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Pomenti S, Katzka DA. Current state of rumination syndrome. Dis Esophagus 2024:doae041. [PMID: 38741462 DOI: 10.1093/dote/doae041] [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: 04/11/2024] [Accepted: 04/29/2024] [Indexed: 05/16/2024]
Abstract
Rumination syndrome (RS) is an underdiagnosed behavioral disorder of recurrent regurgitation. Regurgitation occurs in RS due to increased gastric pressure achieved by subconscious contraction of the abdominal musculature wall, reversing the pressure gradient between the esophagus and the stomach. RS is mainly diagnosed clinically by the Rome Criteria with symptoms of regurgitation without retching of recently ingested food into the mouth and subsequent spitting or re-mastication. When the diagnosis is unable to be made clinically, supportive testing including fed impedance manometry can be considered. RS occurs worldwide, affecting patients of all ages, races, and genders with a prevalence of 3.1-5.8%. There is significant overlap with RS and disorders of a gut-brain interaction and upright gastroesophageal reflux driven by aerophagia and supragastric belching. There is also an association with mood disorder, fibromyalgia, and eating disorders. RS may be misdiagnosed as a variety of other syndromes including gastroesophageal reflux disease, gastroparesis, achalasia, and bulimia nervosa. Once RS is diagnosed, the mainstay of treatment is diaphragmatic breathing to lower the intragastric pressure and increase the lower esophageal pressure. Diaphragmatic breathing can be supported with biofeedback and cognitive behavioral therapy as well as medication options for more refractory cases. Response to therapy overtime and changes in symptoms overtime can now be tracked with a validated questionnaire.
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Affiliation(s)
- Sydney Pomenti
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
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Elsheikh M, Akanbi L, Selby L, Ismail B. Esophageal Motility Abnormalities in Lung Transplant Recipients With Esophageal Acid Reflux Are Different From Matched Controls. J Neurogastroenterol Motil 2024; 30:156-165. [PMID: 38062800 PMCID: PMC10999846 DOI: 10.5056/jnm23017] [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: 02/02/2023] [Revised: 05/10/2023] [Accepted: 07/07/2023] [Indexed: 04/06/2024] Open
Abstract
Background/Aims There is an increased incidence of gastroesophageal reflux disease (GERD) after lung transplantation (LT) that can be associated with graft dysfunction. It is unclear if the underlying esophageal motility changes in GERD are different following LT. This study aimed to use esophageal high-resolution manometry (HRM) to explore GERD mechanisms in LT recipients compared to matched controls. Methods This was a retrospective study including patients with pathologic acid reflux who underwent HRM and pH testing at our healthcare facility July 2012 to October 2019. The study included 12 LT recipients and 36 controls. Controls were matched in a 1:3 ratio for age, gender, and acid exposure time (AET). Results LT recipients had less hypotensive esophagogastric junction (EGJ) (mean EGJ-contractile integral 89.2 mmHg/cm in LT vs 33.9 mmHg/cm in controls, P < 0.001). AET correlated with distal contractile integral and total EGJ-contractile integral only in LT group (r = -0.79, P = 0.002 and r = -0.57, P = 0.051, respectively). Conclusions Following LT, acid reflux is characterized by a less hypotensive EGJ compared to controls with similar AET. The strongest correlation with AET after LT was found to be esophageal peristaltic vigor. These results add to the understanding of reflux after LT and may help tailor an individualized treatment plan.
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Affiliation(s)
- Mazen Elsheikh
- Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Lekan Akanbi
- Department of Gastroenterology and Hepatology, University of Missouri Health Care, Columbia, MO, USA
| | - Lisbeth Selby
- Division of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY, USA
| | - Bahaaeldeen Ismail
- Division of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY, USA
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Azuma D, Shimamura Y, Inoue H, Tanaka H, Ushikubo K, Yamamoto K, Kimoto Y, Okada H, Nishikawa Y, Tanaka I, Onimaru M. Endoscopic pressure study integrated system using an ultrathin gastroscope for the functional assessment of the lower esophageal sphincter. Dig Endosc 2024. [PMID: 38659275 DOI: 10.1111/den.14809] [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: 12/26/2023] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES The endoscopic pressure study integrated system (EPSIS) represents an innovative approach for evaluating lower esophageal sphincter function by monitoring intragastric pressure using diagnostic gastroscopes. This study aimed to assess the feasibility and validity of employing ultrathin gastroscopes for EPSIS. METHODS A retrospective analysis was conducted on a database of consecutive patients who underwent EPSIS using both ultrathin and regular gastroscopes between September 2021 and October 2023. The study compared EPSIS parameters between the two gastroscope types to evaluate the correlation of key metrics. RESULTS Thirty patients underwent EPSIS with both ultrathin and regular gastroscopes. Significant positive correlations were observed in the pressure waveform: maximum intragastric pressure (mmHg) (ρ = 0.82, P < 0.001) and intragastric pressure gradient (mmHg/s) (ρ = 0.80, P < 0.001) when comparing the two gastroscopes. Maximum intragastric pressure (15.5 [5.3-20.3] vs. 18.5 [3.4-21.6], P < 0.001) and pressure gradient (0.16 [0.013-0.41] vs. 0.24 [0.0039-1.13], P < 0.001), (median [range]) were significantly lower with ultrathin gastroscopes. CONCLUSIONS This study establishes that EPSIS parameters obtained with an ultrathin gastroscope exhibit a significant correlation with those obtained using a regular gastroscope, with each EPSIS parameter consistently lower. These findings support the viability of EPSIS for ultrathin gastroscopy and highlight its potential as a diagnostic tool for assessing lower esophageal sphincter function.
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Affiliation(s)
- Daisuke Azuma
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hitoshi Tanaka
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kei Ushikubo
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuki Yamamoto
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yoshiaki Kimoto
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hiroki Okada
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yohei Nishikawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ippei Tanaka
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Niu S, Zhang T, Li W, Wen S, Dong L, Wang S, Shi W, Shi C, Shen Y, Huang Q, Tan Y, Xu X, Yu L. Positive effect of deep diaphragmatic breathing training on gastroesophageal reflux-induced chronic cough: a clinical randomized controlled study. Respir Res 2024; 25:169. [PMID: 38637797 PMCID: PMC11027235 DOI: 10.1186/s12931-024-02783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/21/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVE To explore the efficacy of deep diaphragmatic breathing training (DEP) in patients with gastroesophageal reflux-induced chronic cough (GERC). METHODS A randomized controlled study was conducted involving 60 GERC patients who were divided into the intervention group and the control group (each with 30 patients). Both groups received routine medication treatment for GERC, while the intervention group received DEP training additionally. Both groups were evaluated by cough symptom scores, Hull airway reflux questionnaire (HARQ), gastroesophageal reflux diagnostic questionnaire (GerdQ), generalized anxiety disorder scale-7 (GAD-7), patient health questionnaire-9 (PHQ-9), Pittsburgh sleep quality index (PSQI), the Leicester cough questionnaire (LCQ), as well as capsaicin cough sensitivity testing, B-ultrasound and surface electromyography (sEMG) of the diaphragmatic muscles before and after treatment. The cough resolution rate and changes of the above indictors was compared between the two groups after eight weeks of treatment. RESULTS After eight weeks of treatment, cough symptoms improved in both groups, but the cough resolution rate in the intervention group of 94% was significantly higher than that in the control group of 77% (χ2 = 6.402, P = 0.041). The intervention group showed significant improvements to the control group in GerdQ (6.13(0.35) VS 6.57(0.77)), GAD-7 (0(0;1) VS 1(0;3)), PSQI (2(1;3) VS 4(3;6)), LCQ (17.19(1.56) VS 15.88(1.92)) and PHQ-9 (0(0;0) VS 0(0;3)) after treatment. Compared to control group, sEMG activity of the diaphragmatic muscle was significantly increased in the intervention group after treatment, measured during DEP (79.00(2.49) VS 74.65 (1.93)) and quiet breathing (72.73 (1.96) VS 67.15 (2.48)). CONCLUSION DEP training can improve cough symptoms as an adjunctive treatment in GERC patients. TRIAL REGISTRATION The protocol was registered in February 2, 2022 via the Chinese Clinical Trials Register ( http://www.chictr.org.cn/ ) [ChiCTR2200056246].
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Affiliation(s)
- Shanshan Niu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
- Department of Oncology, Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, China
| | - Tongyangzi Zhang
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Wanzhen Li
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Siwan Wen
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Lei Dong
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Shengyuan Wang
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Wenbo Shi
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Cuiqin Shi
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Yuqin Shen
- Department of Cardiac Rehabilitation, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Qianchun Huang
- Department of Cardiac Rehabilitation, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Yaling Tan
- Department of Neurology, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Xianghuai Xu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
| | - Li Yu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
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Guadagnoli L, Yadlapati R, Pandolfino J, Bedell A, Pandit AU, Dunbar KB, Fass R, Gevirtz R, Gyawali CP, Lupe SE, Petrik M, Riehl ME, Salwen-Deremer J, Simons M, Tomasino KN, Taft T. Behavioral Therapy for Functional Heartburn: Recommendation Statements. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00285-4. [PMID: 38518891 DOI: 10.1016/j.cgh.2024.03.004] [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: 12/18/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND & AIMS Brain-gut behavior therapies (BGBT) are increasingly recognized as effective therapeutic interventions for functional heartburn. However, recommendations regarding candidacy for treatment, initial treatment selection, and navigating treatment non-response have not been established for functional heartburn specifically. The aim of this study was to establish expert-based recommendations for behavioral treatment in patients with functional heartburn. METHODS The validated RAND/University of California, Los Angeles Appropriateness Method was applied to develop recommendations. A 15-member panel composed of 10 gastrointestinal psychologists and 5 esophageal specialists ranked the appropriateness of a series of statements on a 9-point interval scale over 2 ranking periods. Statements were within the following domains: pre-therapy evaluation, candidacy criteria for BGBT, selection of initial BGBT, role of additional therapy for initial non-response to BGBT, and role of pharmacologic neuromodulation. The primary outcome was appropriateness of each intervention based on the recommendation statements. RESULTS Recommendations for psychosocial assessment (eg, hypervigilance, symptom-specific anxiety, health-related quality of life), candidacy criteria (eg, motivated for BGBT, acknowledges the role of stress in symptoms), and treatment were established. Gut-directed hypnotherapy or cognitive behavioral therapy were considered appropriate BGBT for functional heartburn. Neuromodulation and/or additional BGBT were considered appropriate in the context of non-response. CONCLUSIONS Gut-directed hypnotherapy and/or cognitive behavioral therapy are recommended as appropriate behavioral interventions for heartburn symptoms, depending on clinical indication, specific gut-brain targets, and preferred treatment modality (pharmacologic vs non-pharmacologic). Pre-therapy evaluation of psychosocial processes and candidacy for BGBT are important to determine eligibility for referral to psychogastroenterology services.
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Affiliation(s)
- Livia Guadagnoli
- Laboratory for Brain-Gut Axis Studies (LaBGAS), Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium.
| | - Rena Yadlapati
- Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California
| | - John Pandolfino
- Kenneth C. Griffin Esophageal Center, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alyse Bedell
- Departments of Psychiatry & Behavioral Neuroscience and Medicine (Section of Gastroenterology, Hepatology, and Nutrition), The University of Chicago, Chicago, Illinois
| | - Anjali U Pandit
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kerry B Dunbar
- Division of Digestive Diseases, University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Texas
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Case Western Reserve University, Cleveland, Ohio
| | - Richard Gevirtz
- Clinical PhD Program, CSPP@Alliant International University, San Diego, California
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Stephen E Lupe
- Department of Gastroenterology, Hepatology, and Nutrition, The Cleveland Clinic, Cleveland, Ohio
| | - Megan Petrik
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Megan E Riehl
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jessica Salwen-Deremer
- Departments of Psychiatry and Medicine (Section of Gastroenterology & Hepatology), Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Madison Simons
- Department of Gastroenterology, Hepatology, and Nutrition, The Cleveland Clinic, Cleveland, Ohio
| | - Kathryn N Tomasino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tiffany Taft
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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6
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Davis TA, Gyawali CP. Refractory Gastroesophageal Reflux Disease: Diagnosis and Management. J Neurogastroenterol Motil 2024; 30:17-28. [PMID: 38173155 PMCID: PMC10774805 DOI: 10.5056/jnm23145] [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: 09/11/2023] [Accepted: 10/16/2023] [Indexed: 01/05/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.
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Affiliation(s)
- Trevor A Davis
- Division of Pediatric Gastroenterology, Washington University School of Medicine, Saint Louis Children’s Hospital, St. Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Hungin AP, Yadlapati R, Anastasiou F, Bredenoord AJ, El Serag H, Fracasso P, Mendive JM, Savarino EV, Sifrim D, Udrescu M, Kahrilas PJ. Management advice for patients with reflux-like symptoms: an evidence-based consensus. Eur J Gastroenterol Hepatol 2024; 36:13-25. [PMID: 38006602 PMCID: PMC10695341 DOI: 10.1097/meg.0000000000002682] [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: 08/23/2023] [Accepted: 10/11/2023] [Indexed: 11/27/2023]
Abstract
Patients with reflux-like symptoms (heartburn and regurgitation) are often not well advised on implementing individualised strategies to help control their symptoms using dietary changes, lifestyle modifications, behavioural changes or fast-acting rescue therapies. One reason for this may be the lack of emphasis in management guidelines owing to 'low-quality' evidence and a paucity of interventional studies. Thus, a panel of 11 gastroenterologists and primary care doctors used the Delphi method to develop consolidated advice for patients based on expert consensus. A steering committee selected topics for literature searches using the PubMed database, and a modified Delphi process including two online meetings and two rounds of voting was conducted to generate consensus statements based on prespecified criteria (67% voting 'strongly agree' or 'agree with minor reservation'). After expert discussion and two rounds of voting, 21 consensus statements were generated, and assigned strength of evidence and Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) rating. Eleven statements achieved the strongest (100%) agreement: five are related to diet and include identification and avoidance of dietary triggers, limiting alcohol, coffee and carbonated beverages, and advising patients troubled by postprandial symptoms not to overeat; the remaining six statements concern advice around smoking cessation, weight loss, raising the head-of-the-bed, avoiding recumbency after meals, stress reduction and alginate use. The aim of developing the consensus statements is that they may serve as a foundation for tools and advice that can routinely help patients with reflux-like symptoms better understand the causes of their symptoms and manage their individual risk factors and triggers.
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Affiliation(s)
- A. Pali Hungin
- Professor Emeritus, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Foteini Anastasiou
- 4th Local Primary Care Team, Municipality Practice and Academic Practice of Heraklion; University of Crete, Crete, Greece
| | - Albert J. Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Hashem El Serag
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Pierluigi Fracasso
- Department of Gastroenterology and Digestive Endoscopy, Ospedale Sandro Pertini, Local Health Agency Roma 2, Rome, Italy
| | - Juan M Mendive
- La Mina Primary Care Academic Centre, Catalan Health Institute, University of Barcelona, Spain
| | - Edoardo V. Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | | | - Peter J Kahrilas
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Mosa HES, El- Bready HG, El-Sol AESH, Bayomy HE, Taman RO, Shehata HS. Efficacy of abdominal breathing on sleep and quality of life among patients with non-erosive gastroesophageal reflux. J Public Health Res 2024; 13:22799036241231788. [PMID: 38370147 PMCID: PMC10874155 DOI: 10.1177/22799036241231788] [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: 10/08/2023] [Accepted: 01/24/2024] [Indexed: 02/20/2024] Open
Abstract
Aim Abdominal breathing recently has demonstrated an important role in managing symptoms of Gastroesophageal Reflux Disease (GERD), improving quality of life, medication adherence, and sleep quality. This study aimed to evaluate the effectiveness of abdominal breathing on sleep and quality of life in patients with non-erosive gastroesophageal reflux. Subject and methods A Quasi-experimental design was used. A purposive sample of 100 patients was selected from the medical outpatient clinics of Menoufia University Hospital and the outpatient clinics of the National Liver Institute in Menoufia Governorate, Egypt. A Structured interview questionnaire was used to collect data on patients' sociodemographic characteristics, belly breathing exercise performance and self-reported compliance, GERD symptoms severity and frequency, Pittsburgh Sleep Quality Index, and GERD Health-Related Quality of Life. Results The frequency of GERD symptoms decreased from 26.64 pre-intervention to 17.61 and 9.58, respectively, at two- and four-months post-intervention. Antacid consumption among patients taking it 7 days/week was reduced from 34% pre-intervention to 2% and 0% post-intervention by two and four months, respectively. Good sleepers were 24% pre-intervention then increased to 62% and 90% post-intervention by 2 and 4 months, respectively. Regarding GERD related quality of life, only 1% was satisfied pre-intervention, which increased to 32% and 72% post-intervention by 2 and 4 months, respectively. Conclusion Abdominal breathing offers better therapeutic improvements in all patients' outcomes such as reduced severity and frequency of GERD symptoms, reduced antacid consumption, increased sleep quality, and increased satisfaction with life quality. Healthcare professionals are encouraged to incorporate abdominal breathing into treatment protocols for patients with non-erosive GERD.
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Affiliation(s)
- Hassnaa Eid Shaban Mosa
- Department of Medical Surgical Nursing, Faculty of Nursing, Menoufia University, Shebin El Kom, Egypt
- Department of Medical Surgical Nursing, Nursing Faculty, Jouf University, Sakakah, Saudi Arabia
| | - Hanan G. El- Bready
- Department of Family and Community Health Nursing, Faculty of Nursing, Menoufia University, Shebin El Kom, Egypt
| | | | - Hanaa E. Bayomy
- Department of Public Health and Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt
- Department of Family and Community Medicine, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia
| | - Rehab Omar Taman
- Department of Medical Surgical Nursing, Faculty of Nursing, Menoufia University, Shebin El Kom, Egypt
| | - Hanady Sh. Shehata
- Department of Family and Community Health Nursing, Faculty of Nursing, Menoufia University, Shebin El Kom, Egypt
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9
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Jiang D, Zhuang Q, Jia X, Chen S, Tan N, Zhang M, Xiao Y. Current complementary and alternative therapy forgastroesophageal reflux disease. Gastroenterol Rep (Oxf) 2023; 11:goad057. [PMID: 37810946 PMCID: PMC10551227 DOI: 10.1093/gastro/goad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/13/2023] [Indexed: 10/10/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a widely prevalent gastrointestinal disorder, affecting ∼13.3% of the global population. There are shortages and limitations of current GERD treatment modalities, and complementary and alternative therapy (CAT) is a promising option to fill in the gap. Dietary and lifestyle modifications might play an important and complementary role in alleviating GERD symptoms. Traditional Chinese medicine and brain-gut behavior therapy, particularly transcutaneous electrical acustimulation and diaphragmatic breathing therapy were shown to be useful adjuncts or alternatives in treating GERD. CAT may help to relieve GERD symptoms, minimize medication dosage, and slow the demand for surgery. The aim of this review was to summarize the existing evidence of some common CATs in treating symptomatic GERD, including dietary modification, lifestyle change, traditional Chinese medicine, and brain-gut behavior therapy.
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Affiliation(s)
- Dianxuan Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qianjun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xingyu Jia
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Songfeng Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Niandi Tan
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Mengyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
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Patel J, Wong N, Mehta K, Patel A. Gastroesophageal Reflux Disease. Prim Care 2023; 50:339-350. [PMID: 37516506 DOI: 10.1016/j.pop.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Symptoms potentially attributable to gastroesophageal reflux disease are among those most commonly reported to primary care providers in the outpatient setting. In this review, we discuss clinical approaches to the evaluation and management of these symptoms, including proton pump inhibitor trials as well as specific indications or clinical settings that warrant referral to Gastroenterology specialists.
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Affiliation(s)
- Janaki Patel
- Department of Medicine, Ohio State University College of Medicine, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Natalie Wong
- Division of Gastroenterology, Duke University School of Medicine, Duke University Medical Center, Box 3913, Durham, NC 27710, USA
| | - Kurren Mehta
- Department of Medicine, Duke University School of Medicine, Duke University Medical Center, Box 3913, Durham, NC 27710, USA
| | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine, 10207 Cerny Street, Suite 200, Raleigh, NC 27617, USA; Division of Gastroenterology, Durham Veterans Affairs Medical Center.
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Taft TH, Carlson DA, Marchese SH, Pandolfino JE. Initial assessment of medical post-traumatic stress among patients with chronic esophageal diseases. Neurogastroenterol Motil 2023; 35:e14540. [PMID: 36703507 PMCID: PMC10133015 DOI: 10.1111/nmo.14540] [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: 11/11/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Diagnosis and management of chronic esophageal disease requires the use of potentially traumatic medical procedures, performed with or without sedation. Medical trauma and post-traumatic stress (PTS) are emerging as important considerations in patients with digestive illness. To date, no study assesses medical PTS from procedures in patients with esophageal disease. METHODS Adult patients with achalasia, eosinophilic esophagitis, gastroesophageal reflux disease, or functional esophageal disease at a university-based gastroenterology clinic completed: Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5), Gastroesophageal Disease Questionnaire, Brief Esophageal Dysphagia Questionnaire, Northwestern Esophageal Quality of Life scale (HRQoL), NIH-PROMIS Depression scale, and a study-specific questionnaire about esophageal procedures (endoscopy with sedation; functional lumen imaging probe (FLIP) with sedation; high-resolution manometry (HRM); wireless pH testing; or 24-h pH-impedance testing). KEY RESULTS Half of 149 participants reported at least one traumatic procedure, with HRM most often cited. Only 2.7% met the cutoff for PTS on PCL-5. This increased to 7.1% for patients with a traumatic procedure combined with experiencing intense fear. Rates of moderate-severe PTS ranged from 7.4%-12% for all patients and 14%-29% for those with a traumatic procedure with fear. Medical PTS was associated with poorer HRQoL, and increased esophageal symptoms, depression, and hypervigilance and symptom anxiety. CONCLUSIONS & INFERENCES Preliminary evidence suggests medical PTS affects few patients with esophageal disease. However traumatic procedures, most often associated with HRM, significantly increase PTS symptoms. The potential impacts of medical PTS on esophageal patient assessment and outcomes are considerable and warrants further study.
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Affiliation(s)
- Tiffany H Taft
- Division of Gastroenterology & Hepatology Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology & Hepatology Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sara H Marchese
- Division of Gastroenterology & Hepatology Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology & Hepatology Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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12
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Zdrhova L, Bitnar P, Balihar K, Kolar P, Madle K, Martinek M, Pandolfino JE, Martinek J. Breathing Exercises in Gastroesophageal Reflux Disease: A Systematic Review. Dysphagia 2023; 38:609-621. [PMID: 35842548 PMCID: PMC9888515 DOI: 10.1007/s00455-022-10494-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 07/01/2022] [Indexed: 02/02/2023]
Abstract
The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial. The severity of abnormal reflux burden corresponds to the dysfunction of the antireflux barrier and inability to clear refluxate. The crural diaphragm is one of the main components of the esophagogastric junction and plays an important role in preventing gastroesophageal reflux. The diaphragm, as a skeletal muscle, is partially under voluntary control and its dysfunction can be improved via breathing exercises. Thus, diaphragmatic breathing training (DBT) has the potential to alleviate symptoms in selected patients with GERD. High-resolution esophageal manometry (HRM) is a useful method for the assessment of antireflux barrier function and can therefore elucidate the mechanisms responsible for gastroesophageal reflux. We hypothesize that HRM can help define patient phenotypes that may benefit most from DBT, and that HRM can even help in the management of respiratory physiotherapy in patients with GERD. This systematic review aimed to evaluate the current data supporting physiotherapeutic practices in the treatment of GERD and to illustrate how HRM may guide treatment strategies focused on respiratory physiotherapy.
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Affiliation(s)
- Lucie Zdrhova
- First Department of Internal Medicine, Pilsen University Hospital, Charles University in Prague, Alej Svobody 80, Pilsen, 304 06, Czech Republic.
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic.
| | - Petr Bitnar
- Department of Rehabilitation and Sports Medicine, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Karel Balihar
- First Department of Internal Medicine, Pilsen University Hospital, Charles University in Prague, Alej Svobody 80, Pilsen, 304 06, Czech Republic
| | - Pavel Kolar
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic
- Department of Rehabilitation and Sports Medicine, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Katerina Madle
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic
| | - Milan Martinek
- Faculty of Physical Education and Sport, Charles University in Prague, Prague, Czech Republic
| | - John Erik Pandolfino
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Evanston, USA
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, IKEM, Prague, Czech Republic
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13
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Abstract
The upper gastrointestinal (GI) tract is frequently involved in systemic sclerosis (SSc) and may impact quality of life, physical function and survival. Although we are currently very proactive in terms of screening for heart and lung involvement, patients with SSc are not routinely screened for GI involvement. This review details the available investigations for common upper GI symptoms in SSc, including dysphagia, reflux and bloating and provides advice as to how to integrate these investigations into current clinical care.
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14
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Abdominophrenic Dyssynergia: A Narrative Review. Am J Gastroenterol 2023; 118:41-45. [PMID: 36191283 PMCID: PMC9810002 DOI: 10.14309/ajg.0000000000002044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/16/2022] [Indexed: 11/07/2022]
Abstract
Chronic bloating and abdominal distension are common and highly bothersome gastrointestinal symptoms. Although the differential diagnoses for bloating and distension are broad, these symptoms are frequently associated with disorders of the gut-brain interaction. Functional abdominal bloating may be a result of visceral hypersensitivity, whereas abdominal distension seems to be a somatic behavioral response associated with abdominophrenic dyssynergia, featuring diaphragmatic contraction and abdominal wall relaxation. We review the available literature regarding abdominophrenic dyssynergia and comment on its epidemiology, diagnosis, treatment, and avenues to address in the near future.
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15
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Burton Murray H, Ljótsson B. Future of Brain-Gut Behavior Therapies: Mediators and Moderators. Gastroenterol Clin North Am 2022; 51:723-739. [PMID: 36375992 DOI: 10.1016/j.gtc.2022.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
With growing evidence to support their efficacy, brain-gut behavior therapies are increasingly viewed as a key component to integrated care management of disorders of gut-brain interaction. However, the types of brain-gut behavior therapies differ in how and for whom they purportedly work. We provide a conceptual review of these brain-gut behavior therapies, with an emphasis on describing how (ie, mechanisms) and for whom (ie, moderators) they work as hypothesized and/or supported by evidence. Based on evidence to date, we recommend that brain-gut behavior therapies prioritize gastrointestinal-specific targets, such as gastrointestinal-specific anxiety.
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Affiliation(s)
- Helen Burton Murray
- Division of Gastroenterology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, Solna, Stockholm 171 65, Sweden
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16
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Srinivasan SG, Muthyala A, Sharma M, Feuerhak K, Boon A, Bailey KR, Bharucha AE. Abdomino-anal Dyscoordination in Defecatory Disorders. Clin Gastroenterol Hepatol 2022; 20:2091-2101.e5. [PMID: 34896282 PMCID: PMC9174349 DOI: 10.1016/j.cgh.2021.11.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/19/2021] [Accepted: 11/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The contribution of the abdominal muscles to normal defecation and disturbances thereof in defecatory disorders (DDs) are unknown. METHODS In 30 healthy and 60 constipated women with normal rectal balloon expulsion time (BET) (n = 26) or prolonged BET (ie, DD; n = 34), seated anorectal pressures (manometry) and thickness (ultrasound) of the external and internal oblique and transversus abdominis muscles were measured simultaneously at rest, during hollowing, squeeze, evacuation, and a Valsalva maneuver. RESULTS Compared with healthy women with a normal BET, DD women had a lower rectal and greater anal pressure increase during evacuation (P ≤ .05), and more activation of the internal oblique and the transversus abdominis muscles during squeeze (P < .05). The change in transversus abdominis thickness during a Valsalva maneuver vs hollowing (rho = 0.5; P = .002) and separately vs evacuation (rho = 0.7; P < .0001) were correlated in DD but not in healthy women with a normal BET. A principal component (PC) analysis of anorectal pressures and muscle thicknesses during evacuation uncovered a PC (PC3) that was associated with a prolonged BET. Higher PC3 scores were associated with low rectal and high anal pressures at rest and during evacuation, thinner external oblique muscle, and thicker internal oblique muscle during evacuation. A greater PC3 score was associated with increased odds for DD vs health (odds ratio, 1.84; 95% CI, 1.05-3.23), and separately vs constipation with a normal BET (odds ratio, 3.64; 95% CI, 1.73-7.69). CONCLUSIONS Taken together, these findings show 3, possibly inter-related, disturbances suggestive of dyscoordination in DD: aberrant activation of abdominal muscles during squeeze in DD, dyscoordination of the abdominal muscles during various tasks in constipated women, and abdomino-anal dyscoordination.
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Affiliation(s)
| | - Anjani Muthyala
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota
| | - Mayank Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota
| | - Andrea Boon
- Department of Neurology, Rochester, Minnesota
| | - Kent R Bailey
- Division of Clinical Trials and Statistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota.
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17
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Ma S, Patel V, Yadlapati R. Factors that Impact Day-to-Day Esophageal Acid Reflux Variability and Its Diagnostic Significance for Gastroesophageal Reflux Disease. Dig Dis Sci 2022; 67:2730-2738. [PMID: 35441274 PMCID: PMC9377569 DOI: 10.1007/s10620-022-07496-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/23/2022] [Indexed: 01/10/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a common disease affecting a significant number of adults both globally and in the USA. GERD is clinically diagnosed based on patient-reported symptoms, and the gold standard for diagnosis is ambulatory reflux monitoring, a tool particularly utilized in the common scenario of non-response to therapy or atypical features. Over the past 20 years, there has been a shift toward extending the duration of reflux monitoring, initially from 24 to 48 h and more recently to 96 h, primarily based on a demonstrated increase in diagnostic yield. Further, multiple studies demonstrate clinically relevant variability in day-to-day acid exposure levels in nearly 30% of ambulatory reflux monitoring studies. For these reasons, an ongoing clinical dilemma relates to the optimal activities patients should engage in during prolonged reflux monitoring. Thus, the aims of this review are to detail what is known about variability in daily acid exposure, discuss factors that are known to influence this day-to-day variability (i.e., sleep patterns, dietary/eating habits, stress, exercise, and medications), and finally provide suggestions for patient education and general GERD management to reduce variation in esophageal acid exposure levels.
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Affiliation(s)
- Steven Ma
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Vandan Patel
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Rena Yadlapati
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
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18
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Hungin APS, Scarpignato C, Keefer L, Corsetti M, Anastasiou F, Muris JWM, Mendive JM, Kahrilas PJ. Review article: rethinking the "ladder" approach to reflux-like symptom management in the era of PPI "resistance" - a multidisciplinary perspective. Aliment Pharmacol Ther 2022; 55:1492-1500. [PMID: 35460095 PMCID: PMC9324949 DOI: 10.1111/apt.16930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/26/2021] [Accepted: 04/03/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite widespread adoption of potent acid suppression treatment with proton pump inhibitors (PPI) for reflux-like symptoms, persistent symptoms are commonly reported in primary care and community studies. AIMS This multidisciplinary review critically evaluates how the management of reflux-like symptoms could better reflect their multifactorial pathophysiology. METHODS A panel of experts (from general practice, gastroenterology and gastropsychology) attended a series of workshops to review current management and propose a framework for the provision of more individualised care. RESULTS It was agreed that the perceptual (as well as the physiological) causes of reflux-like symptoms should be considered at the start of management, not as a last resort when all else has failed. A short course of PPI is a pragmatic approach to address reflux-like symptoms, but equally important is counselling about the gut-brain axis and provision of symptom-specific behavioural interventions for those who show signs of somatisation, hypervigilance or co-existing disorders of gut-brain interaction. Other low-harm interventions such as lifestyle and dietary advice, should also be better integrated into care at an early stage. Multidisciplinary care management programmes (including dietary, weight loss, exercise and behavioural intervention) should be developed to promote greater self-management and take advantage of the general shift toward the use of remotely accessed health care resources. CONCLUSIONS Management of reflux-like symptoms should be adapted to reflect the advances in knowledge about the multifactorial aetiology of these symptoms, addressing both acid-related and behavioural components early in management. The time has come to treat the patient, not the "disease".
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Affiliation(s)
- A. Pali S. Hungin
- Primary Care and General Practice, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | | | - Laurie Keefer
- Icahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research CentreNottingham University Hospitals NHS TrustNottinghamUK,School of Medicine, University of Nottingham and Translational Medical Science – Nottingham Digestive Diseases CentreUniversity of NottinghamNottinghamUK
| | - Foteini Anastasiou
- 4th Local Primary Care TeamMunicipality Practice and Academic Practice of HeraklionCreteGreece
| | - Jean W. M. Muris
- Department of Family MedicineCare and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtThe Netherlands
| | - Juan M. Mendive
- La Mina Primary Care Academic Centre, Catalan Health InstituteUniversity of BarcelonaBarcelonaSpain
| | - Peter J. Kahrilas
- Division of Gastroenterology, Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
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19
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Yadlapati R, Gyawali CP, Pandolfino JE. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. Clin Gastroenterol Hepatol 2022; 20:984-994.e1. [PMID: 35123084 PMCID: PMC9838103 DOI: 10.1016/j.cgh.2022.01.025] [Citation(s) in RCA: 91] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/12/2022] [Accepted: 01/20/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS As many as one-half of all patients with suspected gastroesophageal reflux disease (GERD) do not derive benefit from acid suppression. This review outlines a personalized diagnostic and therapeutic approach to GERD symptoms. METHODS The Best Practice Advice statements presented here were developed from expert review of existing literature combined with extensive discussion and expert opinion to provide practical advice. Formal rating of the quality of evidence or strength of recommendations was not the intent of this clinical practice update. BEST PRACTICE ADVICE 1: Clinicians should develop a care plan for investigation of symptoms suggestive of GERD, selection of therapy (with explanation of potential risks and benefits), and long-term management, including possible de-escalation, in a shared-decision making model with the patient. BEST PRACTICE ADVICE 2: Clinicians should provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors, relaxation strategies, and awareness about the brain-gut axis relationship to patients with reflux symptoms. BEST PRACTICE ADVICE 3: Clinicians should emphasize safety of proton pump inhibitors (PPIs) for the treatment of GERD. BEST PRACTICE ADVICE 4: Clinicians should provide patients presenting with troublesome heartburn, regurgitation, and/or non-cardiac chest pain without alarm symptoms a 4- to 8-week trial of single-dose PPI therapy. With inadequate response, dosing can be increased to twice a day or switched to a more effective acid suppressive agent once a day. When there is adequate response, PPI should be tapered to the lowest effective dose. BEST PRACTICE ADVICE 5: If PPI therapy is continued in a patient with unproven GERD, clinicians should evaluate the appropriateness and dosing within 12 months after initiation, and offer endoscopy with prolonged wireless reflux monitoring off PPI therapy to establish appropriateness of long-term PPI therapy. BEST PRACTICE ADVICE 6: If troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy and, in the absence of erosive reflux disease (Los Angeles B or greater) or long-segment (≥3 cm) Barrett's esophagus, perform prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or to rule out GERD. BEST PRACTICE ADVICE 7: Complete endoscopic evaluation of GERD symptoms includes inspection for erosive esophagitis (graded according to the Los Angeles classification when present), diaphragmatic hiatus (Hill grade of flap valve), axial hiatus hernia length, and inspection for Barrett's esophagus (graded according to the Prague classification and biopsied when present). BEST PRACTICE ADVICE 8: Clinicians should perform upfront objective reflux testing off medication (rather than an empiric PPI trial) in patients with isolated extra-esophageal symptoms and suspicion for reflux etiology. BEST PRACTICE ADVICE 9: In symptomatic patients with proven GERD, clinicians should consider ambulatory 24-hour pH-impedance monitoring on PPI as an option to determine the mechanism of persisting esophageal symptoms despite therapy (if adequate expertise exists for interpretation). BEST PRACTICE ADVICE 10: Clinicians should personalize adjunctive pharmacotherapy to the GERD phenotype, in contrast to empiric use of these agents. Adjunctive agents include alginate antacids for breakthrough symptoms, nighttime H2 receptor antagonists for nocturnal symptoms, baclofen for regurgitation or belch predominant symptoms, and prokinetics for coexistent gastroparesis. BEST PRACTICE ADVICE 11: Clinicians should provide pharmacologic neuromodulation, and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies in patients with functional heartburn or reflux disease associated with esophageal hypervigilance reflux hypersensitivity and/or behavioral disorders. BEST PRACTICE ADVICE 12: In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients. BEST PRACTICE ADVICE 13: In patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients, and a salvage option in non-obese patients, whereas sleeve gastrectomy has potential to worsen GERD. BEST PRACTICE ADVICE 14: Candidacy for invasive anti-reflux procedures includes confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla, California
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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20
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The effects of diaphragmatic breathing training on the quality of life and clinical symptoms of patients with gastroesophageal reflux disease: A randomized controlled trial. ADVANCES IN INTEGRATIVE MEDICINE 2022. [DOI: 10.1016/j.aimed.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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21
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Sasegbon A, Hasan SS, Disney BR, Vasant DH. Rumination syndrome: pathophysiology, diagnosis and practical management. Frontline Gastroenterol 2022; 13:440-446. [PMID: 36046491 PMCID: PMC9380772 DOI: 10.1136/flgastro-2021-101856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/28/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ayodele Sasegbon
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK,Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Syed Shariq Hasan
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Benjamin R Disney
- Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Dipesh Harshvadan Vasant
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK,Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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22
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Bhardwaj R, Knotts R, Khan A. Functional Chest Pain and Esophageal Hypersensitivity: A Clinical Approach. Gastroenterol Clin North Am 2021; 50:843-857. [PMID: 34717874 DOI: 10.1016/j.gtc.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Functional chest pain, functional heartburn, and reflux hypersensitivity are 3 functional esophageal disorders defined by the Rome IV criteria. Specific criteria, combining symptoms and the results of objective testing, allow for an accurate diagnosis of these conditions. Management may include medications targeted at optimizing acid suppression or neuromodulation, as well as a host of complementary or alternative treatment options. Psychological and behavioral interventions, such as cognitive behavioral therapy and hypnotherapy, have displayed substantial benefits in the treatment of functional chest pain and functional heartburn. Acid suppression and focused neuromodulation are key evidence-based treatment options for reflux hypersensitivity.
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Affiliation(s)
- Richa Bhardwaj
- Department of Internal Medicine, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10075, USA
| | - Rita Knotts
- Department of Medicine, NYU Langone Health, 240 East 38th Street, 23rd Floor, New York, NY 10016, USA
| | - Abraham Khan
- Department of Medicine, NYU Langone Health, 240 East 38th Street, 23rd Floor, New York, NY 10016, USA.
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23
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Gyawali CP, Tutuian R, Zerbib F, Rogers BD, Frazzoni M, Roman S, Savarino E, de Bortoli N, Vela MF, Sifrim D. Value of pH Impedance Monitoring While on Twice-Daily Proton Pump Inhibitor Therapy to Identify Need for Escalation of Reflux Management. Gastroenterology 2021; 161:1412-1422. [PMID: 34270955 DOI: 10.1053/j.gastro.2021.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Acid exposure time (AET) and reflux episode thresholds from the Lyon Consensus may not apply for pH impedance studies performed while on proton pump inhibitor (PPI) therapy. We aimed to determine metrics from "on PPI" pH impedance studies predicting need for escalation of therapy. METHODS De-identified pH impedance studies performed while on twice-daily PPI (Diversatek, Boulder, CO) in healthy volunteers (n = 66, median age 37.5 years, 43.9% female), and patients with proven gastroesophageal reflux disease (GERD) (European heartburn-predominant cohort: n = 43, median age 57.0 years, 55.8% female; North American regurgitation-predominant cohort: n = 42, median age 41.6 years, 42.9% female) were analyzed. Median values and interquartile ranges for pH impedance metrics in healthy volunteers were compared with proven GERD patients with and without 50% symptom improvement on validated measures. Receiver operating characteristic (ROC) analyses identified optimal thresholds predicting symptom response. RESULTS Both conventional and novel reflux metrics were similar between PPI responders and nonresponders (P ≥ .1 for each) despite differences from healthy volunteers. Combinations of metrics associated with conclusively abnormal reflux burden (AET >4%, >80 reflux episodes) were seen in 32.6% and 40.5% of heartburn and regurgitation-predominant patients, respectively, 57.1% and 82.4% of whom reported nonresponse; and 85% with these metrics improved with invasive GERD management. On ROC analysis, AET threshold of 0.5% modestly predicted nonresponse (sensitivity, 0.62; specificity, 0.51; P = .22), and 40 reflux episodes had better performance characteristics (sensitivity, 0.80; specificity, 0.51; P = .002); 79% with these metrics improved with invasive GERD management. CONCLUSION Combinations of abnormal "on PPI" pH impedance metrics are associated with PPI nonresponse in proven GERD patients, and can be targeted for treatment escalation, including surgery, particularly in regurgitation-predominant GERD.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri.
| | - Radu Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Frank Zerbib
- Centre Hospitalier Universitaire de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, Institut National de la Santé et de la Recherche Médicale CIC 1401, Bordeaux, France
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri; Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
| | - Marzio Frazzoni
- Department of Specialized Medicine, Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université de Lyon, Lyon, France; Laboratory of Therapeutic Applications of Ultrasound, Institut National de la Santé et de la Recherche Médicale U1032, Université de Lyon, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technology in Medicine and Surgery. University of Pisa, Pisa, Italy
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic, Scottsdale, Arizona
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry Queen Mary, University of London, London, United Kingdom
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Gyawali CP, Zerbib F, Bhatia S, Cisternas D, Coss-Adame E, Lazarescu A, Pohl D, Yadlapati R, Penagini R, Pandolfino J. Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility. Neurogastroenterol Motil 2021; 33:e14134. [PMID: 33768698 DOI: 10.1111/nmo.14134] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/24/2021] [Accepted: 03/09/2021] [Indexed: 12/12/2022]
Abstract
Esophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high-resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100-450 mmHg·cm·s), transition zone defects >5 cm measured using a 20 mmHg isobaric contour, or failure of peristalsis (DCI < 100 mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%-70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, Bordeaux, France
| | - Shobna Bhatia
- Department of Gastroenterology, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago de Chile, Chile
| | - Enrique Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Tlalpan, Mexico
| | - Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Rena Yadlapati
- Center for Esophageal Diseases, University of California, San Diego, CA, USA
| | - Roberto Penagini
- Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Murray HB, Pasricha TS, Jehangir A, Thomas JJ, Kuo B, Parkman HP. Detection and characteristics of rumination syndrome in patients presenting for gastric symptom evaluation. Neurogastroenterol Motil 2021; 33:e14103. [PMID: 33729638 DOI: 10.1111/nmo.14103] [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: 12/14/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Rumination syndrome involves effortless, repeated regurgitation, and can overlap with other upper gastrointestinal disorders, including gastroparesis. To inform better diagnostic detection of rumination, we aimed to (1) identify frequency and characteristics of rumination in patients presenting for gastric symptom evaluation; and (2) assess demographic and clinical characteristics that could differentiate those with versus those without rumination. METHODS Consecutively referred patients to two tertiary academic centers for gastric symptom specialty evaluation were included (N = 242). We obtained demographic information, gastric emptying scintigraphy, upper gastrointestinal symptoms using the Patient Assessment of Upper Gastrointestinal Symptoms (PAGI-SYM), and Rome IV-based rumination questionnaire. KEY RESULTS Thirty-one of the 242 (12.8%) patients met criteria for rumination syndrome, of which 48% reported associated psychosocial impairment. Comparing those with rumination and those without, there were no differences in race, gender, frequency of diabetes, or frequency of gastroparesis. The median PAGI-SYM score for rumination patients was higher than for those without (3.03 vs. 2.55; unadjusted p = 0.043, adjusted p = 0.30). This was largely driven by increased heartburn/regurgitation subscale scores (2.71 vs. 1.57, unadjusted p = 0.0067, adjusted p = 0.046), itself influenced by elevated daytime regurgitation/reflux (3.0 vs. 2.0; unadjusted p = 0.007, adjusted p = 0.048). There were no significant differences on the remaining PAGI-SYM subscales. CONCLUSIONS AND INFERENCES Rumination syndrome determined by Rome IV criteria was present in 12.8% of patients presenting for gastric symptom evaluation. Higher self-report PAGI-SYM heartburn/regurgitation subscale scores, particularly daytime regurgitation/reflux symptoms, were the only parameters that distinguished rumination. The PAGI-SYM heartburn/regurgitation subscale could be used to screen for rumination, in addition to GERDAQ6.
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Affiliation(s)
- Helen Burton Murray
- Division of Gastroenterology, Department of Medicine, Center for Neurointestinal Health, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Trisha S Pasricha
- Division of Gastroenterology, Department of Medicine, Center for Neurointestinal Health, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Asad Jehangir
- Gastroenterology Division, Temple University Hospital, Philadelphia, PA, USA
| | - Jennifer J Thomas
- Harvard Medical School, Boston, MA, USA.,Eating Disorders Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Braden Kuo
- Division of Gastroenterology, Department of Medicine, Center for Neurointestinal Health, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Henry P Parkman
- Gastroenterology Division, Temple University Hospital, Philadelphia, PA, USA
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