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Xie C, Peng L, Deng W, Xie X, Xiu Z, Guo L, Liu A. Relationship between endoscopic gastroesophageal valve grading and mean nocturnal baseline impedance and postreflux swallow-induced peristaltic wave index in patients with gastroesophageal reflux disease. Medicine (Baltimore) 2024; 103:e37101. [PMID: 38669387 PMCID: PMC11049794 DOI: 10.1097/md.0000000000037101] [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: 08/09/2023] [Accepted: 01/08/2024] [Indexed: 04/28/2024] Open
Abstract
This study aimed to investigate the relationship between endoscopic gastroesophageal valve grading and mean nocturnal baseline impedance (MNBI) and postreflux swallow-induced peristaltic wave index (PSPWI) in patients with gastroesophageal reflux disease (GERD). A total of 120 patients diagnosed with GERD disease were included in the study. According to the classification of endoscopic gastroesophageal valves, the patients were divided into 5 groups, group 1 as baseline group, and Group 2-4 as Hill grade I-IV. Basic information about the patients was collected, including age and gender. The mean nocturnal baseline impedance and creep wave index induced by swallowing after rumination were measured by high resolution creep measurement technique. Through statistical analysis, the relationship between valve classification and observation index was discussed. In terms of MNBI, impedance values gradually decreased with increasing valve classification. The average impedance of the Grade 1 group was 23.5 mm Hg/cm2, while the average impedance of the Grade 5 group was 15.2 mm Hg/cm2. This reduction showed a significant decreasing trend (P < .001). In addition, in terms of the peristaltic wave index caused by swallowing after regurgitation, the peristaltic wave index gradually increased with the increase of valve classification. The mean index in the Grade 1 group was 1.8 beats/min, while the mean index in the Grade 5 group was 3.6 beats/min. This increase showed a significant positive relationship (P < .001). Endoscopic gastroesophageal valve grading was significantly correlated with MNBI and PSPWI in patients with GERD. These observations can serve as useful tools for assessing the severity of GERD and monitoring disease progression.
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Affiliation(s)
- Chunyan Xie
- Department of Deputy Chief Physician of Gastroenterology, The First People’s Hospital of Longquanyi District, Chengdu, Sichuan, China
| | - Li Peng
- Department of Chief Physician of Ultrasound, The First People’s Hospital of Longquanyi District, Chengdu, Sichuan, China
| | - Wei Deng
- Department of Gastroenterology, The Second Traditional Chinese Medicine Hospital of Sichuan Province, Chengdu, Sichuan, China
| | - Xiaoli Xie
- Department of Deputy Chief Physician of Gastroenterology, The First People’s Hospital of Longquanyi District, Chengdu, Sichuan, China
| | - Zhigang Xiu
- Department of Radiology, The First People’s Hospital of Longquanyi District, Chengdu, Sichuan, China
| | - Li Guo
- Department of Deputy Chief Physician of Gastroenterology, The First People’s Hospital of Longquanyi District, Chengdu, Sichuan, China
| | - Anli Liu
- Department of Respiratory and Critical Care Medicine, The First People’s Hospital of Longquanyi District, Chengdu, Sichuan, China
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Bao Y, Chen X, Xu Y, Wang Y, Lin L, Tang Y. Association Between Gastroesophageal Flap Valve and Endoscopically Diagnosed Gastroesophageal Reflux Disease According to Lyon Consensus: A Meta-analysis of Asian Studies. J Clin Gastroenterol 2022; 56:393-400. [PMID: 33973961 DOI: 10.1097/mcg.0000000000001552] [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] [Received: 12/02/2020] [Accepted: 03/21/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND Lyon Consensus altered the previous understanding of endoscopic gastroesophageal reflux disease (GERD) and pointed out that only high-grade reflux esophagitis (RE) [Los Angeles (LA) grades C or D], Barrett's esophagus or peptic stricturing were considered confirmatory evidence for GERD but low-grade RE (LA grades A or B) was regarded as suspected GERD. We aimed to summarize the possible relationship between gastroesophageal flap valve (GEFV) and endoscopic GERD according to Lyon Consensus using meta-analysis of studies done in Asia. MATERIALS AND METHODS Comprehensive searches of PubMed, WOS, Embase, SinoMed, and CNKI databases were completed to identify eligible studies published before September 22, 2019. A total of 237 articles have been reviewed and 2 reviewers independently evaluated the eligibility for inclusion, extracted, and analyzed the statistical data. The pooled risk ratios (RRs) with 95% confidence intervals (CI) were measured for the association. Random-effects models were used when observing significant heterogeneity. RESULTS A total of 15 studies were included and we found that abnormal GEFV (III and IV) could be associated with RE and the correlation become stronger as the grade increases (RE-A vs. controls-RR: 2.186, 95% CI: 1.560-3.064, P<0.001; RE-B vs. RE-A-RR: 1.268, 95% CI: 1.128-1.425, P<0.001; RE-C vs. RE-B-RR: 1.181, 95% CI: 1.000-1.395, P=0.049; RE-D vs. RE-C-RR: 1.471, 95% CI: 1.151-1.879, P=0.002). Both suspected GERD (RR: 2.400, 95% CI: 1.761-3.271, P<0.001) and endoscopic GERD (RR: 1.388, 95% CI: 1.127-1.711, P=0.002) were related to abnormal GEFV. CONCLUSION Abnormal GEFV could provide useful information for reflux conditions, but it could not distinguish confirmatory GERD from low-grade RE under the upper endoscopy.
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Affiliation(s)
- Yun Bao
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
- Department of Gastroenterology and Hepatology, Pinghu Hospital, Health Science Center, Shenzhen University, Shenzhen, People's Republic of China
| | - Xiaosu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | - Ying Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | - Yan Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | - Lin Lin
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | - Yurong Tang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing
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Guo Z, Wu Y, Zhan Y, Zhang C. Correlation between gastroesophageal flap valve abnormality and novel parameters in patients with gastroesophageal reflux disease symptoms by the lyon consensus. Sci Rep 2021; 11:15076. [PMID: 34301972 PMCID: PMC8302560 DOI: 10.1038/s41598-021-94149-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022] Open
Abstract
Gastroesophageal flap valve (GEFV) grading is a simple and reproducible parameter. There is limited information about the association between GEFV abnormality and novel parameters in patients with gastroesophageal reflux disease(GERD) symptoms by the Lyon Consensus. To investigate the value of GEFV grading in GERD, the clinical data of 320 patients with GERD symptoms who underwent endoscopy, 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring, and high-resolution manometry (HRM) were retrospectively analyzed. The percentage of acid exposure time (AET%)(4.2 [1.5–7.4] vs. 1.3 [0.3–4.2], P < 0.001) and the proportion of abnormal esophagogastric junction (EGJ) morphology (71 [87.7%] vs. 172 [72.0%], P = 0.011) were significantly higher, while the mean nocturnal baseline impedance (MNBI) (2068.3 [1658.4–2432.4] vs. 2228.5 [1794.8–2705.3]Ω, P = 0.012) and post-reflux swallow-induced peristaltic wave index (PSPWI) (19.7 [13.9–29.0] vs. 33.3 [25.0–44.0]%, P < 0.001) were significantly lower in the abnormal GEFV group compared with the normal GEFV group. AET% and EGJ morphology showed positive correlations with GEFV grade, while PSPWI and MNBI showed negative correlations. Patients with an abnormal GEFV had a significantly greater risk of conclusive evidence of GERD compared to those with a normal GEFV (OR 3.035, 95% CI 1.758–5.240, P < 0.001). Further, when identifying patients with conclusive evidence of GERD, abnormal GEFV had a specificity of 80.4% (95% CI 75.3–85.5%). GEFV grading might be regarded as supportive evidence for GERD diagnosis.
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Affiliation(s)
- Zihao Guo
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, No.1, Dongjiaominxiang, Dongcheng District, Beijing, 100730, China
| | - Yanhong Wu
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, No.1, Dongjiaominxiang, Dongcheng District, Beijing, 100730, China
| | - Yutao Zhan
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, No.1, Dongjiaominxiang, Dongcheng District, Beijing, 100730, China.
| | - Chuan Zhang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, No.1, Dongjiaominxiang, Dongcheng District, Beijing, 100730, China.
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Yoo IH, Joo JY, Yang HR. Usefulness of Endoscopic Hill Grade in Evaluating Children Suspected of Having Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2021; 27:191-197. [PMID: 33504689 PMCID: PMC8026377 DOI: 10.5056/jnm20033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/13/2020] [Accepted: 10/24/2020] [Indexed: 11/20/2022] Open
Abstract
Background/Aims This study aim to evaluate the relationship between the Hill grade confirmed by esophagogastroduodenoscopy (EGD) and the degree of gastroesophageal reflux (GER) by 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH) in children suspected of having gastroesophageal reflux disease (GERD). Methods A retrospective review of 105 children and adolescents who underwent EGD and MII-pH for the evaluation of GERD from March 2013 to July 2019 was performed. Clinical features and results of EGD and 24-hour MII-pH were collected and statistically analyzed. Results Hill grades 1, 2, 3, and 4 were identified using EGD in 56 (53.3%), 22 (22.0%), 16 (15.2%), and 11 (10.5%) patients, respectively. As the Hill grade increased, the proportion of neurological diseases (P < 0.001) and endoscopic erosive esophagitis (P < 0.001) increased significantly. The acid exposure index, bolus exposure index, number of reflux episodes, and number of GER reaching proximal extent on MII-pH increased significantly as the endoscopic Hill grade increased (all P < 0.001). Linear regression analysis revealed an increase in the Hill grade by 1 increased the acid exposure index by 2.0%, bolus exposure index by 0.7%, number of reflux episodes by 18.9 episodes, and the number of GER reaching the proximal esophagus increased by 10.5 episodes on average (all P < 0.001). Conclusions Hill grade on EGD was associated with GER in children. Estimating the degree of GER by applying Hill grade in the retroflexion view may be useful in practice when evaluating children suspected with GERD.
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Affiliation(s)
- In Hyuk Yoo
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Jung Yeon Joo
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Ciciora SL, Woodley FW. Optimizing the Use of Medications and Other Therapies in Infant Gastroesophageal Reflux. Paediatr Drugs 2018; 20:523-537. [PMID: 30198060 DOI: 10.1007/s40272-018-0311-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastroesophageal reflux (GER) is the retrograde movement of gastric (and sometimes duodenal) contents into the esophagus. While the majority of GER is physiologic, for patients, it can be associated with symptoms. While some symptoms are merely bothersome (crying), others can be life threatening (cough, gagging, choking). The main driver of GER in infants is the frequent feedings that produce increased intra-abdominal pressure, which is known to trigger transient relaxations of the lower esophageal sphincter. The recent 2018 clinical practice guidelines reported by the North American and European Societies for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN/ESPGHAN) have recommended non-pharmacologic management initially with subsequent consideration of brief trials with acid suppressants. The main target for these acid suppressants is the gastric parietal cells. Our review of the literature has revealed a paucity of data regarding the use of histamine-2 receptor antagonists and proton pump inhibitors in infants. Despite the absence of well-controlled clinical studies, the prescription rate of these medications has increased internationally. Risks to patients of all ages have become increasingly recognized, with new associations being reported all too often. Here we report our review of all pharmacologic modalities as well as some non-surgical options.
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Affiliation(s)
- Steven L Ciciora
- Division of Gastroenterology, Hepatology and Nutrition, Center for Functional Motility Disorders, Nationwide Children's Hospital, Columbus, OH, 43205, USA.,Department of Pediatrics, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Frederick W Woodley
- Division of Gastroenterology, Hepatology and Nutrition, Center for Functional Motility Disorders, Nationwide Children's Hospital, Columbus, OH, 43205, USA. .,Department of Pediatrics, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA.
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Quach DT, Nguyen TT, Hiyama T. Abnormal Gastroesophageal Flap Valve Is Associated With High Gastresophageal Reflux Disease Questionnaire Score and the Severity of Gastroesophageal Reflux Disease in Vietnamese Patients With Upper Gastrointestinal Symptoms. J Neurogastroenterol Motil 2018; 24:226-232. [PMID: 29605978 PMCID: PMC5885721 DOI: 10.5056/jnm17088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/17/2017] [Accepted: 10/13/2017] [Indexed: 12/11/2022] Open
Abstract
Background/Aims There have been no studies investigating the distribution of abnormal gastroesophageal flap valve (GEFV) among patients with dyspepsia, non-erosive reflux disease (NERD), and reflux esophagitis (RE) in the same set of patients. The aims of this study are to investigate (1) the association between GEFV and gastroesophageal reflux disease questionnaire (GERDQ) score, and (2) the distribution of abnormal GEFV in Vietnamese patients presenting with upper gastrointestinal symptoms. Methods Three hundred and thirty-one patients recruited in this prospective cross-sectional study were classified into 3 groups: reflux esophagitis (RE), non-erosive reflux disease (NERD) (GERDQ score ≥ 8, no endoscopic mucosal injury), and dyspepsia (GERDQ score < 8, no endoscopic mucosal injury). The GEFV was graded endoscopically according to the Hill classification. GEFV grades I and II were regarded as normal, while grades III and IV were regarded as abnormal GEFV. Results There were 215 (65.0%) patients with dyspepsia, 55 (16.6%) patients with NERD, and 61 (18.4%) patients with RE. Abnormal GEFV was an independent risk factor for GERD (OR, 2.93; CI 95%, 1.76–4.88) and RE (OR, 3.41; CI 95%, 1.78–6.53). The mean GERDQ score of patients with abnormal GEFV was significantly higher than that of patients with normal GEFV (5.7 ± 2.4 vs 4.9 ± 2.7, P = 0.011). The prevalence of abnormal GEFV gradually increased in patients with dyspepsia (27.4%), NERD (43.6%), grade A RE (56.8%), and grades B/C RE (80.0%) (P < 0.001). Conclusions Abnormal GEFV was significantly associated with high GERDQ score. Its prevalence gradually increased in patients with dyspepsia, NERD, and RE, respectively.
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Affiliation(s)
- Duc T Quach
- Department of Internal Medicine, University of Medicine and Pharmacy at Hochiminh City, Vietnam.,Department of Gastroenterology, Gia-Dinh People's Hospital, Hochiminh, Vietnam
| | - Trang T Nguyen
- Department of Internal Medicine, University of Medicine and Pharmacy at Hochiminh City, Vietnam.,Department of Internal Medicine, Thong-Nhat Hospital, Hochiminh, Vietnam
| | - Toru Hiyama
- Health Service Center, Hiroshima University, Higashihiroshima, Japan
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Liao D, Gregersen H, Agger P, Laustsen C, Ringgaard S, Stødkilde-Jørgensen H, Zhao J. 3D reconstruction and fiber quantification in the pig lower esophageal sphincter region using
in vitro
diffusion tensor imaging. Biomed Phys Eng Express 2018. [DOI: 10.1088/2057-1976/aa976e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Xie C, Li Y, Zhang N, Xiong L, Chen M, Xiao Y. Gastroesophageal flap valve reflected EGJ morphology and correlated to acid reflux. BMC Gastroenterol 2017; 17:118. [PMID: 29166876 PMCID: PMC5700691 DOI: 10.1186/s12876-017-0693-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 11/17/2017] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The anatomy of esophagogastric junction (EGJ) serves as the anti-reflux barrier. The gastroesophageal flap valve (GEFV) is a component of EGJ. The aim of the current study was to assess its correlation with the esophageal acid exposure and the impact on anti-reflux barrier function by using the metrics of EGJ contraction. METHODS Eighty three patients with typical GERD symptoms were included in the study. Upper endoscopy, high-resolution manometry (HRM) and 24 h multichannel intraluminal impedance-pH (MII-pH) monitoring were performed in all patients. GEFV was determined as four grades during endoscopic examination based on the Hill classification. The esophageal pressure topography (EPT) metrics defined in the updated Chicago Classification were measured by HRM, including integrated relaxation pressure (IRP), EGJ contractile index (EGJ-CI),expiratory EGJ pressure(EGJP-exp) and inspiratory EGJ pressure (EGJP-insp). RESULTS The GEFV grade III and IV was more commonly found in patients with esophagitits (p < 0.05). The acid exposure time (AET%) and supine AET% were lower in patients with GEFV grade I (p < 0.01). There was weak correlation between AET% and GEFV grades (r = 0.27, p = 0.013). There were more EGJ morphology type III in patients with GEFV grade IV (p < 0.05).There were no significant differences on the values of four HRM metrics among the patients with different GEFV grades (p > 0.05). CONCLUSION The GEFV grades were associated with acid reflux positively and could be a good reflection of EGJ morphology in HRM. But it had no impact on the four HRM metrics. Our research revealed that GEFV may play an assistant role in the anti-reflux barrier.
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Affiliation(s)
- Chenxi Xie
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Yuwen Li
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Ning Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Lishou Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, 510080, People's Republic of China.
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Ida T, Inamori M, Inoh Y, Fujita K, Hamanaka J, Chiba H, Kusakabe A, Morohashi T, Goto T, Maeda S. Clinical Characteristics of Severe Erosive Esophagitis among Patients with Erosive Esophagitis: A Case-control Study. Intern Med 2017; 56:1293-1300. [PMID: 28566589 PMCID: PMC5498190 DOI: 10.2169/internalmedicine.56.8058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective The risk factors associated with severe erosive esophagitis are not well defined in Japan. We aimed to evaluate the risk factors associated with the endoscopic severity of esophageal mucosal injury. Methods Eighty consecutive Japanese patients with severe erosive esophagitis [Los Angeles (LA) classification grade C or D] who had undergone upper endoscopies in the Gastroenterology Division of Omori Red Cross Hospital between June 2010 and March 2013 were retrospectively analyzed. For each case, a control with mild erosive esophagitis (LA classification grade A or B) who was matched by sex and age was randomly selected during the same period. Among the endoscopic findings, the condition of the gastroesophageal flap valve (GEFV) was graded according to Hill's classification. We identified the risk factors for severe erosive esophagitis using a multivariable logistic regression model. Results A poor performance status (PS) (odds ratio [OR]=17.1201, 95% confidence interval [CI]=3.0268-140.3121, p=0.0008) and an abnormal GEFV (OR=3.0176, 95% CI=1.0589-9.4939, p=0.0385) were risk factors for severe erosive esophagitis, while the presence of open-type gastric mucosal atrophy (GMA) was inversely associated with severe erosive esophagitis (OR=0.2772, 95% CI=0.1087-0.6675, p=0.0040). Conclusion Among patients with erosive esophagitis, a poor PS and an abnormal GEFV were associated while GMA was inversely associated with severe erosive esophagitis. Drug therapy alone or in combination with physical therapy may improve the therapeutic effect on severe erosive esophagitis in patients with a poor PS.
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Affiliation(s)
- Tomonori Ida
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Masahiko Inamori
- Department of Medical Education, Yokohama City University School of Medicine, Japan
| | - Yumi Inoh
- Office of Postgraduate Medical Education, Yokohama City University Hospital, Japan
| | - Koji Fujita
- Office of Postgraduate Medical Education, Yokohama City University Hospital, Japan
| | - Jun Hamanaka
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Akihiko Kusakabe
- Department of General Medicine, Yokohama City University Hospital, Japan
| | - Taiki Morohashi
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Toru Goto
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Hospital, Japan
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