Diagnosis of GERD in typical and atypical manifestations

Microbiota profiling in esophageal diseases: Novel insights into molecular staining and clinical outcomes

Gut microbiota is recognized nowadays as one of the key players in the development of several gastro-intestinal diseases. The first studies focused mainly on healthy subjects with staining of main bacterial species via culture-based techniques. Subsequently, lots of studies tried to focus on principal esophageal disease enlarged the knowledge on esophageal microbial environment and its role in pathogenesis. Gastro Esophageal Reflux Disease (GERD), the most widespread esophageal condition, seems related to a certain degree of mucosal inflammation, via interleukin (IL) 8 potentially enhanced by bacterial components, lipopolysaccharide (LPS) above all. Gram- bacteria, producing LPS), such as Campylobacter genus, have been found associated with GERD. Barrett esophagus (BE) seems characterized by a Gram- and microaerophils-shaped microbiota. Esophageal cancer (EC) development leads to an overturn in the esophageal environment with the shift from an oral-like microbiome to a prevalently low-abundant and low-diverse Gram--shaped microbiome. Although underinvestigated, also changes in the esophageal microbiome are associated with rare chronic inflammatory or neuropathic disease pathogenesis. The paucity of knowledge about the microbiota-driven mechanisms in esophageal disease pathogenesis is mainly due to the scarce sensitivity of sequencing technology and culture methods applied so far to study commensals in the esophagus. However, the recent advances in molecular techniques, especially with the advent of non-culture-based genomic sequencing tools and the implementation of multi-omics approaches, have revolutionized the microbiome field, with promises of implementing the current knowledge, discovering more mechanisms underneath, and giving insights into the development of novel therapies aimed to re-establish the microbial equilibrium for ameliorating esophageal diseases..

Manual censoring of impedance tracings by the Wingate consensus reduces the number of impedance episodes, impacting on reflux categorization

BACKGROUND

The Lyon consensus classifies the evidence of gastroesophageal reflux (GERD) based on endoscopic features and results of pH/impedance monitoring (pH-MII) including the post-reflux swallow-induced peristaltic wave index (PSPWI) and mean nocturnal baseline impedance (MNBI). The Wingate consensus established criteria to reduce inter-reviewer variability when assessing reflux episodes and PSPWI by impedance. This study aims to assess the influence of the Wingate criteria on the different pH-MII parameters obtained by automated analysis.

METHODS

Thirty consecutive pH-MII off PPI were reviewed according to Wingate criteria. Number of impedance episodes and PSPWI were compared before and after censoring from automatic analysis. Reflux categorization according to Lyon consensus between censored and uncensored data was compared. Pearson correlations between impedance parameters and censored episodes were calculated.

KEY RESULTS

Censoring the tracings significantly reduced the number of reflux episodes (66 [42-90.25] vs. 44.5 [21.5-61.5], p = 0.0105). Reasons for censoring were as follows: 1/ anterograde episode: 9.5 [6-13], 2/ impedance drop <50%: 1 [0-3], 3/ duration <4 s: 1 [0-2], 4/ <2 distal channels: 2.5 [1-4], and 5/ artifacts: 2 [1-5]. Censored episodes were in majority non-acid (16.5 [13-26.5] vs. 2 [0-4], p < 0.00001). Censoring altered the categorization of impedance episodes (<40 episodes, 6 vs. 13 for resp. uncensored vs. censored tracings, 40-80 episodes: 13 vs. 13, and >80 episodes: 11 vs. 4, p = 0.0264), but not the symptom index, the symptom association probability, or the categorization according to the Lyon consensus. Nevertheless, individual tracings were affected. The percentage of censored episodes was inversely correlated with the number of acidic impedance episodes (r = -0.62, p = 0.0002).

CONCLUSION AND INFERENCES

Manual interpretation of impedance tracings based on the Wingate consensus reduces the number of impedance episodes, impacting on reflux categorization. Acidic reflux episodes are less likely to be censored, harboring a potential at improving automatic pH-MII analysis.

The Spectrum of Treatment Modalities for Gastroesophageal Reflux Disease (GERD): A Narrative Review

Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disease that is encountered and treated by physicians all over the world. It is a chronic and non-progressive condition. Symptoms can range from mild heartburn to chronic, recurrent, and severe symptoms like constant acid regurgitation, laryngitis, bad breath, otitis media, and severe heartburn, which can be debilitating to the patient. Hence, the administration of appropriate therapy according to the patient's severity of symptoms is imperative, more so because over-the-counter drugs like antacids are very common to treat GERD. Often, in some instances, mere changes in lifestyle prove highly effective in reversing GERD symptomatology. Depending on the severity, response to treatment, and presence or absence of complications, treatment with medical or surgical modalities can be decided. It has now been found that although the gold standard in medical therapy for GERD has been proton pump inhibitors (PPIs), there has been increasing research about their side effects and recurrence after treatment. Hence, newer anti-GERD drugs have been under trial, which has been discussed in detail in the review. The use of surgical fundoplications has drastically decreased and is being widely replaced by incisionless laparoscopic fundoplications and newer endoluminal techniques such as the LINX device. This review aims to compile the vast spectrum of treatment modalities for GERD, ranging from more contemporary diagnostic methods, lifestyle modifications, medical therapy, and surgical and endoluminal techniques, with a particular focus on newer directions.

Revision paraesophageal hernia repair outcomes in patients with typical and atypical reflux

BACKGROUND

Revision laparoscopic anti-reflux surgery (RLARS) is effective in alleviating the typical symptoms of gastroesophageal reflux disease (GERD). RLARS outcomes in patients with atypical GERD symptoms has not been well established. A composite Reflux Symptom Index (RSI) score greater than 13 indicates extraesophageal manifestation of pathological reflux. In this study, we analyzed the differences in quality-of-life (QOL) and perioperative outcomes between patients with atypical versus typical GERD who underwent RLARS.

METHODS

A retrospective review was conducted of a prospectively maintained database of patients with pathologic reflux who underwent RLARS from February 2003 to October 2019. The cohort was divided into two groups, those with typical versus atypical manifestations of GERD, as defined by their RSI score. Patients with a RSI score of  > 13 were assigned to the Atypical group and those ≤ 13 were assigned to the Typical group. Patient QOL outcomes were prospectively followed using the RSI survey. Significance was defined by p-value less than 0.05.

RESULTS

A total of 133 patients (Typical 61, Atypical 72) were included in the final analysis. The two groups were similar (p > 0.05) in mean age (58.1 ± 13.3 vs. 55.3 ± 15.5 years), body mass index (29.6 ± 5.0 vs. 30.3 ± 5.4), female sex distribution (60.7% vs. 59.7%) and age adjusted Charlson score (1.76 ± 1.58 vs. 1.98 ± 1.94). The Typical group had a higher frequency of type III hiatal hernia (62.3% vs. 29.2%) and Collis gastroplasty (29.5% vs. 5.6%). The groups had similar rates of partial and complete fundoplication with similar median length of stay (Typical: 3.0 ± 3.4 days vs. Atypical: 2.4 ± 1.7 days). After a mean follow-up of 30.2 ± 33.6 months, both groups reported similar rates of improvement in RSI outcome from baseline (58.1% vs 43.3%, p = .149). However, the RSI outcome at the latest follow-up for the Typical group was significantly better than the Atypical group after RLARS (2.8 ± 5.3 vs. 15.9 ± 11.1, respectively).

CONCLUSION

Patients who undergo revision paraesophageal hernia repair with objective findings of GERD and subjective complaints of atypical reflux symptoms may show long-term improvement in QOL outcomes. However, these results are contingent on proper patient selection and a thorough work-up for pathological reflux in this population. Further research is needed to determine universal diagnostic criteria to assist in the early detection and surgical treatment of patients with atypical GERD.

Associations between gastro-oesophageal reflux disease and a range of diseases: an umbrella review of systematic reviews and meta-analyses

OBJECTIVE

Numerous meta-analyses have revealed the association between gastro-oesophageal reflux disease (GORD) and a range of diseases; however, the certainty of the evidence remains unclear. This study aimed to summarise and assess the certainty of evidence derived from meta-analyses.

METHODS

Embase, PubMed, Web of Science, Cochrane Databases of Systematic Reviews, CNKI and Wangfang databases from their inception to 22 February 2020 were queried for systematic reviews and meta-analyses on the association between GORD and various diseases. The methodological quality of the included studies was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), and evidence certainty was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Statistical analysis was conducted using Stata V.15.

RESULTS

Ten publications with associations between GORD and different types of diseases were included. There was high heterogeneity (I² >75%) among seven independent meta-analyses. Evidence for publication bias in two independent meta-analyses was also observed. According to the AMSTAR 2 approach, the methodological quality was high for 20% of meta-analyses, moderate for 10%, low for 40% and critically low for 30%. Based on GRADE approach, the certainty of evidence was high for the association between GORD and higher risk of chronic obstructive pulmonary disease (COPD) exacerbation (OR 5.37; 95% CI 2.71 to 10.64) and higher prevalence of oesophageal adenocarcinoma (OR 4.57; 95% CI 3.89 to 5.36), and it was moderate for the association between GORD and higher chronic rhinosinusitis prevalence (OR 2.16; 95% CI 1.37 to 3.48).

CONCLUSION

The association between GORD and a range of diseases was extensively studied, and our findings revealed a high certainty of evidence of the association between GORD and an increased risk of COPD exacerbation as well as increased prevalence of oesophageal adenocarcinoma. Further investigations using systematic reviews and meta-analyses of high methodological quality that include prospective large cohort studies and adjusted confounders are warranted.

PROSPERO REGISTRATION NUMBER

CRD42019122264.

Extra-Esophageal Presentation of Gastroesophageal Reflux Disease: 2020 Update

Gastroesophageal reflux disease (GERD) is defined by the presence of symptoms induced by the reflux of the stomach contents into the esophagus. Although clinical manifestations of GERD typically involve the esophagus, extra-esophageal manifestations are widespread and less known. In this review, we discuss extra-esophageal manifestations of GERD, focusing on clinical presentations, diagnosis, and treatment. Common extra-esophageal manifestations of GERD include chronic cough, asthma, laryngitis, dental erosions, and gingivitis. Extra-esophageal involvement can be present also when classic GERD symptoms are absent, making the diagnosis more challenging. Although available clinical studies are heterogeneous and frequently of low quality, a trial with proton pump inhibitors can be suggested as a first-line diagnostic strategy in case of suspected extra-esophageal manifestations of GERD.

Efficacy of Chinese Herbal Formula Sini Zuojin Decoction in Treating Gastroesophageal Reflux Disease: Clinical Evidence and Potential Mechanisms

Background

Based on 122 cases reported in China, data mining indicated that Sini Powder (SNP) and the Zuojin Pill (ZJP) are both widely used as the basic recipe for treating Gastroesophageal Reflux Disease (GERD).

Objectives

To evaluate the intervention effects of Sini Zuojin Decoction (SNZJD) in patients with GERD.

Methods

A comprehensive collection of randomized controlled trials (RCTs) using SNZJD in patients with GERD that were published in domestic and foreign journals was made by computer retrieval. RevMan 5.3 software was used for meta-analysis and bias risk assessment, Stata 14.0 software was used for sensitivity analysis, GRADE profiler 3.6 was used to evaluate the level of evidence, and trial sequential analysis (TSA), employed to control for random errors, was performed to assess the main outcomes. Network pharmacology analysis was applied to preliminarily study the mechanisms of action of SNZJD on GERD.

Results

Thirteen articles were eventually included, covering a total of 966 patients. Meta-analysis indicated that: ① the SNZJD plus traditional stomach medicines (SPTSM) group was more effective than the traditional stomach medicines (TSM) group (RR = 1.16, 95% CI [1.04, 1.29], P = 0.009); ② the experimental group with SNZJD was significantly better than TSM controls in improving heartburn, substernal chest pain, acid regurgitation, and food regurgitation symptoms (P < 0.0001); ③ SPTSM could significantly decrease total symptom scores with substantial effectiveness (P < 0.00001). The recurrence rate and adverse effects of SNZJD treatment were significantly reduced (P < 0.05). TSA showed that the effective rate of meta-analysis might be reliable, but the recurrence and safety results were still uncertain. According to the evaluation by the GRADE method, the quality of evidence was low. Besides, SNZJD might treat GERD by acting on related targets and pathways such as inflammation, hormone regulation, and so on.

Conclusions

SNZJD might be useful in the treatment of GERD, but its long-term effects and specific clinical mechanisms are unclear. Due to the poor quality of the evidence, more samples and high-quality clinical studies should be tested and verified in the future.