCLUSIONS

Gastroesophageal reflux disease is a serious and unresolved problem in Western countries, and its increasing prevalence correlates with an increasing prevalence of adenocarcinoma of distal esophagus. The prevalence of gastroesophageal reflux disease appears to be increasing in Iran also; therefore, it is recommended that major attention be paid to this disease.

Systematic review: maintenance treatment of gastro-oesophageal reflux disease with proton pump inhibitors taken 'on-demand'

BACKGROUND

Proton pump inhibitors (PPI) therapy 'on-demand' is often used as an alternative to continuous maintenance therapy in gastro-oesophageal reflux disease (GERD).

AIM

We conducted a systematic review with the specific objectives to ascertain whether on-demand PPI therapy was effective in preventing symptomatic relapse and to assess the relative efficacy of on-demand vs. continuous PPI maintenance strategy.

METHODS

Randomized-controlled clinical trials comparing on-demand PPI vs. placebo or on-demand vs. continuous PPI therapy in GERD patients were identified by searching the Medline database and the Cochrane Controlled Trials Register.

RESULTS

Seventeen studies were found which met inclusion criteria. Out of the 17 studies: five investigated exclusively patients with non-erosive reflux disease (NERD), four patients with NERD and mild oesophagitis, two patients with erosive oesophagitis only, and two patients with uninvestigated GERD symptoms, respectively. Four further studies were not investigating the effectiveness of the therapies but primarily pharmacoeconomic or quality of life parameters.

CONCLUSIONS

On the basis of the analysis of 17 studies, we can conclude that on-demand therapy with currently available PPI appears to be effective in the long-term management of patients with NERD or mild and uninvestigated forms of GERD, but not in patients with (severe) erosive oesophagitis.

Temporal trends in new and recurrent oesophageal strictures in a Medicare population

BACKGROUND

The widespread use of proton pump inhibitors for gastro-oesophageal reflux disease could result in a decline in new as well as recurrent gastro-oesophageal reflux disease-related oesophageal strictures. The temporal trends of strictures have not been examined in population-based studies.

METHODS

To examine the temporal trends in strictures, we calculated the age-adjusted incidence rates of new oesophageal strictures with or without oesophageal dilation in a sample of Medicare beneficiaries between 1992 and 2000. We also examined recurrent dilations recorded at least 3 months after a new stricture or the preceding recurrent stricture.

RESULTS

The age-adjusted rates for strictures accompanied with dilation declined by approximately 11% from 215 per million to 192 per million. New oesophageal strictures with dilation declined as a proportion of all upper endoscopies procedures (from 2.6% to 1.9%). Recurrent dilation within 1 year declined dramatically from 16% (9.5% CI: 12.5-20.3) in 1992 to 8% (95% CI: 4.43-10.62) in 2000. In multivariable proportional hazards model, there was a 30% risk reduction of recurrent oesophageal strictures.

CONCLUSIONS

This population-based study indicates that the incidence of new as well as recurrent oesophageal strictures has been declining. In the face of rising incidence of other gastro-oesophageal reflux disease-related complications, it is important to understand the explanation of the present observations.

Gastroesophageal reflux disease is a progressive disease

It is controversial whether gastrooesophageal reflux disease represents a spectrum disease from a nonerosive to a complicated one, or whether it is a categorial disease, i.e. it can be divided into three categories, such as nonerosive gastrooesophageal reflux disease, erosive gastrooesophageal reflux disease and Barrett's esophagus (BE) with little or no transition from one category to the other. This controversy might be of general interest, because it has some implications in the management of the patient. However, literature data concerning the natural history of gastrooesophageal reflux disease are very limited, and in particular very few papers have dealt with the issue of describing the natural history of patients with nonerosive gastrooesophageal reflux disease. Aim of the present review is to reassess these scanty data, and to try to demonstrate that progression from milder to more severe forms of gastrooesophageal reflux disease is possible and documented.

Gas-related symptoms after laparoscopic 360 degrees Nissen or 270 degrees Toupet fundoplication in gastrooesophageal reflux disease patients with aerophagia as comorbidity

BACKGROUND

Aerophagia is a rare but well-known comorbidity in patients with gastrooesophageal reflux disease. Particularly after laparoscopic Nissen fundoplication, it has proven to result in worse symptomatic outcome and a lower postoperative quality of life in comparison to patients without preoperative gas-related symptoms.

AIMS

Aim of the study was to compare the postoperative outcome in gastrooesophageal reflux disease patients with aerophagia as comorbidity after either laparoscopic 360 degrees 'floppy' Nissen fundoplication or 270 degrees Toupet fundoplication with main focus on the frequency and subjective impairment of gas-related symptoms.

PATIENTS AND METHODS

In 56 gastrooesophageal reflux disease patients, the comorbidity of aerophagia was diagnosed prior to laparoscopic antireflux surgery. Irrespective of their preoperative manometric findings, the patients were either scheduled to a laparoscopic 360 degrees 'floppy' Nissen (n=28) or a laparoscopic 270 degrees Toupet fundoplication (n=28). All patients have been analysed concerning the presence of gas-related symptoms preoperatively as well as 3 months after surgery. Additionally, the subjective degree of impairment was evaluated using a numerous rating scale (0=no perception/impairment, 100=most severe perception/impairment). The following symptoms have been analysed: ability/inability to belch, 'gas bloat', flatulence, postprandial fullness and epigastric pain.

RESULTS

Before surgery, there were no significant differences between both surgical groups. Three months after surgery, significant differences (p<0.05-0.01) were found: patients who underwent a laparoscopic 270 degrees Toupet fundoplication suffered from less impairing gas bloat, flatulence and postprandial fullness when compared with patients with a 360 degrees 'floppy' Nissen fundoplication. The majority of these patients were able to belch postoperatively but felt no impairment due to this symptom. In contrast, patients of the Nissen group felt a significant impairment due to the inability to belch.

CONCLUSION

Gas-related symptoms are very common in gastrooesophageal reflux disease patients with aerophagia as a comorbidity. Patients who undergo a laparoscopic Toupet fundoplication show less impairment in relation to gas-related problems compared with patients treated with a Nissen fundoplication for a follow-up period of at least 3 months. In the Toupet group, the ability to belch postoperatively seems to be a positive aspect from the patients' view which also improves the percentage of gas-related problems. However, long-term results are necessary.

Erosive esophagitis and nonerosive reflux disease (NERD): comparison of epidemiologic, physiologic, and therapeutic characteristics

Nonerosive reflux disease (NERD) and erosive esophagitis are the main presentations of gastroesophageal reflux disease. However, NERD is the most common presentation of gastroesophageal reflux disease in community-based patients. Patients with NERD differ in demographic characteristics from patients with erosive esophagitis, primarily in sex distribution, weight/body mass index, and prevalence of hiatal hernia. Physiologically, patients with NERD tend to have normal lower esophageal sphincter resting pressure, minimal esophageal body motility abnormalities, low esophageal acid exposure profile and minimal nighttime esophageal acid exposure. Patients with NERD have a lower symptom response rate to proton pump inhibitor once daily than patients with erosive esophagitis. Additionally, NERD patients demonstrate a longer lag-time for symptom resolution and lack of difference in symptom response rate between half to full dose proton pump inhibitor as compared with patients with erosive esophagitis.

Pathophysiological characteristics of the various forms of gastro-oesophageal reflux disease. Spectrum disease or distinct phenotypic presentations?

BACKGROUND

The traditional approach to gastro-oesophageal reflux disease as a spectrum disease has recently been criticised and the distinct phenotypic presentations model has been proposed.

AIM

To evaluate the main pathophysiological characteristics of various gastro-oesophageal reflux disease presentations.

METHODS

Oesophageal manometry and 24-h pH-monitoring were performed in a gastro-oesophageal reflux disease series collected in a 7-year period.

RESULTS

Four hundred and twenty-one subjects were studied. Mean total percentage acid reflux time was significantly higher in long-segment Barrett's oesophagus and in ulcerative oesophagitis than in all the other gastro-oesophageal reflux disease groups, whilst in short-segment Barrett's oesophagus results were quite similar to those found in non-erosive reflux disease and in erosive reflux disease. Patients with ulcerative oesophagitis and long-segment Barrett's oesophagus were older than all the other gastro-oesophageal reflux disease groups. The mean lower oesophageal sphincter pressure was significantly reduced in non-erosive reflux disease, erosive reflux disease, ulcerative oesophagitis, short-segment Barrett's oesophagus and long-segment Barrett's oesophagus as compared with functional heartburn and hypersensitive oesophagus and with controls.

CONCLUSIONS

In keeping with the spectrum model of gastro-oesophageal reflux disease, severity of acid reflux increases from non-erosive reflux disease through erosive reflux disease up to ulcerative oesophagitis and long-segment Barrett's oesophagus. Ulcerative oesophagitis and long-segment Barrett's oesophagus could represent an advanced step in the natural history of gastro-oesophageal reflux disease. Our results do not confirm the distinct phenotypic presentations hypothesis.

Temporal trends in new and recurrent esophageal strictures in Department of Veterans Affairs

BACKGROUND

Anecdotal experience suggests that gastroenterologists are encountering fewer patients with esophageal strictures; however, the temporal trends of esophageal strictures have not been well examined in large studies.

METHODS

We examined the incidence rates of new esophageal strictures as well as esophageal dilations among patients presenting to VA facilities between 1998 and 2003 as a proportion of the annual frequency of all endoscopic procedures and/or imaging procedures. Recurrent strictures were defined as those recorded at least 3 months after the index date of a new stricture or the date of the preceding recurrent stricture. Stricture was defined only in the presence of an upper endoscopy or upper gastrointestinal (UGI) contrast imaging within 30 days before or after the date of diagnosis. This algorithm was validated by manually reviewing the medical records of 180 patients; the positive predictive value was approximately 84%. The risk of recurrent strictures was examined using Cox proportional hazards model for multiple failures.

RESULTS

There were 19,157 patients identified between fiscal year (FY) 1998 and FY 2003 with new esophageal strictures. New strictures comprised a constant annual proportion of total EGD and UGI imaging studies. New strictures declined by 11.6% as a proportion of all upper endoscopies (not including UGI imaging). However, esophageal dilations associated with new stricture diagnoses declined among patients with new esophageal strictures, 16.8% had at least one episode of recurrence. The 1-yr incidence rate of recurrent strictures declined significantly (-36.0%) from 13.9 per 100 person-years for patients diagnosed with new strictures in 1998 to 8.9 per 100 person-years in patients diagnosed with new strictures in 2003. In the full multivariable model, new strictures diagnoses during 2001-2003 were associated with a reduced risk of having recurrent strictures (19% in the first year and 13% throughout follow-up) independent of age, gender, race, geographic region, or the presence of Barrett's esophagus.

CONCLUSION

The incidence of recurrent strictures has declined between 1998 and 2003 by approximately one-third. Although there has been only a small decline in the incidence of new esophageal strictures among patients undergoing endoscopy, the use of esophageal dilations has declined considerably among these patients. The role of proton pump inhibitors needs to be examined.

Systematic review: does gastro-oesophageal reflux disease progress?

BACKGROUND

Gastro-oesophageal reflux disease affects approximately 20% of western populations. Barrett's oesophagus, associated with severe gastro-oesophageal reflux disease, is premalignant and regular endoscopic surveillance is generally performed. In contrast, mild gastro-oesophageal reflux disease is thought not to progress and is not generally subjected to endoscopic follow-up. Aim To investigate whether gastro-oesophageal reflux disease progresses endoscopically.

METHODS

Systematic review of the literature.

RESULTS

Well-designed prospective studies are few, diagnostic criteria were not always standardized, management strategies varied and various sources of bias could not be excluded. Whilst most patients do not progress to more severe forms of gastro-oesophageal reflux disease, and some cases actually regress, progression is seen in a small proportion of patients. Annual progression rates for non-erosive gastro-oesophageal reflux disease developing erosive oesophagitis ranged from 0% to 30%. About 1-22% of patients with mild erosive oesophagitis developed more severe inflammation annually, while 1-13% of patients with erosive oesophagitis developed Barrett's oesophagus each year.

CONCLUSION

Although most patients with gastro-oesophageal reflux disease do not progress, and some actually regress, progression does occur in a minority. Better data are required to determine whether patients with mild gastro-oesophageal reflux disease would benefit from increased surveillance with the aim of detecting more advanced disease.

Surgical approach to gastroesophageal reflux disease: what the radiologist needs to know

Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.

A systematic review and meta-analysis of the sex ratio for Barrett's esophagus, erosive reflux disease, and nonerosive reflux disease

Barrett's esophagus is associated with reflux disease and substantially increases the risk of esophageal adenocarcinoma. The authors undertook a systematic review and meta-analysis of the sex ratio for Barrett's esophagus, erosive reflux disease (ERD), and nonerosive reflux disease (non-ERD) to compare these results with the sex ratio for esophageal adenocarcinoma. MEDLINE (US National Library of Medicine, Bethesda, Maryland) (1966-2004) and EMBASE (Reed Elsevier PLC, Amsterdam, Netherlands) (1980-2004) were searched for relevant citations with a highly sensitive search strategy. Studies to be included required a sample size of 50 or more patients and consecutive recruitment at an institute accessible by all. Stata, version 8.2, software (StataCorp LP, College Station, Texas) was used to conduct random effects meta-analyses. Excess heterogeneity was investigated by meta-regression. The Barrett's esophagus meta-analysis gave an overall pooled male/female sex ratio of 1.96/1 (95% confidence interval (CI): 1.77, 2.17/1). For ERD, the pooled male/female sex ratio was 1.57/1 (95% CI: 1.40, 1.76/1) and, for non-ERD, 0.72/1 (95% CI: 0.62, 0.84/1). All of these estimates were associated with substantial heterogeneity (I2 = 81.1%, 92.7%, and 88.8%, respectively). The meta-analysis estimates for ERD and Barrett's esophagus, while showing an excess of males, are substantially lower than similar estimates for esophageal adenocarcinoma. It is important to establish why male Barrett's esophagus and ERD patients are at increased risk of malignancy compared with females.

Esophageal mucosal damage may promote dysmotility and worsen esophageal acid exposure

This study determines the relationship among esophageal dysmotility, esophageal acid exposure, and esophageal mucosal injury in patients with gastroesophageal reflux disease (GERD). A total of 827 patients with GERD (confirmed by ambulatory pH monitoring) were divided into three groups based on the degree of mucosal injury: group A, no esophagitis, 493 patients; group B, esophagitis grades I to III, 273 patients; and group C, Barrett's esophagus, 61 patients. As mucosal damage progressed from no esophagitis to Barrett's esophagus, there was a significant decrease in lower esophageal sphincter pressure and amplitude of peristalsis in the distal esophagus, with a subsequent increase in the number of reflux episodes in 24 hours, the number of reflux episodes longer than 5 minutes, and the reflux score. These data suggest that in patients with GERD, worsening of esophageal mucosal injury may determine progressive deterioration of esophageal motor function with impairment of acid clearance and increase of esophageal acid exposure. These findings suggest that Barrett's esophagus is an end-stage form of gastroesophageal reflux, and that if surgical therapy is performed early in the course of the disease, this cascade of events might be blocked.

Impact of referral for gastro-oesophageal reflux disease on the workload of an academic Gastroenterology Unit

BACKGROUND

Gastro-oesophageal reflux disease is known to be a frequent cause of patients' referral to hospital gastroenterologists.

AIM

To increase knowledge on referral for reflux disease, in an Italian academic setting.

PATIENTS AND METHODS

The impact of gastro-oesophageal reflux disease on 1 year's workload, comprising upper endoscopy, outpatients' consultations in the general clinic, oesophageal pH monitoring and oesophageal manometry was retrospectively assessed. Appropriateness of oesophageal pH monitoring and oesophageal manometry was also evaluated.

RESULTS

Endoscopy: Out of 2269 upper endoscopies reflux symptoms comprised 16.9% (n=386) of referrals; 19.1% only of these 386 patients had erosive oesophagitis at endoscopy and none had oesophagogastric malignancies (68% of the patients were >45 years). Consultations: Thirty-three percent out of 553 patients were referred for reflux symptoms. Upper endoscopy had already been performed before consultation in 64% of them. pH monitoring and oesophageal manometry: Two hundred and sixteen oesophageal pH monitorings and 160 oesophageal manometries were performed and 29% and 28%, respectively, were inappropriate, being performed in the diagnostic work-up of patients with typical reflux symptoms.

CONCLUSIONS

At an academic Gastroenterology Unit, (a) gastro-oesophageal reflux disease is a frequent referral for upper endoscopy and consultations, (b) prevalence of oesophagitis is low, (c) consultation is preceded by endoscopy in the majority of patients and (d) oesophageal pH monitoring and oesophageal manometry are often inappropriately used.