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Lages RB, Fontes LHDS, Barbuti RC, Navarro-Rodriguez T. Esophageal Mucosal Impedance Assessment for the Diagnosis of Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2024; 30:352-360. [PMID: 38972870 PMCID: PMC11238107 DOI: 10.5056/jnm23063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/27/2023] [Accepted: 07/17/2023] [Indexed: 07/09/2024] Open
Abstract
Background/Aims Diagnosing gastroesophageal reflux disease (GERD) is sometimes challenging because the performance of available tests is not entirely satisfactory. This study aims to directly measure the esophageal mucosal impedance during upper gastrointestinal endoscopy for the diagnosis of GERD. Methods Sixty participants with typical symptoms of GERD underwent high-resolution esophageal manometry, 24-hour multichannel intraluminal impedance-pH monitoring, upper gastrointestinal endoscopy, and mucosal impedance measurement. Mucosal impedance measurement was performed at 2, 5, 10, and 18 cm above the esophagogastric junction during gastrointestinal endoscopy using a specific catheter developed based on devices described in the literature over the last decade. The patients were divided into groups A (acid exposure time < 4%) and B (acid exposure time ≥ 4%). Results The mucosal impedance was significantly lower in group B at 2 cm (2264.4 Ω ± 1099.0 vs 4575.0 Ω ± 1407.6 [group A]) and 5 cm above the esophagogastric junction (4221.2 Ω ± 2623.7 vs 5888.2 Ω ± 2529.4 [group A]). There was no significant difference in the mucosal impedance between the 2 groups at 10 cm and 18 cm above the esophagogastric junction. Mucosal impedance value at 2 cm > 2970 Ω resulted in a sensitivity of 96.4% and a specificity of 87.5% to exclude GERD. Conclusions Direct measurement of mucosal impedance during endoscopy is a simple and promising method for diagnosing GERD. Individuals with an abnormal acid exposure time have lower mucosal impedance measurements than those with a normal acid exposure time.
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Affiliation(s)
- Rafael B Lages
- Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Luiz H de Souza Fontes
- Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Ricardo C Barbuti
- Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Tomas Navarro-Rodriguez
- Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
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Tan X, Wang S, Wu F, Zhu J. Bidirectional correlation between gastroesophageal reflux disease and sleep problems: a systematic review and meta-analysis. PeerJ 2024; 12:e17202. [PMID: 38646475 PMCID: PMC11027907 DOI: 10.7717/peerj.17202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives Gastroesophageal reflux disease (GERD) and sleep problems are highly prevalent among the general population. Both them are associated with a variety of psychiatric disorders such as depression and anxiety, which is highlighting an underexplored connection between them. This meta-analysis aims to explore the association between sleep problems and GERD. Methods We conducted a comprehensive search on PubMed, Cochrane Library, Embase, and Web of Science, using Medical Subject Headings (MeSH) and keywords, covering articles from the inception of the databases until August 2023. Stata statistical software, version 14.0, was utilized for all statistical analyses. A fixed-effects model was applied when p > 0.1 and I2 ≤ 50%, while a random-effects model was employed for high heterogeneity (p < 0.1 and I2 > 50%). Funnel plots and Egger's test were used to assess publication bias. Results Involving 22 studies, our meta-analysis revealed that insomnia, sleep disturbance, or short sleep duration significantly increased the risk of GERD (OR = 2.02, 95% CI [1.64-2.49], p < 0.001; I2 = 66.4%; OR = 1.98, 95% CI [1.58-2.50], p < 0.001, I2 = 50.1%; OR = 2.66, 95% CI [2.02-3.15], p < 0.001; I2 = 62.5%, respectively). GERD was associated with an elevated risk of poor sleep quality (OR = 1.47, 95% CI [1.47-1.79], p < 0.001, I2 = 72.4%), sleep disturbance (OR = 1.47, 95% CI [1.24-1.74], p < 0.001, I2 = 71.6%), or short sleep duration (OR = 1.17, 95% CI [1.12-1.21], p < 0.001, I2 = 0). Conclusion This meta-analysis establishes a bidirectional relationship between four distinct types of sleep problems and GERD. The findings offer insights for the development of innovative approaches in the treatment of both GERD and sleep problems.
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Affiliation(s)
- Xiaolong Tan
- Department of Gastrointestinal Surgery, Binzhou Medical University Hospital, Binzhou, Shandong Province, China
| | - Shasha Wang
- Department of Oncology, The People’s Hospital of Binzhou City, Binzhou, Shandong Province, China
| | - Fengjie Wu
- Department of Gastrointestinal Surgery, Binzhou Medical University Hospital, Binzhou, Shandong Province, China
| | - Jun Zhu
- Department of Gastrointestinal Surgery, Binzhou Medical University Hospital, Binzhou, Shandong Province, China
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Argüero J, Sifrim D. Pathophysiology of gastro-oesophageal reflux disease: implications for diagnosis and management. Nat Rev Gastroenterol Hepatol 2024; 21:282-293. [PMID: 38177402 DOI: 10.1038/s41575-023-00883-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/06/2024]
Abstract
Gastro-oesophageal reflux disease (GERD) is a common gastrointestinal disorder in which retrograde flow of gastric content into the oesophagus causes uncomfortable symptoms and/or complications. It has a multifactorial and partially understood pathophysiology. GERD starts in the stomach, where the refluxate material is produced. Following the trajectory of reflux, the failure of the antireflux barrier, primarily the lower oesophageal sphincter and the crural diaphragm, enables the refluxate to reach the oesophageal lumen, triggering oesophageal or extra-oesophageal symptoms. Reflux clearance mechanisms such as primary and secondary peristalsis and the arrival of bicarbonate-rich saliva are critical to prevent mucosal damage. Alterations of the oesophageal mucosal integrity, such as macroscopic oesophagitis or microscopic changes, determine the perception of symptoms. The intensity of the symptoms is affected by peripheral and central neural and psychological mechanisms. In this Review, we describe an updated understanding of the complex and multifactorial pathophysiology of GERD. It is now recognized that different GERD phenotypes have different degrees of reflux, severity of mucosal integrity damage and type, and severity of symptoms. These variations are probably due to the occurrence of a predominant pathophysiological mechanism in each patient. We also describe the main pathophysiological mechanisms of GERD and their implications for personalized diagnosis and management.
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Affiliation(s)
- Julieta Argüero
- Neurogastroenterology section of Gastroenterology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK.
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Leech T, Peiris M. Mucosal neuroimmune mechanisms in gastro-oesophageal reflux disease (GORD) pathogenesis. J Gastroenterol 2024; 59:165-178. [PMID: 38221552 PMCID: PMC10904498 DOI: 10.1007/s00535-023-02065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/30/2023] [Indexed: 01/16/2024]
Abstract
Gastro-oesophageal reflux disease (GORD) is a chronic condition characterised by visceral pain in the distal oesophagus. The current first-line treatment for GORD is proton pump inhibitors (PPIs), however, PPIs are ineffective in a large cohort of patients and long-term use may have adverse effects. Emerging evidence suggests that nerve fibre number and location are likely to play interrelated roles in nociception in the oesophagus of GORD patients. Simultaneously, alterations in cells of the oesophageal mucosa, namely epithelial cells, mast cells, dendritic cells, and T lymphocytes, have been a focus of GORD research for several years. The oesophagus of GORD patients exhibits both macro- and micro-inflammation as a response to chronic acidic reflux at the epithelium. In other conditions of the GI tract, such as IBS and IBD, well-characterised bidirectional processes between immune cells and mucosal nerve fibres contribute to pathogenesis and symptom generation. Sensory alterations in these conditions such as nerve fibre outgrowth and hypersensitivity can be driven by inflammatory processes, which promote visceral pain signalling. This review will examine what is currently known of the molecular pathways linking inflammation and sensory perception leading to the development of GORD symptoms and explore potentially relevant mechanisms in other GI regions which may indicate new areas in GORD research.
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Affiliation(s)
- Tom Leech
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Madusha Peiris
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
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Sawada A, Sifrim D, Fujiwara Y. Esophageal Reflux Hypersensitivity: A Comprehensive Review. Gut Liver 2023; 17:831-842. [PMID: 36588526 PMCID: PMC10651372 DOI: 10.5009/gnl220373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/01/2022] [Accepted: 10/18/2022] [Indexed: 01/03/2023] Open
Abstract
Reflux hypersensitivity (RH) is one of the phenotypes of gastroesophageal reflux disease. The latest Rome IV defines RH as a condition with typical reflux symptoms and positive reflux-symptom association despite normal acid exposure. Subsequently, the Lyon consensus proposed detailed cutoff values for the criteria on the basis of experts' consensus. Rome IV brought a clear-cut perspective into the pathophysiology of gastroesophageal reflux disease and the importance of esophageal hypersensitivity. This perspective can be supported by the fact that other functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia often overlap with RH. Although several possible pathophysiological mechanisms of esophageal hypersensitivity have been identified, there is still unmet medical needs in terms of treatment for this condition. This review summarizes the current knowledge regarding RH.
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Affiliation(s)
- Akinari Sawada
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Hoshikawa Y, Momma E, Kawami N, Iwakiri K. Lemborexant Attenuates Regurgitation without Worsening Objective Parameters on Reflux Monitoring in Patients with Gastroesophageal Reflux Disease and Insomnia: A Single-Arm Proof-of-Concept Study. Digestion 2023; 104:438-445. [PMID: 37429270 DOI: 10.1159/000531412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/31/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Esophageal hypersensitivity is associated with gastroesophageal reflux disease (GERD). Since sleep disturbance causes esophageal hypersensitivity, hypnotics may ameliorate GERD. However, zolpidem prolongs esophageal acid clearance. Lemborexant is a new hypnotic with higher efficacy and fewer adverse events than zolpidem. Therefore, the present study investigated the effects of lemborexant on GERD. METHODS Patients with heartburn and/or regurgitation and insomnia who did not take acid suppressants or hypnotics in the last month were recruited. Symptom assessments using GerdQ and reflux monitoring were performed before and after a 28-day treatment with 5 mg lemborexant at bedtime. The primary outcome was a change in the total GerdQ score, excluding the score for insomnia. Secondary outcomes were changes in each GerdQ score and the following parameters on reflux monitoring: the acid exposure time (AET), number of reflux events (RE), acid clearance time (ACT), and post-reflux swallow-induced peristaltic wave (PSPW) index. RESULTS Sixteen patients (age 45.0 [33.3-56.0], 11 females [68.8%]) completed the intervention (1 patient did not tolerate the second reflux monitoring). The total GerdQ score, excluding the score for insomnia, did not significantly change (8.0 [6.0-9.0] before vs. 7.0 [6.3-9.0] after p = 0.16). GerdQ showed the significant attenuation of regurgitation (2.0 [2.0-3.0] vs. 1.0 [0-2.8] p = 0.0054) but not heartburn (2.5 [1.0-3.0] vs. 1.0 [0.3-2.0] p = 0.175). No significant differences were observed in AET, RE, ACT, or PSPW index before and after the intervention. CONCLUSION Lemborexant attenuated regurgitation without the worsening of objective reflux parameters. A randomized placebo-controlled study is warranted in the future.
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Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Eri Momma
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Wong MW, Hung JS, Lei WY, Liu TT, Yi CH, Liang SW, Gyawali CP, Wang JH, Chen CL. Esophageal secondary peristalsis following acid infusion and chemical clearance correlate with mucosal integrity and acid sensitivity in GERD patients. Therap Adv Gastroenterol 2023; 16:17562848231179329. [PMID: 37440930 PMCID: PMC10333995 DOI: 10.1177/17562848231179329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/15/2023] [Indexed: 07/15/2023] Open
Abstract
Background Acid sensitivity can be altered in patients with gastroesophageal reflux disease (GERD). Secondary peristalsis helps clear gastro-esophageal refluxate and residual ingested food bolus. Objectives The aim of this study was to investigate the associations among acid sensitivity, esophageal mucosal integrity, chemical clearance, and secondary peristalsis before and after esophageal acid infusion. Design This was an investigator-initiated, prospective, cross-sectional study. Methods Adult reflux patients underwent high resolution manometry and 24 h impedance-pH monitoring off acid suppression to identify GERD phenotypes, including non-erosive reflux disease (NERD), reflux hypersensitivity (RH), and functional heartburn (FH). Secondary peristalsis was assessed using five rapid 20 mL air injections into the esophagus before and after infusion of hydrochloric acid (0.1 N) into the mid-esophagus. Conventional acid infusion parameters recorded included lag time, intensity rating, and sensitivity score. Chemical clearance was evaluated using the post-reflux swallow-induced peristaltic wave (PSPW), and mucosal integrity was assessed by the mean nocturnal baseline impedance (MNBI) derived from impedance-pH monitoring. Results A total of 88 patients (age 21-64 years, 62.5% women) completed the study including 12 patients with NERD, 45 with RH, and 31 with FH. There was no significant difference in acid infusion parameters between patients with NERD, RH, and FH. Upon acid infusion, patients who exhibited successful secondary peristalsis had longer lag time, higher MNBI, and shorter bolus contact time than those without secondary peristalsis. Meanwhile, patients with intact PSPW demonstrated significantly higher intensity ratings in response to acid perfusion and higher MNBI than those with impaired PSPW. The lag time correlated positively with MNBI (r = 0.285; p = 0.007). Conclusion In conclusion, the protective effect of esophageal secondary peristalsis and chemical clearance on esophageal mucosal integrity was demonstrated. Concerning acid sensitivity, longer lag time in patients with intact secondary peristalsis may be attributed to better esophageal mucosal integrity, while stronger intensity ratings may have a greater tendency to induce PSPW and protect esophageal mucosal integrity.
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Affiliation(s)
- Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi
Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University,
Hualien School of Post-Baccalaureate Chinese Medicine, Tzu Chi University,
Hualien
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi
Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University,
Hualien
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi
Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University,
Hualien
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi
Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University,
Hualien
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi
Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University,
Hualien
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi
Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University,
Hualien
| | | | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi
Hospital, Buddhist Tzu Chi Medical Foundation, Hualien
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Blaine-Sauer S, Samuels TL, Yan K, Johnston N. The Protease Inhibitor Amprenavir Protects against Pepsin-Induced Esophageal Epithelial Barrier Disruption and Cancer-Associated Changes. Int J Mol Sci 2023; 24:ijms24076765. [PMID: 37047737 PMCID: PMC10095080 DOI: 10.3390/ijms24076765] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) significantly impacts patient quality of life and is a major risk factor for the development of Barrett’s esophagus (BE) and esophageal adenocarcinoma (EAC). Proton pump inhibitors (PPIs) are the standard-of-care for GERD and are among the most prescribed drugs in the world, but do not protect against nonacid components of reflux such as pepsin, or prevent reflux-associated carcinogenesis. We recently identified an HIV protease inhibitor amprenavir that inhibits pepsin and demonstrated the antireflux therapeutic potential of its prodrug fosamprenavir in a mouse model of laryngopharyngeal reflux. In this study, we assessed the capacity of amprenavir to protect against esophageal epithelial barrier disruption in vitro and related molecular events, E-cadherin cleavage, and matrix metalloproteinase induction, which are associated with GERD severity and esophageal cancer. Herein, weakly acidified pepsin (though not acid alone) caused cell dissociation accompanied by regulated intramembrane proteolysis of E-cadherin. Soluble E-cadherin responsive matrix metalloproteinases (MMPs) were transcriptionally upregulated 24 h post-treatment. Amprenavir, at serum concentrations achievable given the manufacturer-recommended dose of fosamprenavir, protected against pepsin-induced cell dissociation, E-cadherin cleavage, and MMP induction. These results support a potential therapeutic role for amprenavir in GERD recalcitrant to PPI therapy and for preventing GERD-associated neoplastic changes.
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Affiliation(s)
- Simon Blaine-Sauer
- Department of Otolaryngology and Communication Science, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tina L. Samuels
- Department of Otolaryngology and Communication Science, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Ke Yan
- Department of Pediatrics Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Nikki Johnston
- Department of Otolaryngology and Communication Science, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Wong MW, Rogers BD, Liu MX, Lei WY, Liu TT, Yi CH, Hung JS, Liang SW, Tseng CW, Wang JH, Wu PA, Chen CL. Application of Artificial Intelligence in Measuring Novel pH-Impedance Metrics for Optimal Diagnosis of GERD. Diagnostics (Basel) 2023; 13:diagnostics13050960. [PMID: 36900104 PMCID: PMC10000892 DOI: 10.3390/diagnostics13050960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Novel metrics extracted from pH-impedance monitoring can augment the diagnosis of gastroesophageal reflux disease (GERD). Artificial intelligence (AI) is being widely used to improve the diagnostic capabilities of various diseases. In this review, we update the current literature regarding applications of artificial intelligence in measuring novel pH-impedance metrics. AI demonstrates high performance in the measurement of impedance metrics, including numbers of reflux episodes and post-reflux swallow-induced peristaltic wave index and, furthermore, extracts baseline impedance from the entire pH-impedance study. AI is expected to play a reliable role in facilitating measuring novel impedance metrics in patients with GERD in the near future.
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Affiliation(s)
- Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, 707, Section 3, Chung-Yang Road, Hualien 97004, Taiwan
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Benjamin D. Rogers
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY 40292, USA
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Min-Xiang Liu
- AI Innovation Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, 707, Section 3, Chung-Yang Road, Hualien 97004, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, 707, Section 3, Chung-Yang Road, Hualien 97004, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, 707, Section 3, Chung-Yang Road, Hualien 97004, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, 707, Section 3, Chung-Yang Road, Hualien 97004, Taiwan
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, 707, Section 3, Chung-Yang Road, Hualien 97004, Taiwan
| | - Chiu-Wang Tseng
- NVIDIA AI Technology Center, NVIDIA Corporation, Taipei 11492, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
| | - Ping-An Wu
- AI Innovation Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, 707, Section 3, Chung-Yang Road, Hualien 97004, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien 97004, Taiwan
- Correspondence:
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Ustaoglu A, Woodland P. Sensory Phenotype of the Oesophageal Mucosa in Gastro-Oesophageal Reflux Disease. Int J Mol Sci 2023; 24:ijms24032502. [PMID: 36768825 PMCID: PMC9917190 DOI: 10.3390/ijms24032502] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/14/2023] [Accepted: 01/18/2023] [Indexed: 02/03/2023] Open
Abstract
Gastroesophageal reflux disease (GORD) affects up to 20% of Western populations, yet sensory mechanisms underlying heartburn pathogenesis remain incompletely understood. While central mechanisms of heartburn perception have been established in earlier studies, recent studies have highlighted an important role of neurochemical, inflammatory, and cellular changes occurring in the oesophageal mucosa itself. The localization and neurochemical characterisation of sensory afferent nerve endings differ among GORD phenotypes, and could explain symptom heterogeneity among patients who are exposed to similar levels of reflux. Acid-induced stimulation of nociceptors on pain-sensing nerve endings can regulate afferent signal transmission. This review considers the role of peripheral mechanisms of sensitization in the amplification of oesophageal sensitivity in patients with GORD.
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Wang N, Guo ZH, Wu YH, Zhang C. Mean nocturnal baseline impedance: Influencing factors and diagnostic value in gastroesophageal reflux disease. Technol Health Care 2023; 31:1875-1886. [PMID: 36970927 DOI: 10.3233/thc-220814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND At present, there are few studies related to mean nocturnal baseline impedance (MNBI), esophageal dynamic reflux monitoring, high-resolution esophageal manometry (HRM) parameter indexes, and its diagnostic value in gastroesophageal reflux disease (GERD). OBJECTIVE To analyze the factors influencing MNBI and examine the diagnostic value of MNBI in GERD. METHODS A retrospective analysis on 434 patients with typical reflux symptoms who underwent gastroscopy, 24-hour multichannel intraluminal impedance and pH monitoring (MII/pH) and HRM. They were divided into the conclusive evidence group (103 cases), borderline evidence group (229 cases), and exclusion evidence group (102 cases) according to the level of diagnostic evidence of GERD based on the Lyon Consensus. We analyzed the differences in MNBI, esophagitis grade, MII/pH and HRM index among the groups; the correlation between MNBI and the above indexes and its influence on MNBI; and to evaluate the diagnostic value of MNBI in GERD. RESULTS There were significant differences in MNBI, Acid Exposure Time (AET) 4%, DeMeester score, and total reflux episodes among the three groups (P< 0.001). EGJ contractile integral (EGJ-CI) of the conclusive evidence group and the borderline evidence group was significantly lower than that in the exclusion evidence group (P< 0.001). MNBI was significantly and negatively correlated with age, BMI, AET 4%, DeMeester score, total reflux episodes, EGJ classification, esophageal motility abnormalities, and esophagitis grade (all P< 0.05), and significantly and positively correlated with EGJ-CI (P< 0.001). Age, BMI, AET 4%, EGJ classification, EGJ-CI, and esophagitis grade had significant effects on MNBI (P< 0.05); MNBI was used to diagnose GERD with a diagnostic cutoff of 2061 Ω, and AUC was 0.792 (sensitivity 74.9%, specificity 67.4%); MNBI was used to diagnose exclusion evidence group with a diagnostic cutoff of 2432 Ω, AUC was 0.774 (sensitivity 67.6%, specificity 72%). CONCLUSION AET, EGJ-CI, and esophagitis grade are the most important influence factors of MNBI. MNBI has good diagnostic value in identifying conclusive GERD.
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Affiliation(s)
- Ning Wang
- Department of Digestive Diseases, Beijing Tongren Hospital Affiliated to Capital Medical University, Beijing, China
| | - Zi-Hao Guo
- Department of Digestive Diseases, Beijing Tongren Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yan-Hong Wu
- Department of Digestive Disease, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Chuan Zhang
- Department of Digestive Diseases, Beijing Tongren Hospital Affiliated to Capital Medical University, Beijing, China
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12
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Ilia S, Monica V, Daniel S. Mean nocturnal baseline impedance and endoscopic mucosal impedance measurements in patients with eosinophilic esophagitis: a new tool for follow up and management? Updates Surg 2023; 75:389-393. [PMID: 35840790 PMCID: PMC9852170 DOI: 10.1007/s13304-022-01331-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/05/2022] [Indexed: 01/24/2023]
Abstract
Eosinophilic esophagitis (EoE) is the second most common cause of chronic esophageal inflammation after GERD, with increasing incidence and prevalence across all age groups. Since current diagnosis and follow up of EoE require endoscopy with biopsies, there is an increased interest in non or less invasive tests for its diagnosis and follow up. Baseline mucosal impedance measurement allows evaluation of mucosal barrier properties and is widely accepted as an adjunct method in GERD diagnosis. As EoE is associated with increased mucosal permeability, the use of baseline impedance to evaluate mucosal integrity has been investigated in several studies. It was found that baseline mucosal impedance, measured either during 24 h reflux monitoring or during endoscopy, was significantly lower in all parts of the esophagus in EoE patients. Impedance measurement correlated with eosinophil counts on biopsies, offering a tool to monitor treatment response. Additionally, baseline impedance patterns differed between those responding to proton pump inhibitor (PPI) treatment and those resistant to PPI, potentially allowing to tailor future treatment to the individual patient. In summary, baseline impedance measurement offers a potential tool for diagnosis and follow up in EoE. Its exact place in EoE treatment is yet to be determined and requires further future studies.
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Affiliation(s)
- Sergeev Ilia
- Barts and the London School of Medicine and Dentistry, Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Velosa Monica
- Barts and the London School of Medicine and Dentistry, Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Sifrim Daniel
- Barts and the London School of Medicine and Dentistry, Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
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Samuels TL, Yan K, Patel N, Plehhova K, Coyle C, Hurley BP, Johnston N. Alginates for Protection Against Pepsin-Acid Induced Aerodigestive Epithelial Barrier Disruption. Laryngoscope 2022; 132:2327-2334. [PMID: 35238407 DOI: 10.1002/lary.30087] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are chronic conditions caused by backflow of gastric and duodenal contents into the esophagus and proximal aerodigestive tract, respectively. Mucosal barrier dysfunction resultant from the synergistic actions of chemical injury and the mucosal inflammatory response during reflux contributes to symptom perception. Alginates effectively treat symptoms of mild to moderate GERD and have recently shown benefit for LPR. In addition to forming a "raft" over gastric contents to reduce acidic reflux episodes, alginates have been found to bind the esophageal mucosa thereby preserving functional barrier integrity measured by transepithelial electrical resistance. The aim of this study was to further examine the topical protective capacity of alginate-based Gaviscon Advance (GA) and Double Action (GDA) against pepsin-acid mediated aerodigestive epithelial barrier dysfunction in vitro. STUDY DESIGN Translational. METHODS Immortalized human esophageal and vocal cord epithelial cells cultured in transwells were pretreated with liquid formula GA, GDA, matched viscous placebo solution, or saline (control), then treated for 1 h with saline, acid (pH 3-6) or pepsin (0.1-1 mg/ml) at pH 3-6. Endpoint measure was taken of horseradish peroxidase (HRP) allowed to diffuse across monolayers for 2 h. RESULTS Pepsin (0.1-1 mg/ml) at pH 3-6 increased HRP flux through cultures pretreated with saline or placebo (p < 0.05); acid alone did not. GA and GDA prevented barrier dysfunction. CONCLUSIONS GA and GDA preserved epithelial barrier function during pepsin-acid insult better than placebo suggesting that protection was due to alginate. These data support topical protection as a therapeutic approach to GERD and LPR. Laryngoscope, 132:2327-2334, 2022.
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Affiliation(s)
- Tina L Samuels
- Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Ke Yan
- Pediatrics Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Nishma Patel
- Reckitt Benckiser, Hull, England, United Kingdom
| | | | - Cathal Coyle
- Reckitt Benckiser, Hull, England, United Kingdom
| | - Bryan P Hurley
- Pediatrics, Mucosal Immunology & Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Nikki Johnston
- Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.,Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
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14
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Zhao Y, Cao Y, Yang X, Guo M, Wang C, Zhang Z, Zhang Q, Huang X, Sun M, Xi C, Tangthianchaichana J, Bai J, Du S, Lu Y. Network pharmacology-based prediction and verification of the active ingredients and potential targets of Huagan Decoction for reflux esophagitis. JOURNAL OF ETHNOPHARMACOLOGY 2022; 298:115629. [PMID: 35988839 DOI: 10.1016/j.jep.2022.115629] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/19/2022] [Accepted: 08/06/2022] [Indexed: 06/15/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Huagan Decoction (HGD), a famous traditional Chinese medicine (TCM) formula, has been widely used in the treatment of reflux esophagitis (RE). However, its effective compounds, potential targets and molecular mechanism remain unclear. AIM OF THE STUDY To investigate effective compounds, potential targets and molecular mechanism of HGD against RE by using network pharmacology combined with in vitro validation, with the aims of observing the action of HGD and exploring new therapeutic strategies for RE treatment. MATERIALS AND METHODS Effective compounds and potential targets of HGD, as well as related genes of RE, were collected from public databases. Pharmacological clustering and Gene Ontology (GO) enrichment analysis were applied to find targets that involving in the anti-inflammatory module. The pathways were drawn using Cytoscape 3.8.0. Important ingredients, potential targets, and signaling pathways were determined through the construction of protein-protein interaction (PPI), GO and Kyoto Encyclopedia of Genes and Genomes (KEGG). Subsequently, cell experiments were carried out. RESULTS A total of 54 active ingredients and 240 RE-related gene targets of HGD were identified. The active compound-target network was visualized and pharmacological clustering further sorted 53 proteins that involve in the regulation of inflammatory responses. GO analysis confirmed the classification was statistically significant. Analysis of compound-target network revealed that quercetin and geniposide may be key ingredients for the anti-inflammatory effect of HGD against RE. The potential targets regulated by HGD are IL-6, IL-1β, PTGS2, AKT1, TNF-α, MAPK1, IL-8, IL-10, CCL2 and MAPK3. In vitro experiment showed that quercetin and geniposide could inhibit the inflammatory response of HET-1A cells through p38MAPK/NF-κB signaling pathway, which was consistent with the prediction by the network pharmacology approach. CONCLUSIONS Geniposide and quercetin could be effective therapeutic ingredients for the HGD against RE. They play anti-inflammatory effects via down-regulating the pro-inflammatory cytokines and the conduction of p38MAPK/NF-κB signal. This research provides a comprehensive study on the active components, potential targets, and molecular mechanisms of HGD against RE. Moreover, the study supplies a feasible approach to reveal the mechanisms of TCM formula.
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Affiliation(s)
- Yueying Zhao
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Yanfeng Cao
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Xueying Yang
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Mingxue Guo
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Changhai Wang
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Zekang Zhang
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Qing Zhang
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Xingyue Huang
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Meng Sun
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Cheng Xi
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | | | - Jie Bai
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Shouying Du
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
| | - Yang Lu
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
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15
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Liang SW, Wong MW, Yi CH, Liu TT, Lei WY, Hung JS, Lin L, Rogers BD, Chen CL. Current advances in the diagnosis and management of gastroesophageal reflux disease. Tzu Chi Med J 2022; 34:402-408. [PMID: 36578634 PMCID: PMC9791847 DOI: 10.4103/tcmj.tcmj_323_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/10/2022] [Accepted: 02/23/2022] [Indexed: 12/31/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is very common and defined as troublesome symptoms owing to excessive acid reflux. The spectrum of GERD is broad, including not only erosive esophagitis and Barrett's esophagus but also nonerosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn. Patients with reflux symptoms despite normal endoscopy remain common clinical presentation, can be heterogeneous overlapping with functional gastrointestinal disorders. Ambulatory esophageal pH monitoring with and without impedance helps the diagnosis of NERD. Metrics such as baseline impedance and postreflux swallow induced peristaltic wave enhance diagnostic accuracy in patients with inconclusive diagnoses. The major treatment of all manifestations of GERD is acid suppression with proton pump inhibitors, while other therapies, such as reflux-reducing agents and adjunctive medications, can be individualized where the response to traditional management is incomplete. GERD patients often need long-term treatment due to frequent relapses. Anti-reflux surgery can be effective too. Endoscopic therapies have some promising results, but long-term outcomes remain to be determined.
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Affiliation(s)
- Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan,School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Lin Lin
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Benjamin D. Rogers
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA,Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan,Address for correspondence: Dr. Chien-Lin Chen, Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien, Taiwan. E-mail:
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16
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Nikaki K, Sifrim D. Pathophysiology of Pediatric Gastroesophageal Reflux Disease: Similarities and Differences With Adults. J Clin Gastroenterol 2022; 56:99-113. [PMID: 34560757 DOI: 10.1097/mcg.0000000000001604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Gastroesophageal reflux (GOR) is defined as "the passage of gastric contents into the esophagus with or without regurgitation and vomiting" and gastroesophageal reflux disease (GORD) is defined "when GOR leads to troublesome symptoms affecting the daily functioning and/or complications." This definition was first developed in 2006 by the Montreal consensus group (1) and later on adopted by pediatric gastroenterology societies such as ESPGHAN and NASPGHAN in 2009 (2). The definition of gastroesophageal reflux reveals little about its pathophysiology and is focused on symptomatology. In this way, it acts as an umbrella term for the multifactorial causes of the disease and the various phenotypes encountered; from functional heartburn to hypersensitive esophagus and nonerosive reflux disease, to erosive esophagitis and Barrett's esophagus. This article is devoted to the pathophysiology of pediatric GORD in comparison to adult GORD and is divided in 2 parts. In the first part, we will systematically describe the different mechanisms for the generation and clearance of reflux events, while on the second part we will discuss the mechanisms involved in symptoms generation. Finally, we will discuss the similarities and differences between pediatric and adult GORD.
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Affiliation(s)
- Kornilia Nikaki
- Gastroenterology Department, Great Ormond Street Hospital for Children
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, The Blizard Institute, QMUL, London, UK
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17
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Visaggi P, Mariani L, Svizzero FB, Tarducci L, Sostilio A, Frazzoni M, Tolone S, Penagini R, Frazzoni L, Ceccarelli L, Savarino V, Bellini M, Gyawali PC, Savarino EV, de Bortoli N. Clinical use of mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index for the diagnosis of gastro-esophageal reflux disease. Esophagus 2022; 19:525-534. [PMID: 35768671 PMCID: PMC9436885 DOI: 10.1007/s10388-022-00933-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/07/2022] [Indexed: 02/03/2023]
Abstract
The clinical diagnosis of gastro-esophageal reflux disease (GERD) is based on the presence of typical esophageal troublesome symptoms. In clinical practice, heartburn relief following a proton pump inhibitor (PPI) trial or endoscopy can confirm a diagnosis of GERD. In cases of diagnostic uncertainty or before anti-reflux interventions, combined impedance-pH monitoring (MII-pH) provides a comprehensive assessment of both physical and chemical properties of the refluxate, allowing to achieve a conclusive diagnosis of GERD. Recently, the Lyon Consensus proposed the use of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPW-I) as novel MII-pH metrics to support the diagnosis of GERD. The calculation of MNBI and PSPW-I currently needs to be performed manually, but artificial intelligence systems for the automated analysis of MII-pH tracings are being developed. Several studies demonstrated the increased diagnostic yield MNBI and PSPW-I for the categorization of patients with GERD at both on- and off-PPI MII-pH monitoring. Accordingly, we performed a narrative review on the clinical use and diagnostic yield of MNBI and PSPW-I when the diagnosis of GERD is uncertain. Based on currently available evidence, we strongly support the evaluation of PSPW-I and MNBI as part of the standard assessment of MII-pH tracings for the evaluation of GERD, especially in patients with endoscopy-negative heartburn.
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Affiliation(s)
- Pierfrancesco Visaggi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Lucia Mariani
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Federica Baiano Svizzero
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Luca Tarducci
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Andrea Sostilio
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, University of Caserta Luigi Vanvitelli, Caserta, Italy
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Linda Ceccarelli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine "DiMI", University of Genoa, Genoa, Italy
| | - Massimo Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Prakash C Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA
| | - Edoardo V Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy.
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18
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Zhao Y, Ma T, Zou D. Identification of Unique Transcriptomic Signatures and Hub Genes Through RNA Sequencing and Integrated WGCNA and PPI Network Analysis in Nonerosive Reflux Disease. J Inflamm Res 2021; 14:6143-6156. [PMID: 34848992 PMCID: PMC8627320 DOI: 10.2147/jir.s340452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/12/2021] [Indexed: 01/17/2023] Open
Abstract
Purpose Transcriptomic studies on gastroesophageal reflux disease are scarce, and gene expression signatures in nonerosive reflux disease (NERD) remain elusive. The aim of the study was to identify gene expression profiles and potential hub genes in NERD. Patients and Methods We performed RNA sequencing on biopsy samples from nine consecutive patients with NERD and six healthy controls. Differentially expressed genes (DEGs) were analysed with the DESeq2 R package. A DEG-based protein-protein interaction (PPI) network was constructed to filter hub genes using Cytoscape. Weighted gene coexpression network analysis (WGCNA) was conducted to identify the coexpression relationships of all modules and explore the relationship between gene sets and clinical traits. Results In total, 1195 DEGs were identified, including 649 upregulated and 546 downregulated genes involved in regulating the inflammatory response and epithelial cell differentiation. Overlap of the PPI and WGCNA networks identified five shared genes, namely, THY1, BMP2, LOX, KDR and MMP9, as candidate hub genes in NERD. Quantitative PCR analysis of the expression of these five genes confirmed the sequencing results. Receiver operating characteristic analyses indicated that these hub genes had diagnostic potential for NERD patients. Gene set enrichment analysis confirmed that each hub gene was closely associated with the pathophysiological processes of NERD. In addition, a regulatory network comprising 42 transcription factors (TFs), 28 miRNAs and 5 hub genes was established. Conclusion The five core genes may be promising biomarkers of NERD. The TF/miRNA/hub gene network can improve the understanding of the molecular mechanisms underlying disease progression.
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Affiliation(s)
- Ye Zhao
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Teng Ma
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China
| | - Duowu Zou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
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19
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Wang Y, Ye B, Wang M, Lin L, Jiang L. Esophageal Nocturnal Baseline Impedance and Post-reflux Swallow-induced Peristaltic Wave Index in Identifying Proton Pump Inhibitor-refractory Non-erosive Reflux Disease. J Neurogastroenterol Motil 2021; 27:525-532. [PMID: 34642272 PMCID: PMC8521464 DOI: 10.5056/jnm20073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 12/12/2022] Open
Abstract
Background/Aims Esophageal mean nocturnal baseline impedance (MNBI) levels and post-reflux swallow-induced peristaltic wave (PSPW) index could increase the diagnostic value of 24-hour multichannel intraluminal impedance and pH monitoring in patients with gastroesophageal reflux disease. This study aims to compare the MNBI and PSPW index in patients with no evidence of erosive reflux disease. Methods Impedance-pH monitoring tracings from 70 patients, 50 with non-erosive reflux disease (NERD) and 20 with functional heartburn (FH), were reviewed. According to proton pump inhibitors (PPI) treatment response, NERD patients were divided into NERD/PPI responders and NERD/PPI nonresponders. MNBI, PSPW index, and intercellular spaces were measured and compared among each group. Results MNBI values and PSPW index were lower in NERD patients than in FH (P < 0.01 and P < 0.05, respectively). MNBI positively correlated with PSPW index (r = 0.525, P < 0.001). NERD/PPI responders had lower MNBI values and PSPW index compared to NERD/PPI nonresponders (both P < 0.01). MNBI and PSPW index distinguished NERD from FH patients with an area under the curve of 0.914 and 0.677, respectively. Wider intercellular space could be identified in patients with NERD (P < 0.01). Conclusion MNBI and PSPW index may differentiate NERD from FH patients and relate to PPI treatment efficacy in patients with NERD.
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Affiliation(s)
- Yan Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bixing Ye
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Meifeng Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lin Lin
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Liuqin Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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20
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Fass R, Boeckxstaens GE, El-Serag H, Rosen R, Sifrim D, Vaezi MF. Gastro-oesophageal reflux disease. Nat Rev Dis Primers 2021; 7:55. [PMID: 34326345 DOI: 10.1038/s41572-021-00287-w] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 02/07/2023]
Abstract
Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.
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Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical System, Case Western Reserve University, Cleveland, OH, USA.
| | - Guy E Boeckxstaens
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
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21
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Manabe N, Yamamoto T, Matsusaki M, Akashi M, Haruma K. Measurement of low-grade inflammation of the esophageal mucosa with electrical conductivity shows promise in assessing PPI responsiveness in patients with GERD. Am J Physiol Gastrointest Liver Physiol 2021; 321:G29-G40. [PMID: 33949214 DOI: 10.1152/ajpgi.00365.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A device that can easily measure electrical impedance might be a helpful tool for investigating the pathophysiology of gastroesophageal reflux disease. The first aim of this study was to validate our newly developed bioelectrical admittance measurement (BAM) through in vitro experimentation. The second aim was to investigate whether evaluation of BAM by this measurement differed between patients with heartburn according to their response to proton pump inhibitor (PPI) therapy. Caco-2 cell monolayers and three-dimensional tissues were examined by BAM using a frequency response analyzer. BAM was also used to measure the impedance through cell layers. Subsequently, BAM was performed during endoscopy in 41 patients experiencing heartburn without esophageal mucosal breaks. After 2-wk administration of 20-mg rabeprazole twice daily, patient responses to PPI were classified as "good" or "poor" according to their clinical course. In each patient, histological alterations and gene expression levels of inflammation mediators and tight junction proteins were evaluated. Impedance profiles indicated that monolayer Caco-2 cells on top of eight-layered normal human dermal fibroblasts had the highest magnitude of impedance over the range of frequencies. In vivo results revealed that patients with good responses to PPI displayed significantly higher admittance. Severity of low-grade inflammation was significantly associated with esophageal wall admittance. Moreover, esophageal wall admittance may be more closely related to basal zone hyperplasia than dilatation of intercellular spaces. Thus, BAM may be able to detect abnormalities in the subepithelial layer of the esophagus.NEW & NOTEWORTHY Bioelectrical admittance measurement is a new method to evaluate esophageal mucosal permeability vertically during upper gastrointestinal endoscopy. Measurement of low-grade inflammation of the esophageal mucosa with electrical conductivity shows promise in assessing proton pump inhibitor responsiveness in patients with gastroesophageal reflux disease. As various gastrointestinal diseases are associated with changes in mucosal permeability, bioelectrical admittance measurement is expected to be clinically applied to therapeutic decision-making for these diseases in the future.
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Affiliation(s)
- Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takatoki Yamamoto
- Department of Mechanical and Control Engineering, Graduate School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - Michiya Matsusaki
- Department of Applied Chemistry, Graduate School of Engineering, Osaka University, Osaka, Japan
| | - Mitsuru Akashi
- Graduate School of Frontier Biosciences, Osaka University, Osaka, Japan
| | - Ken Haruma
- Department of General Internal Medicine 2, Kawasaki Medical School, Okayama, Japan
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Patel D, Fass R, Vaezi M. Untangling Nonerosive Reflux Disease From Functional Heartburn. Clin Gastroenterol Hepatol 2021; 19:1314-1326. [PMID: 32246998 DOI: 10.1016/j.cgh.2020.03.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have nonerosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common phenotype of gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. A diagnosis of NERD requires endoscopy and reflux testing, whereas a diagnosis of functional heartburn also requires esophageal manometry. NERD is treated most commonly with medical, endoscopic, and surgical antireflux approaches, whereas functional heartburn as well as NERD can be treated with neuromodulators, psychological intervention, and complementary medicine options.
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Affiliation(s)
- Dhyanesh Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth System, Case Western Reserve University, Cleveland, Ohio
| | - Michael Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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Frazzoni M, Frazzoni L, De Bortoli N, Russo S, Tolone S, Arsiè E, Conigliaro R, Penagini R, Savarino E. Response of eosinophilic oesophagitis to proton pump inhibitors is associated with impedance-pH parameters implying anti-reflux mechanism of action. Aliment Pharmacol Ther 2021; 53:1183-1189. [PMID: 33857331 DOI: 10.1111/apt.16371] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/01/2021] [Accepted: 03/31/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are effective therapies for eosinophilic oesophagitis (EoE), but the mechanism of action is uncertain. At on-PPI impedance-pH monitoring, improvement in oesophageal chemical clearance assessed with post-reflux swallow-induced peristaltic wave (PSPW) index characterises PPI-responsive EoE and reflux disease. Off-PPI, higher efficacy of the oesophago-salivary reflex as measured with PSPW-associated pH increments characterises PPI-responsive reflux disease and could typify PPI-responsive EoE as well. AIM To establish whether PPI responsiveness in EoE is associated with higher efficacy of the oesophago-salivary reflex. METHODS Prospective multicentre study in EoE patients investigated with impedance-pH monitoring before starting PPI. Impedance-pH parameters in PPI-responsive and PPI-refractory cases were compared. PPI response was defined histologically. RESULTS Considerable PSPW-associated pH increments (median 1.4 units) were found in 80 EoE patients, with significantly higher values in 48 PPI-responsive than in 32 PPI-refractory cases (1.8 vs 1.0, P = 0.02). Mucosal integrity, as measured with mean nocturnal baseline impedance was more severely impaired in the distal oesophagus in PPI-responsive cases, the gradient between mid and distal oesophagus being significantly higher (546 vs 137 Ω, P = 0.0002). PSPW-associated pH increments and the baseline impedance gradient between mid and distal oesophagus were independently associated with histological response at multivariable logistic regression; at receiver operating characteristic analysis, the area under the curve of PPI response calculated by combined assessment was 0.88. CONCLUSION Higher efficacy of oesophago-salivary reflex and more severe mucosal damage in the distal oesophagus are associated with EoE response to PPIs, implying an anti-reflux mechanism of action as most likely.
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Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Nicola De Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Salvatore Russo
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, 2nd University of Napoli, Naples, Italy
| | - Elena Arsiè
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Rita Conigliaro
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
| | - Roberto Penagini
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
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Ustaoglu A, Sawada A, Lee C, Lei WY, Chen CL, Hackett R, Sifrim D, Peiris M, Woodland P. Heartburn sensation in nonerosive reflux disease: pattern of superficial sensory nerves expressing TRPV1 and epithelial cells expressing ASIC3 receptors. Am J Physiol Gastrointest Liver Physiol 2021; 320:G804-G815. [PMID: 33655767 DOI: 10.1152/ajpgi.00013.2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The underlying causes of heartburn, characteristic symptom of gastroesophageal reflux disease (GERD), remain incompletely understood. Superficial afferent innervation of the esophageal mucosa in nonerosive reflux disease (NERD) may drive nociceptive reflux perception, but its acid-sensing role has not yet been established. Transient receptor potential vanilloid subfamily member-1 (TRPV1), transient receptor potential melastatin 8 (TRPM8), and acid-sensing ion channel 3 (ASIC3) are regulators of sensory nerve activity and could be important reflux-sensing receptors within the esophageal mucosa. We characterized TRPV1, TRPM8, and ASIC3 expression in esophageal mucosa of patients with GERD. We studied 10 patients with NERD, 10 with erosive reflux disease (ERD), 7 with functional heartburn (FH), and 8 with Barrett's esophagus (BE). Biopsies obtained from the distal esophageal mucosa were costained with TRPV1, TRPM8, or ASIC3, and CGRP, CD45, or E-cadherin. RNA expression of TRPV1, TRPM8, and ASIC3 was assessed using qPCR. Patients with NERD had significantly increased expression of TRPV1 on superficial sensory nerves compared with ERD (P = 0.028) or BE (P = 0.017). Deep intrapapillary nerve endings did not express TRPV1 in all phenotypes studied. ASIC3 was exclusively expressed on epithelial cells most significantly in patients with NERD and ERD (P ≤0.0001). TRPM8 was expressed on submucosal CD45+ leukocytes. Superficial localization of TRPV1-immunoreactive nerves in NERD, and increased ASIC3 coexpression on epithelial cells in NERD and ERD, suggests a mechanism for heartburn sensation. Esophageal epithelial cells may play a sensory role in acid reflux perception and act interdependently with TRPV1-expressing mucosal nerves to augment hypersensitivity in patients with NERD, raising the enticing possibility of topical antagonists for these ion channels as a therapeutic option.NEW & NOTEWORTHY We demonstrate for the first time that increased pain perception in patients with nonerosive reflux disease likely results from expression of acid-sensitive channels on superficial mucosal afferents and esophageal epithelial cells, raising the potential for topical therapy.
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Affiliation(s)
- Ahsen Ustaoglu
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Akinari Sawada
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Chung Lee
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Richard Hackett
- Centre for Tumour Biology, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Madusha Peiris
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Advances in the diagnosis of GERD. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MÉDECINE INTERNE 2021; 59:3-9. [PMID: 33010143 DOI: 10.2478/rjim-2020-0027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Indexed: 12/22/2022]
Abstract
Gastroesophageal reflux disease (GERD) is considered one of the most frequent chronic gastrointestinal diseases globally with high costs due to treatment and investigations.First line therapy is with proton pump inhibitors, those who do not respond to initial treatment usually require further investigations such as upper gastrointestinal endoscopy or ambulatory 24-hours esophageal pH monitoring. The total time of exposure to acid and the DeMeester score represent the most useful parameters associated with conventional pH-metry, because they can identify gastroesophageal reflux disease.Although pH-metry is considered the gold standard for the evaluation of gastroesophageal reflux disease, new impedance-based parameters have been introduced in recent years with the role of increasing the accuracy of diagnosing gastroesophageal reflux disease and characterizing the type of reflux. The development of multichannel intraluminal pH-impedance has improved the ability to detect and quantify gastroesophageal reflux. New parameters such as post-reflux swallowing peristaltic wave (PSPW) index and the mean nocturnal basal impedance (MNBI) have recently been introduced to assess GERD phenotypes more accurately. This review evaluates current GERD diagnotic tools while also taking a brief look at newer diagnostic parameters like PSPW and MNBI.
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26
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Ustaoglu A, Nguyen A, Spechler S, Sifrim D, Souza R, Woodland P. Mucosal pathogenesis in gastro-esophageal reflux disease. Neurogastroenterol Motil 2020; 32:e14022. [PMID: 33118247 DOI: 10.1111/nmo.14022] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite gastro-esophageal reflux disease affecting up to 20% of Western populations, relatively little is known about the molecular mechanisms underlying its most troublesome symptom: heartburn. Recent findings have unveiled the role of components of the esophageal mucosa in the pathogenesis of GERD including sensory nociceptive nerves and inflammatory mediators. Erosive esophagitis was long believed to develop as a result of acid injury at the esophageal lumen, but novel concepts suggest the generation of reflux-induced esophageal injury as a result of cytokine-mediated inflammation. Moreover, the localization and characterization of mucosal afferent nerves vary between GERD phenotypes and could explain the heterogeneity of symptom perception between patients who experience similar levels of acid reflux. PURPOSE The purpose of this review is to consider the crosstalk of different factors of the esophageal mucosa in the pathogenesis of GERD, with a particular focus on mucosal innervation and molecular basis of acid-induced cytokine response. We discuss the current understanding of the mucosal response to acid injury, the nociceptive role of acid-sensitive receptors expressed in the esophageal mucosa, and the role of esophageal epithelial cells in initiating the onset of erosive esophagitis.
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Affiliation(s)
- Ahsen Ustaoglu
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anh Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Stuart Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rhonda Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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27
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Gyawali CP, Sonu I, Becker L, Sarosiek J. The esophageal mucosal barrier in health and disease: mucosal pathophysiology and protective mechanisms. Ann N Y Acad Sci 2020; 1482:49-60. [PMID: 33128243 DOI: 10.1111/nyas.14521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 12/13/2022]
Abstract
Diseases of the esophagus, such as gastroesophageal reflux (GER), can result in changes to mucosal integrity, neurological function, and the microbiome. Although poorly understood, both age and GER can lead to changes to the enteric nervous system. In addition, the esophagus has a distinct microbiome that can be altered in GER. Mucosal integrity is also at risk due to persistent damage from acid. Diagnostic tools, such as ambulatory pH/impedance testing and esophageal mucosal impedance, can assess short-term and longitudinal GER burden, which can also assess the risk for mucosal compromise. The quality of the mucosal barrier is determined by its intercellular spaces, tight junctions, and tight junction proteins, which are represented by claudins, occludins, and adhesion molecules. Fortunately, there are protective factors for mucosal integrity that are secreted by the esophageal submucosal mucous glands and within saliva that are augmented by mastication. These protective factors have potential as therapeutic targets for GER. In this article, we aim to review diagnostic tools used to predict mucosal integrity, aging, and microbiome changes to the esophagus and esophageal mucosal defense mechanisms.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri
| | - Irene Sonu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Laren Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Jerzy Sarosiek
- Division of Gastroenterology and Hepatology, Molecular Medicine Research Laboratory, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas
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28
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Sifrim D, Roman S, Savarino E, Bor S, Bredenoord AJ, Castell D, Cicala M, de Bortoli N, Frazzoni M, Gonlachanvit S, Iwakiri K, Kawamura O, Krarup A, Lee YY, Soon Ngiu C, Ndebia E, Patcharatraku T, Pauwels A, Pérez de la Serna J, Ramos R, Remes-Troche JM, Ribolsi M, Sammon A, Simren M, Tack J, Tutuian R, Valdovinos M, Xiao Y, Zerbib F, Gyawali CP. Normal values and regional differences in oesophageal impedance-pH metrics: a consensus analysis of impedance-pH studies from around the world. Gut 2020; 70:gutjnl-2020-322627. [PMID: 33037054 DOI: 10.1136/gutjnl-2020-322627] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Limitations of existing impedance-pH thresholds include small sample size of normative studies, inclusion of artefactual pH drops and incorrect identification of impedance reflux events. We aimed to obtain new impedance-pH thresholds from expert consensus analysis of tracings from a large number of healthy subjects. DESIGN Of 541 studies performed worldwide using two different systems (Diversatek, USA, and Laborie, Netherlands), 150 tracings with oesophageal diagnoses, behavioural disorders and study-related artefacts were excluded. The remainder studies were subject to two reviewer consensus analysis, in-person or through video conference, consisting of editing meals and pH drops, identification of impedance reflux and postreflux swallow-induced peristaltic wave (PSPW) using strict pre-established criteria and measurement of distal mean nocturnal baseline impedance (MNBI). RESULTS Consensus analysis was performed in 391 tracings (age 32.7 years, range 18-71, 54.2% female). Normative thresholds were significantly different between Diversatek and Laborie (total acid exposure time: 2.8% and 5%; reflux episodes: 55 and 78; MNBI at 3 cm: 1400 and 1500 ohms, at 5 cm: 1400 and 1800 ohms). Males had higher acid exposure, more reflux episodes and lower MNBI. Significant regional differences were identified, including higher PSPW scores in Western countries, and higher MNBI in Asia using Diversatek, and higher acid exposure in the Netherlands, higher MNBI in Asia and South Africa, and lower MNBI in Turkey using Laborie. CONCLUSION Normal impedance-pH monitoring thresholds have regional and system-related differences. Clinical interpretation needs to use normal thresholds valid for the system used and world region, following careful editing of the tracings.
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Affiliation(s)
- Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Serhat Bor
- Ege University School of Medicine, Izmir, Turkey
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Donald Castell
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michele Cicala
- Digestive Disease, Universita Campus Bio Medico, Roma, Italy
| | | | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Sutep Gonlachanvit
- Department of Medicine, Chlalongkorn University, Bangkok, Thailand
- King Chulalongkorn Memorial Hospital, Thai Red Cross, Bangkok, Thailand
| | - Katsuhiko Iwakiri
- Department of Gaastroenterology, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | | | - Anne Krarup
- Section of Gastroenterology and Hepatology, Department of Medicine and Department of Neurogastroenterology Research, The North Danish Regional Hospital, Hjørring, Denmark
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Chai Soon Ngiu
- Cardiac Vascular Sentral Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Eugene Ndebia
- Division of Medical Physiology, Walter Sisulu University, Mthatha, South Africa
| | - Tanisa Patcharatraku
- Gastropenterology, Center of Excellence in Neurogastroenterology and Motility, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ans Pauwels
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Julio Pérez de la Serna
- Immunology and Gastroenterology Departments, Instituto de Investigacion Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Rosa Ramos
- Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | | | - Mentore Ribolsi
- Digestive Disease, Universita Campus Bio Medico, Roma, Italy
| | - Alastair Sammon
- Division of Medical Physiology, Walter Sisulu University, Mthatha, South Africa
| | - Magnus Simren
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Tack
- Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
| | - Radu Tutuian
- University Clinics for Visceral Surgery and Medcine, Bern University Hospital, Bern, Switzerland
| | - Miguel Valdovinos
- Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Bordeaux, France
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
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Wu PI, Sloan JA, Kuribayashi S, Gregersen H. Impedance in the evaluation of the esophagus. Ann N Y Acad Sci 2020; 1481:139-153. [PMID: 32557676 DOI: 10.1111/nyas.14408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/09/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022]
Abstract
The aim of this paper is to review esophageal electrical impedance technologies and to discuss the use of these technologies for physiological measurements, diagnostics, and therapy of esophageal disease. In order to develop a better understanding of the pathophysiology of and improve the diagnosis of esophageal disorders, such as gastroesophageal reflux disease (GERD) and achalasia, several new diagnostic tests, including intraluminal impedance, esophageal mucosal impedance, and the functional luminal imaging probe, have been developed. These technologies have proven valuable for assessment of the esophagus in recent years. They provide information on esophageal flow properties, mucosal integrity, lumen shape, and distensibility in esophageal disorders, in particular for GERD and achalasia. Despite their promise and novel clinical studies, the potential of these technologies has been far from realized. New multidisciplinary approaches will contribute to our understanding and interpretation of esophageal impedance data and disease mechanisms.
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Affiliation(s)
- Peter I Wu
- Department of Gastroenterology and Hepatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Joshua A Sloan
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Hospital, Maebashi, Japan
| | - Hans Gregersen
- GIOME, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
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Hoshikawa Y, Sawada A, Sonmez S, Nikaki K, Woodland P, Yazaki E, Sifrim D. Measurement of Esophageal Nocturnal Baseline Impedance: A Simplified Method. J Neurogastroenterol Motil 2020; 26:241-247. [PMID: 32235031 PMCID: PMC7176501 DOI: 10.5056/jnm19183] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Mean nocturnal baseline impedance (MNBI) during multichannel intraluminal impedance pH-monitoring (MII-pH) reflects the status of esophageal mucosal integrity. MNBI is suggested as an adjunctive method to distinguish patients with true gastroesophageal reflux disease (GERD) from functional heartburn (FH) and might predict outcomes for anti-reflux treatment. However, current methodology for calculation of MNBI is time-consuming and subject to operator-dependent selection bias. We aim to simplify and provide a more objective method to calculate MNBI. Methods We retrospectively analyzed 100 MII-pH tracings from 20 patients with erosive reflux disease, 20 with non-erosive reflux disease (NERD), 20 with reflux hypersensitivity, 20 with functional heartburn (FH), and 20 healthy asymptomatic volunteers. We compared the current “conventional” MNBI analysis with our “simple” MNBI analysis measured by selecting the whole supine period using the impedance average calculation function in the MII-pH software. Results Absolute values were very similar and there was a strong correlation between conventional and simple MNBI values in the most distal channel in all groups (r ≥ 0.8, P < 0.001) including patients with increased supine acid reflux. Distal esophageal simple MNBI negatively correlated with acid exposure time (r = –0.695, P < 0.001). Patients with erosive reflux disease and NERD had lower simple MNBI values in the most distal channel compared to other groups (P < 0.001). With a cutoff value of 1785 ohms, simple MNBI can discriminate patients with GERD from those with reflux hypersensitivity and FH (sensitivity 80.0% and specificity 89.7%). Conclusion Simple MNBI analysis provides very similar values and has an excellent correlation with conventional MNBI analysis.
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Affiliation(s)
- Yoshimasa Hoshikawa
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - Akinari Sawada
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - Shirley Sonmez
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - Kornilia Nikaki
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - Philip Woodland
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - Etsuro Yazaki
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
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31
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Yin XL, Zhong L, Lin CY, Shi XS, Zhang J, Chen ZY, Che H, Ma XX, Tian YX, Duan YZ, Lu L, Ji HJ, Zhao YP, Tang XD, Wang FY. Tojapride Reverses Esophageal Epithelial Inflammatory Responses on Reflux Esophagitis Model Rats. Chin J Integr Med 2020; 27:604-612. [PMID: 32248515 DOI: 10.1007/s11655-019-3027-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the mechanism of Tojapride, a Chinese herbal formula extract, on strengthening the barrier function of esophageal epithelium in rats with reflux esophagitis (RE). METHODS Ten out of 85 SD rats were randomly selected as the sham group (n10), and 75 rats were developed a reflux esophagitis model (RE) by the esophageal and duodenal side-to-side anastomosis. Fifty successful modeling rats were divided into different medicated groups through a random number table including the model, low-, medium-, and high-dose of Tojapride as well as omeprazole groups (n10). Three doses of Tojapride [5.73, 11.46, 22.92 g/(kg•d)] and omeprazole [4.17 mg/(kg•d)] were administrated intragastrically twice daily for 3 weeks. And the rats in the sham and model groups were administered 10 mL/kg distilled water. Gastric fluid was collected and the supernatant was kept to measure for volume, pH value and acidity. Esophageal tissues were isolated to monitor the morphological changes through hematoxylin-eosin (HE) staining, and esophageal epithelial ultrastructure was observed by transmission electron microscopy. The expressions of nuclear factor kappa-light-chain-enhancer of activated B cells p65 (NF-KBp65), κB kinase beta (IKKß), occludin, and zonula occludens-1 (ZO-1) in the esophageal tissues were measured by immunohistochemistry and Western blot, respectively. RESULTS The gastric pH value in the model group was significantly lower than the sham group (P<0.05). Compared with the model group, gastric pH value in the omeprazole and medium-dose of Tojapride groups were significantly higher (P<0.05). A large area of ulceration was found on the esophageal mucosa from the model rats, while varying degrees of congestion and partially visible erosion was observed in the remaining groups. Remarkable increase in cell gap width and decrease in desmosome count was seen in RE rats and the effect was reversed by Tojapride treatment. Compared with the sham group, the IKKß levels were significantly higher in the model group (P<0.05). However, the IKKß levels were down-regulated after treatment by all doses of Tojapride (P<0.01 or P<0.05). The occluding and ZO-1 levels decreased in the model group compared with the sham group (Ps0.01 or Ps0.05), while both indices were significantly up-regulated in the Tojapride-treated groups (P<0.01 or P<0.05). CONCLUSIONS Tojapride could improve the pathological conditions of esophageal epithelium in RE rats. The underlying mechanisms may involve in down-regulating the IKKß expression and elevating ZO-1 and occludin expression, thereby alleviating the inflammation of the esophagus and strengthening the barrier function of the esophageal epithelium.
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Affiliation(s)
- Xiao-Lan Yin
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Linda Zhong
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong Special Administrative Region, Kowloon, China
| | - Cheng-Yuan Lin
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong Special Administrative Region, Kowloon, China
| | - Xiao-Shuang Shi
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Jiao Zhang
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
- Department of Gastroenterology, Changping Hospital of Traditional Chinese Medicine, Beijing, 102200, China
| | - Zheng-Yi Chen
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
- Department of Traditional Chinese Medicine, Dongfeng General Hospital, Shiyan, Hubei Province, 442000, China
| | - Hui Che
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Xiang-Xue Ma
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Ya-Xin Tian
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Yuan-Zhi Duan
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Lin Lu
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Hai-Jie Ji
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Ying-Pan Zhao
- Center of Clinical Pharmacology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Xu-Dong Tang
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Feng-Yun Wang
- Department of Gastroenterology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
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Nakagawa K, Hara K, Fikree A, Siddiqi S, Woodland P, Masamune A, Aziz Q, Sifrim D, Yazaki E. Patients with dyspepsia have impaired mucosal integrity both in the duodenum and jejunum: in vivo assessment of small bowel mucosal integrity using baseline impedance. J Gastroenterol 2020; 55:273-280. [PMID: 31468184 PMCID: PMC7026227 DOI: 10.1007/s00535-019-01614-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent studies reported that impaired proximal duodenal mucosa, assessed by duodenal biopsy, could play an important role in the development of dyspeptic symptoms. The aims of this study were (a) to develop a method to measure "in vivo" duodenal and jejunal baseline impedance (BI) and (b) to assess small bowel mucosal integrity in patients with functional dyspepsia (FD) and healthy controls (HC). METHODS We recruited 16 patients with FD and 15 HC. All subjects underwent ambulatory duodeno-jejunal manometry combined with impedance (HRM/Z), BI were determined by measuring impedance immediately after the passage of nocturnal migrating motor complex (MMC) phase IIIs. RESULTS The number of MMC phase IIIs in FD was significantly lower than that in HC (2.6 ± 1.4 vs 4.8 ± 1.7, p < 0.001). The BI in patients was significantly lower than that in HC in D1(164.2 ± 59.8 Ω in FD and 243.1 ± 40.5 Ω in HC, p = 0.0061), D2 (191.2 ± 34.1 and 256.5 ± 91.4 Ω, p = 0.01), D3 (214.0 ± 76.9 and 278.1 ± 45.3 Ω, p = 0.009), D4 (270.8 ± 54.2 and 351.8 ± 50.2 Ω, p < 0.001), and J1 (312.2 ± 55.4 and 379.3 ± 38.3 Ω, p = 0.001). CONCLUSIONS This is the first study reporting the duodenal and jejunal BI in vivo. The results have shown significantly lowered BI in the proximal small intestine in patients with FD compared to HC. Furthermore it suggests that measurements of small bowel BI could be used as a biomarker for diagnosis and follow up of patients with FD.
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Affiliation(s)
- Kenichiro Nakagawa
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, 980-8574 Japan
| | - Ken Hara
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
- Division of Gastroenterology, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, 663-8501 Hyogo Japan
| | - Asma Fikree
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
| | - Shahab Siddiqi
- Division of General Surgery, Broomfield Hospital, Court Rd, Broomfield, Chelmsford, CM1 7ET UK
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, 980-8574 Japan
| | - Qasim Aziz
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
| | - Etsuro Yazaki
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
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Rumination Syndrome in Children Presenting With Refractory Gastroesophageal Reflux Symptoms. J Pediatr Gastroenterol Nutr 2020; 70:330-335. [PMID: 32079888 DOI: 10.1097/mpg.0000000000002569] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Up to 40% of children presenting with reflux symptoms do not respond to standard medical interventions. In adults, 20% of patients presenting with Proton Pump Inhibitors refractory Gastro-Esophageal Reflux Disease (GERD) have rumination syndrome. The management of GERD and rumination differ significantly. Our study aimed to identify rumination syndrome amongst children presenting with persistent GERD symptoms based on a distinct pattern on impedance-pH monitoring. METHODS The parameters of impedance-pH monitoring were compared between children with rumination syndrome (n = 12), diagnosed on high-resolution manometry impedance (HRM/Z), children with GERD (n = 18), children with an alternative diagnosis (non-GERD, n = 12) and children negative for rumination based on HRM/Z (n = 14). The parameters that distinguish the rumination group were identified and incorporated into a scoring system, which was blindly applied on a separate group of children with refractory GERD (n = 18) to define its sensitivity and specificity. RESULTS Rumination syndrome presents in 44% of children with refractory GERD. Children with rumination syndrome present with a large number of proximal reflux episodes (>57.5 episodes/24 hours); a high frequency of nonacid reflux events in the postprandial period (>2/hour); and a highly positive symptom-reflux association analysis (SAP ≥ 95%). A score of ≥2 out of the 3 points distinguishes children with rumination syndrome with 75% sensitivity and 80% specificity. CONCLUSIONS Children with rumination syndrome have a distinct pattern of impedance-pH monitoring and can be distinguished amongst children presenting with refractory GERD. Applying a simple scoring system during impedance-pH analysis could lead to early diagnosis of children with rumination syndrome.
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Moonen A, Aguilera-Lizarraga J, Bisschops R, Moonen P, Tack J, Boeckxstaens GE. 24-hour multi-pH recording of the postprandial acid pocket and the nocturnal acid distribution at the esophagogastric junction in healthy volunteers. Neurogastroenterol Motil 2019; 31:e13694. [PMID: 31449342 DOI: 10.1111/nmo.13694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postprandial stationary pH monitoring studies have identified the acid pocket. To what extent a similar pool of acid is present in the fasting state or at night remains however unclear. METHODS The study was performed in 9 HV without a hiatal hernia. A pH-impedance-pressure catheter was positioned at the Z-line. First, the presence of the acid pocket was monitored under stationary conditions during 2 hours after ingestion of a standardized meal. Thereafter, the equipment was connected to an ambulatory monitoring device for 24-hour recording. RESULTS Under stationary conditions, a postprandial acid pocket was present in 7 of the 9 HV, from 9 ± 7 minutes after meal onwards during 47 ± 8 minutes. During ambulatory 24-hour monitoring, postprandial acid pockets emerged significantly later, but no differences in duration or position were detected. During nighttime, an acid pool was detected with its proximal border at the level of the cardia, which at later, time points gradually moved to a more distal position. This led to a gradual decrease in nocturnal acid exposure from proximal to distal, a phenomenon that was preceded by a bust of gastric contractions. Nocturnal reflux originated from the cardiac region, and was more acidic in the early compared with late nocturnal period. CONCLUSION The acid pocket is present in the postprandial period under both stationary and ambulatory conditions. Of interest, at night, a pool of acid can be demonstrated which is periodically shifted more distally. This pool of acid represents the reservoir from which nocturnal reflux originates.
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Affiliation(s)
- An Moonen
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Javier Aguilera-Lizarraga
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Raf Bisschops
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Peter Moonen
- Chaire Imagerie RX, Université de Pau et des Pays de L'Adour, Pau, France
| | - Jan Tack
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
| | - Guy E Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium
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35
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Wong MW, Hung JS, Lei WY, Liu TT, Yi CH, Chen CL. Esophageal acid sensitivity in patients with gastroesophageal reflux disease: Does esophageal hypomotility matter? Neurogastroenterol Motil 2019; 31:e13700. [PMID: 31414561 DOI: 10.1111/nmo.13700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/26/2019] [Accepted: 07/30/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIM Esophageal acid sensitivity plays a role in symptomatic manifestation of gastroesophageal reflux disease (GERD). Esophageal hypomotility is common in patients with GERD. We aimed to determine whether esophageal acid sensitivity may differ between patients with and without esophageal hypomotility. METHODS We prospectively enrolled 41 consecutive patients (10 females, mean age 53 years, range 32-79) with typical reflux symptoms and 10 healthy subjects (5 females, mean age 45 years, range 28-56) for esophageal acid sensitivity and motility tests. Demographics, body mass index (BMI), and reflux symptoms using a validated questionnaire (GERDQ) were recorded. All subjects underwent infusion of 0.1 N hydrochloric acid in the esophagus at a rate of 10 mL/min for 10 minutes. The parameters for esophageal acid infusion included lag time, intensity rating, and acid sensitivity score. RESULTS Esophageal motility diagnosis included 24 patients with normal motility and 17 patients with ineffective esophageal motility (IEM). Lag time was similar between the patient groups. No differences between patients with normal motility and IEM were found for any of other acid infusion parameters. There was a positive correlation between lag time and BMI (r = .33, P = .04). GERDQ was negatively correlated to lag time (r = -.73, P < .001). CONCLUSIONS Esophageal acid sensitivity was similar in GERD patients with and without hypomotility. Decreased acid sensitivity in individuals with increasing body mass index may play a pathological role in symptomatic modulation of patients with GERD.
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Affiliation(s)
- Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,PhD program in Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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Nikaki K, Woodland P, Lee C, Ghisa M, Marinelli C, Savarino E, Sifrim D. Esophageal mucosal innervation in functional heartburn: Closer to healthy asymptomatic subjects than to non-erosive reflux disease patients. Neurogastroenterol Motil 2019; 31:e13667. [PMID: 31225933 DOI: 10.1111/nmo.13667] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/29/2019] [Accepted: 06/12/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mucosal innervation in non-erosive reflux disease (NERD; pathological esophageal acid exposure, normal macroscopic mucosa) is clearly distinct from that of healthy volunteers (HV) and from patients with esophagitis or Barrett's esophagus: The nerves in NERD are situated much closer to the luminal surface of the mucosa. Patients with functional heartburn (FH) have a similar symptom profile to patients with NERD and indistinguishable macroscopic appearances. However, they have physiological acid exposure and no reflux-symptom association. The aim of our study was to delineate the position of esophageal mucosal nerve fibers in patients with FH and compare it with that in NERD and HV. METHODS Distal esophageal biopsies from patients with FH were immunohistochemically stained for CGRP. CGRP-positive nerve fibers were identified, and their position relative to the lumen was determined. These results were compared to our previously published cohort of HV and NERD. RESULTS Eleven patients were included in the FH group with a mean age of 46 years (range 33-69); 7F:4M. Nine patients had visible nerve fibers. The location of the afferent nerve fibers in the distal esophageal mucosa (median of 22, range 10.4-28) was similar to the HV group (median 25.5) and significantly deeper than the superficial nerves seen in NERD (median 9.5). CONCLUSIONS The mucosal innervation pattern in FH is more alike that of healthy individuals than that of NERD, with afferent nerves lying deep in the mucosa, away from the luminal surface. This supports the theory that heartburn in FH has a distinct nociceptive pathophysiology.
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Affiliation(s)
- Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK.,Gastroenterology Department, Royal London Hospital, London, UK
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK.,Gastroenterology Department, Royal London Hospital, London, UK
| | - Chung Lee
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Carla Marinelli
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
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Wang YF, Yang CQ, Chen YX, Cao AP, Yu XF, Yu Y, Zhang ZY, Shen XZ, Liu F, Zhong L, Wang YX, Liu ZJ, Shi YH, Zhong J, Li JN, Lan Y, Lenham RK, Woodcock AD, Dettmar PW, Fang J. Validation in China of a non-invasive salivary pepsin biomarker containing two unique human pepsin monoclonal antibodies to diagnose gastroesophageal reflux disease. J Dig Dis 2019; 20:278-287. [PMID: 31090180 PMCID: PMC6851552 DOI: 10.1111/1751-2980.12783] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/11/2019] [Accepted: 05/13/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Peptest is a new non-invasive reflux diagnostic test based on lateral flow technology that containing two highly specific human pepsin monoclonal antibodies for detecting pepsin, a biomarker for reflux disease. The primary aim of this multicenter clinical study was to validate the efficacy of Peptest in patients diagnosed with gastroesophageal reflux and healthy controls in China. METHODS Patients with suspected gastroesophageal reflux underwent an endoscopy and were classified into non-erosive reflux disease and erosive esophagitis subgroups. A healthy control group was also recruited. All participants were given a reflux disease questionnaire-patients scoring greater than 12 and controls scoring zero. All participants provided a postprandial saliva sample and most patients gave an additional post-symptom sample for pepsin analysis. RESULTS Altogether 1032 participants aged between 19 and 78 years were recruited. They consisted of 488 patients with non-erosive reflux disease, 221 with erosive esophagitis and 323 healthy controls. The number of postprandial and post-symptom samples analyzed totaled 1031 and 692, respectively. The results across all centers showed an overall pepsin-positive sensitivity of 85%, a specificity of 60%, a positive predictive value of 82%, a negative predictive value of 65% and a positive likelihood ratio of 2.12. CONCLUSION The sensitivity of Peptest was high, but the specificity achieved in some centers was low, resulting overall in only a moderate specificity. Further diagnostic investigative studies are warranted.
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Affiliation(s)
- Yong Feng Wang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Chang Qing Yang
- Department of Gastroenterology and Hepatology, Tongji HospitalTongji University School of MedicineShanghaiChina
| | - Ying Xuan Chen
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Ai Ping Cao
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Xiao Feng Yu
- Department of GastroenterologyHuadong Hospital Affiliated to Fudan UniversityShanghaiChina
| | - Yang Yu
- Department of GastroenterologyHuadong Hospital Affiliated to Fudan UniversityShanghaiChina
| | - Zi Yan Zhang
- Department of GastroenterologyHuadong Hospital Affiliated to Fudan UniversityShanghaiChina
| | - Xi Zhong Shen
- Department of Gastroenterology, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Fei Liu
- Department of GastroenterologyShanghai East Hospital Affiliated to Tongji UniversityShanghaiChina
| | - Lan Zhong
- Department of GastroenterologyShanghai East Hospital Affiliated to Tongji UniversityShanghaiChina
| | - Ying Xin Wang
- Department of Gastroenterology and Hepatology, Tongji HospitalTongji University School of MedicineShanghaiChina
| | - Zhan Ju Liu
- Department of GastroenterologyShanghai Tenth People's Hospital of Tongji UniversityShanghaiChina
| | - Yan Hong Shi
- Department of GastroenterologyShanghai Tenth People's Hospital of Tongji UniversityShanghaiChina
| | - Jie Zhong
- Department of Gastroenterology, Ruijin Hospital, School of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Jing Nan Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical SciencesPeking Union Medical CollegeBeijingChina
| | - Yu Lan
- Department of GastroenterologyBeijing Jishuitan HospitalBeijingChina
| | | | | | | | - Jing‐Yuan Fang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of MedicineShanghai Jiao Tong UniversityShanghaiChina
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Patel DA, Higginbotham T, Slaughter JC, Aslam M, Yuksel E, Katzka D, Gyawali CP, Mashi M, Pandolfino J, Vaezi MF. Development and Validation of a Mucosal Impedance Contour Analysis System to Distinguish Esophageal Disorders. Gastroenterology 2019; 156:1617-1626.e1. [PMID: 30711626 PMCID: PMC6990978 DOI: 10.1053/j.gastro.2019.01.253] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Diagnostic testing for chronic esophageal disorders relies on histopathology analysis of biopsies or uncomfortable transnasal catheters or wireless pH monitoring, which capture abnormal intraluminal refluxate. We therefore developed a balloon mucosal impedance (MI) catheter system that instantly detects changes in esophageal mucosal integrity during endoscopy over a long segment of the esophagus. We performed a prospective study to evaluate the ability of a balloon-incorporated MI catheter to detect and evaluate esophageal disorders, including gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE). METHODS We performed a prospective study of 69 patients undergoing esophagogastroduodenoscopy with or without wireless pH monitoring. Patients were classified as having GERD (erosive esophagitis or abnormal pH; n = 24), EoE (confirmed with pathology analysis of tissues from both distal and proximal esophagus; n = 21), or non-GERD (normal results from esophagogastroduodenoscopy and pH tests; n = 24). Receiver operating characteristic curves and area under the operating characteristic curve (AUC) were used to compare the accuracy of balloon MI in diagnosis. Probabilities of assignment to each group (GERD, non-GERD, or EoE) were estimated using multinomial logistic regression. Association between MI patterns and diagnoses were validated using data from patients seen at 3 separate institutions. RESULTS MI pattern along the esophageal axis differed significantly (P < .01) among patients with GERD, EoE, and non-GERD. Patients with non-GERD had higher MI values along all measured segments. The MI pattern for GERD was easily distinguished from that of EoE: in patients with GERD, MI values were low in the distal esophagus and normalized along the proximal esophagus, whereas in patients with EoE, measurements were low in all segments of the esophagus. Intercept and rate of rise of MI value (slope) as distance increased from the squamocolumnar junction identified patients with GERD with an AUC = 0.67, patients with EoE with an AUC = 0.84, and patients with non-GERD with an AUC = 0.83 in the development cohort. One patient had an adverse event (reported mild chest pain after the procedure) and was discharged from the hospital without further events. CONCLUSIONS We developed a balloon MI catheter system that instantly detects changes in esophageal mucosal integrity during endoscopy and found it to be safe and able to identify patients with GERD, EoE, or non-GERD. We validated our findings in a separate cohort for patients. ClinicalTrials.gov ID NCT03103789.
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Affiliation(s)
- Dhyanesh A. Patel
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center
| | - Tina Higginbotham
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center
| | | | - Muhammad Aslam
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center
| | - Elif Yuksel
- Department of Gastroenterology, Izmir Ataturk Teaching and Research Hospital, Katip Celebi University, Izmir, Turkey
| | - David Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University Medical Center, St. Louis, MO
| | - Melina Mashi
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center
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Evaluation of Baseline Impedance During Water-perfused High Resolution Impedance Manometry in Patients With Symptomatic GERD. J Clin Gastroenterol 2019; 53:350-354. [PMID: 30439758 DOI: 10.1097/mcg.0000000000001147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
GOALS We aimed to investigate the hypothesis whether baseline impedance measured during water-perfused high resolution impedance manometry (HRIM) can help discriminate patients with reflux symptoms from the controls and predict the response to the proton pump inhibitors (PPIs). BACKGROUND/AIM Baseline impedance measured during solid-state HRIM can reliably discriminate patients with gastroesophageal reflux disease (GERD) from controls. STUDY We enrolled consecutive patients with typical reflux symptoms and healthy controls for the measurement of baseline impedance during the landmark period of HRIM. All patients were given PPIs and PPI response was assessed after 8 weeks of the treatment. RESULTS Baseline mucosa impedance measured during HRIM was lower in GERD patients than the controls (1861±183 vs. 3371±250 Ω; P<0.001). Baseline impedance during water-perfused HRIM had moderate diagnostic accuracy for differentiating symptomatic GERD with an area under the curve of 0.853 on receiver operating characteristics analysis. A threshold of 2530 Ω for baseline impedance had a sensitivity of 88.3% and specificity of 82.4% for GERD with a positive predictive value of 83.4% and negative predictive value of 87.6%. Among symptomatic GERD patients, poor PPI responders had higher baseline impedance than those without it (2340±260 vs. 1479±189 Ω; P=0.02). BMI negatively correlated to base impedance in either controls (r=-0.59; P=0.012) or GERD patients (r=-0.47; P=0.047). CONCLUSIONS Baseline impedance measurement during water-perfused HRIM helps differentiate patients with typical reflux symptoms from controls and also serves as a potential utility in predicting PPI response.
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40
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Park CH, Lee SK. [Gastroesophageal Reflux Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 73:70-76. [PMID: 30845382 DOI: 10.4166/kjg.2019.73.2.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/24/2019] [Accepted: 02/07/2019] [Indexed: 12/13/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a condition that develops when reflux of stomach contents causes troublesome symptoms and/or complications. The prevalence of GERD is increasing worldwide and in Asia-Pacific. The latest Korean guidelines for GERD were published in 2012, and several international guidelines and consensus statements for the management of GERD have also been recently published. Here, we review these guidelines and consensus statements in order to provide a better understanding of the diagnosis and treatment of GERD.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Naik RD, Evers L, Vaezi MF. Advances in the Diagnosis and Treatment of GERD: New Tricks for an Old Disease. ACTA ACUST UNITED AC 2019; 17:1-17. [DOI: 10.1007/s11938-019-00213-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Niu CY, Zhou YS, Wu FX. Individualized medicine of gastroesophageal reflux disease. Shijie Huaren Xiaohua Zazhi 2018; 26:2046-2056. [DOI: 10.11569/wcjd.v26.i35.2046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common disease worldwide, and its prevalence is increasing in both developed and developing countries. GERD is divided into three subtypes, namely, erosive esophagitis, nonerosive reflux disease (NERD), and Barrett's esophagus. The etiology, pathogenesis, clinical manifestations, and response to treatment of GERD invariably show high heterogeneity or significant individual difference, especially NERD and refractory GERD. On the other hand, advanced technology has currently provided a wide range of methods for the diagnosis and treatment of GERD patients; however, the long-term efficacy and quality of life of some patients are unsatisfactory. Therefore, each GERD patient needs a specialized management strategy aiming at his/her own condition, which is known as individualized medicine or personalized medicine. The goal of GERD treatment is to relieve the symptoms, while symptomatic remission is directly related to the quality of life. In other words, health-related quality of life and patient satisfaction may be reasonable criteria for GERD. In this paper, we will discuss the individualized medicine of GERD.
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Affiliation(s)
- Chun-Yan Niu
- Department of Gastroenterology, Xiang'an Hospital, Xiamen University, Xiamen 361101, Fujian Province, China
| | - Yong-Shun Zhou
- Department of Gastroenterology, Xiamen University Hospital, Xiamen 361005, Fujian Province, China
| | - Fang-Xiong Wu
- Department of Gastroenterology, the First Affiliated Hospital of Xi'an Medical College, Xi'an 710077, Shaanxi Province, China
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Matsumura T, Arai M, Ishigami H, Fujie M, Ishikawa K, Akizue N, Taida T, Ohta Y, Hamanaka S, Okimoto K, Saito K, Maruoka D, Nakagawa T, Kato N. Evaluation of Esophageal Mucosal Integrity in Patients with Gastroesophageal Reflux Disease. Digestion 2018; 97:31-37. [PMID: 29393167 DOI: 10.1159/000484106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Impaired esophageal mucosal integrity plays a role in causing symptoms of gastroesophageal reflux disease (GERD). Recently, the assessment of esophageal baseline impedance (BI) using the multichannel intraluminal impedance-pH (MII-pH) test was suggested as a surrogate technique for the study of esophageal mucosal integrity and was reported to be useful in distinguishing GERD from non-GERD. However, measuring BI requires a 24-h testing period, is complicated, and causes considerable patient discomfort. SUMMARY Recently, endoscopy-guided catheters that can measure mucosal impedance (MI) and mucosal admittance (MA), which is the inverse of impedance, were developed, and their usefulness in measuring MI and MA for the diagnosis of GERD has been reported. In these studies, esophageal MI values were significantly lower in patients with GERD than in those without GERD. In contrast, esophageal MA was significantly higher in patients with GERD than in those without. Furthermore, we reported that MA is inversely correlated with BI and correlated with acid exposure time. Key Messages: Endoscopy-guided real-time measurement of MI and MA may allow the estimation of mucosal integrity and may be a useful diagnostic tool for patients with GERD in a manner similar to 24-h MII-pH monitoring.
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Affiliation(s)
- Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Arai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideaki Ishigami
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mai Fujie
- Department of Clinical Engineering Center, Chiba University Hospital, Chiba, Japan
| | - Kentaro Ishikawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shinsaku Hamanaka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keiko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoo Nakagawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Abstract
PURPOSE OF REVIEW Ambulatory reflux monitoring is typically performed when esophageal symptoms do not respond to usual antireflux medications, or prior to invasive antireflux therapy. Although pH-based metrics have been the standard in defining esophageal reflux burden, novel impedance parameters have been introduced in recent years that can either be extracted from pH-impedance monitoring or obtained directly from esophageal mucosa. This review evaluates the clinical role of esophageal pH-impedance monitoring in clinical practice in the present day. RECENT FINDINGS Elevated acid exposure time in the distal esophagus remains the primary metric that predicts symptom improvement from antireflux therapy. Although conventional impedance-based metrics (numbers of reflux episodes, reflux-symptom association) provide complementary evidence, novel impedance-based metrics show promise in documenting reflux-induced damage to esophageal mucosal integrity, and in potentially predicting treatment outcome. The postreflux swallow-induced peristaltic wave measures integrity of primary peristalsis triggered by a reflux episode. Baseline impedance values reflect histopathological damage to mucosal integrity, and improve following successful antireflux therapy. Mucosal impedance assessed at endoscopy is a new diagnostic tool that is currently being evaluated in multinational research studies. SUMMARY Esophageal pH-impedance monitoring has potential to augment confidence in a reflux diagnosis beyond that provided by pH-monitoring alone.
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45
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Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout AJPM, Vaezi M, Sifrim D, Fox MR, Vela MF, Tutuian R, Tack J, Bredenoord AJ, Pandolfino J, Roman S. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018; 67:1351-1362. [PMID: 29437910 PMCID: PMC6031267 DOI: 10.1136/gutjnl-2017-314722] [Citation(s) in RCA: 801] [Impact Index Per Article: 133.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/11/2018] [Accepted: 01/14/2018] [Indexed: 12/12/2022]
Abstract
Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Peter J Kahrilas
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Francois Mion
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark R Fox
- Gastroenterology, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland,Zürich Neurogastroenterology and Motility Research Group, Clinic for Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Radu Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Jan Tack
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - John Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
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Silva RO, Bingana RD, Sales TMAL, Moreira RLR, Costa DVS, Sales KMO, Brito GAC, Santos AA, Souza MÂN, Soares PMG, Sifrim D, Souza MHLP. Role of TRPV1 receptor in inflammation and impairment of esophageal mucosal integrity in a murine model of nonerosive reflux disease. Neurogastroenterol Motil 2018; 30:e13340. [PMID: 29573069 DOI: 10.1111/nmo.13340] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 02/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Microscopic inflammation and impairment of the esophageal epithelial barrier are considered relevant for perception of symptoms in patients with nonerosive reflux disease (NERD). In these patients, the receptor transient receptor potential vanilloid 1 (TRPV1) is overexpressed in the esophageal mucosa, but its role is not yet fully understood. We evaluated the role of TRPV1 in esophageal inflammation and mucosal barrier impairment in a murine model of NERD. METHODS Nonerosive reflux disease was surgically induced in Swiss mice by pyloric substenosis and ligature of the gastric fundus, and the mice were killed 7 days post surgery. The experimental groups were: I, sham surgery (negative control); II, NERD untreated; III and IV, NERD + SB366791 or capsazepine (TRPV1 antagonists); and V, NERD + resiniferatoxin (for long-term desensitization of TRPV1). The esophagus was collected for western blotting and histopathology and for evaluation of wet weight, myeloperoxidase (MPO), keratinocyte-derived chemokine (KC), transepithelial electrical resistance (TEER), and basal permeability to fluorescein. KEY RESULTS Compared to sham, NERD mice had increased esophageal wet weight and MPO and KC levels. The mucosa had no ulcers but exhibited inflammation. NERD mice showed mucosal TRPV1 overexpression, a more pronounced decrease in TEER at pH 0.5 (containing pepsin and taurodeoxycholic acid), and increased basal permeability. Pharmacological modulation of TRPV1 prevented esophageal inflammation development, TEER changes by acidic exposure, and increase in esophageal permeability. CONCLUSIONS & INFERENCES The TRPV1 receptor has a critical role in esophageal inflammation and mucosal barrier impairment in NERD mice, suggesting that TRPV1 might be a pharmacological target in patients with NERD.
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Affiliation(s)
- R O Silva
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - R D Bingana
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - T M A L Sales
- Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - R L R Moreira
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - D V S Costa
- Department of Morphology, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - K M O Sales
- Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - G A C Brito
- Department of Morphology, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - A A Santos
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Ceará, Brazil
- Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - M Â N Souza
- Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - P M G Soares
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Ceará, Brazil
- Department of Morphology, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - D Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - M H L P Souza
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Ceará, Brazil
- Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
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Zentilin P, Savarino V, Marabotto E, Murdaca G, Sulli A, Pizzorni C, Puppo F, Savarino E. Esophageal baseline impedance levels allow the identification of esophageal involvement in patients with systemic sclerosis. Semin Arthritis Rheum 2018; 47:569-574. [DOI: 10.1016/j.semarthrit.2017.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 07/30/2017] [Accepted: 08/04/2017] [Indexed: 02/07/2023]
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Vaezi MF, Sifrim D. Assessing Old and New Diagnostic Tests for Gastroesophageal Reflux Disease. Gastroenterology 2018; 154:289-301. [PMID: 28774844 DOI: 10.1053/j.gastro.2017.07.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 12/13/2022]
Abstract
A detailed critique of objective measurements of gastroesophageal reflux disease (GERD) would improve management of patients suspecting of having reflux, leading to rational selection of treatment and better outcomes. Many diagnostic tests for GERD have been developed over the past decades. We analyze their development, positive- and negative-predictive values, and ability to predict response to treatment. These features are important for development of medical, surgical, and endoscopic therapies for GERD. We discuss the value of available diagnostic tests and review their role in management of patients with persistent reflux symptoms despite adequate medical or surgical treatment. This is becoming a significant health economic problem, due to the widespread use of proton pump inhibitors. GERD is believed to cause nonesophageal symptoms, such as those provoked by ear, nose, throat, or respiratory disorders. We analyze the value of GERD diagnostic tests in evaluation of these troublesome, nonesophageal symptoms.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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49
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ASAP3 regulates microvilli structure in parietal cells and presents intervention target for gastric acidity. Signal Transduct Target Ther 2017; 2:17003. [PMID: 29263912 PMCID: PMC5661632 DOI: 10.1038/sigtrans.2017.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 01/20/2017] [Accepted: 01/22/2017] [Indexed: 01/28/2023] Open
Abstract
Gastric acidity-associated disorders such as peptic ulcer and reflux diseases are widespread, and the reported resistance and side effects of currently used medicines suggest an urgent requirement for alternative therapeutic approaches. Here we demonstrate a critical role of ASAP3 in regulating the microvilli structure of parietal cells in vivo, and reveal the feasibility of controlling gastric acidity by targeting ASAP3. Conditional knockout of ASAP3 in mice caused elongation and stacking of microvilli in parietal cells, and substantially decreased gastric acid secretion. These were associated with active assembly of F-actin caused by a higher level of GTP-bound Arf6 GTPase. Consistently, a small molecular compound QS11 inhibited ASAP3 function and significantly reduced gastric acidity in vivo. Of note, the expression of ASAP3 was positively correlated with gastric acid secretion in 90 human cases, and high expression of ASAP3 was associated with reflux disease and peptic ulcer. These results reveal for the first time that ASAP3 regulates the microvilli structures in parietal cells. Our data also suggest ASAP3 as a feasible and drugable therapeutic target for gastric acidity-associated diseases.
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50
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Frazzoni L, Frazzoni M, de Bortoli N, Tolone S, Furnari M, Martinucci I, Bertani H, Marchi S, Conigliaro R, Fuccio L, Savarino V, Savarino E. Postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance can link PPI-responsive heartburn to reflux better than acid exposure time. Neurogastroenterol Motil 2017; 29. [PMID: 28543861 DOI: 10.1111/nmo.13116] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acid exposure time (AET) is considered the most useful parameter to predict response of reflux-related heartburn to medical or surgical treatment. However, recent studies showed high rates of heartburn response to proton pump inhibitor (PPI) therapy in patients with normal AET. We aimed to compare the efficacy of postreflux swallow-induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) with AET in linking PPI-responsive heartburn to reflux. METHODS Off-therapy impedance-pH tracings from 425 patients, 317 with PPI-responsive and 108 with PPI-refractory heartburn were blindly re-analyzed. Demographic and endoscopic characteristics, conventional impedance-pH variables, PSPW index, and MNBI were assessed with multivariate logistic regression to identify factors independently associated with PPI responsiveness. Prediction models were developed to assess the strength of reflux linkage with factors independently associated with PPI responsiveness by calculating the area under the curve (AUC) at receiver-operating-characteristic (ROC) analysis. KEY RESULTS At multivariate logistic regression analysis, AET, MNBI, and PSPW index were the only factors independently associated with PPI responsiveness, abnormal values found in 60%, 76%, and 92% of PPI-responsive cases (P<.017). At ROC analysis, PSPW index (AUC:.794, P=.002) and MNBI (AUC: 0.742, P=.003), both separately and combined (AUC: 0.811, P<.001) linked reflux with PPI-responsiveness better than AET (AUC: 0.687). CONCLUSIONS & INFERENCES AET, PSPW index, and MNBI are independently associated with PPI-responsive heartburn. PSPW index and MNBI can link PPI-responsive heartburn to reflux better than AET and should become part of the standard analysis of impedance-pH tracings.
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Affiliation(s)
- L Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - M Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
| | - N de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - S Tolone
- General and Bariatric Surgery Unit, Department of Surgery, Second University of Napoli, Naples, Italy
| | - M Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, Genova, Italy
| | - I Martinucci
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - H Bertani
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
| | - S Marchi
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - R Conigliaro
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
| | - L Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - V Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, Genova, Italy
| | - E Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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