Hiatus hernia in gastroesophageal reflux disease

Building a model for day case hiatal surgery - Lessons learnt over a 10 year period in a high volume unit: A case series

BACKGROUND

Laparoscopic anti-reflux surgery has become the standard treatment for symptomatic gastro-oesophageal reflux disease refractory to medical therapy. Successful anti-reflux surgery involves safe, minimally invasive surgery, resulting in symptom resolution with minimal side effects. This study aims to assess the feasibility and safety of day case anti-reflux surgery focussing on peri- and post-operative outcomes as a measure of success.

METHODS

Data was collected from the hospital database from 2003 to 2012. Data collection included demographics, surgeon, mode of admission, length of stay and complications. Electronic records were independently scrutinised for all patients with a length of stay of more than two nights.

RESULTS

723 patients underwent laparoscopic fundoplication ± small hiatus hernia repair (<5 cm) with a day case rate of 67.1%. The 30 day readmission rate in these patients was 2.9% (21/723 patients). Nine patients had a failure of their initial laparoscopic fundoplication (defined as recurrence of symptoms). Three patients required a re-operation within 12 months of their initial procedure (re-operation rate = 0.41% (3/723 patients)).

CONCLUSION

Laparoscopic hiatal surgery can be performed safely as a day case in high volume specialist centres with good outcomes. Raising the national standard for day case fundoplication promotes good practice and should be the model for future commissioning.

Esophagogastric Junction Morphology and Distal Esophageal Acid Exposure

BACKGROUND

The Chicago classification has recently added a morphological subclassification for the esophagogastric junction (EGJ). Our aim was to assess the distal esophageal acid exposure in patients with this new Chicago EGJ-type IIIa and IIIb classification.

STUDY DESIGN

From a prospectively collected high-resolution manometry (HRM) database, we identified patients who underwent 24-h pH study between October 2011 and June 2015 and were diagnosed with EGJ-type III based on HRM. Chicago EGJ-type III is defined as the inter-peak nadir pressure ≤gastric pressure and a lower esophageal sphincter (LES)-crural diaphragm (CD) separation >2 cm [IIIa-pressure inversion point (PIP) remains at CD level and IIIb-PIP remains at LES level]. We classified the patients into reflux group [DeMeester score >14.72 or Fraction time pH (<4) > 4.2 %] and non-reflux group based on 24-h pH study.

RESULTS

Fifty patients were identified that satisfied the study criteria, of which 37 patients (74 %) were EGJ-type IIIa. In those with EGJ-type IIIb, abdominal LES length (AL) in reflux group was significantly shorter than the non-reflux group (0.8 vs. 1.8, p < 0.05). EGJ-type IIIa patients showed significantly higher value for DeMeester score and Fraction time pH and more often had a positive pH study than EGJ-type IIIb patients (DeMeester score: 26.7 vs. 11.7, p < 0.05; Fraction time pH: 7.9 vs. 2.6, p < 0.05; positive pH study: 81.1 vs. 30.8 %, p < 0.001). Reflux was more common in LES-CD ≥ 3 cm than that in LES-CD < 3 cm (85 vs. 56.7 %, p < 0.05).

CONCLUSION

A subset of patients with >2-cm LES-CD separation (type IIIb) maintain a physiological intra-abdominal location of the EGJ and are less likely to have reflux. A LES-CD ≥ 3 cm seems to discern a hiatus hernia of clinical significance.

The diagnosis of gastro-esophageal reflux disease cannot be made with barium esophagograms

BACKGROUND

For over 50 years, barium studies have been used to diagnose gastro-esophageal reflux disease (GERD), but the value of this test is controversial. Our study aimed to determine if barium esophagograms can be used to diagnose GERD.

METHODS

Barium esophagograms and pH-impedance measurement were performed in 20 subjects with reflux symptoms. pH-impedance measurements were used as gold standard for the diagnosis of GERD. Gastro-esophageal reflux measured with the barium study was defined as a positive outcome.

KEY RESULTS

50% of patients presented gastro-esophageal reflux on the barium esophagogram. No significant differences were observed in acid exposure time between subjects with (median: 7.4%; interquartile range, IQR: 8.4%) or without reflux at barium esophagography (median: 5.95%; IQR: 13.05%; p > 0.05). Nor did we find differences in median proximal extent of reflux measured with impedance monitoring between patients with a positive (median: 6.7%; IQR: 1.95%) and negative barium study (median: 7.1%; IQR: 0.68%; p > 0.05). Patients with reflux on barium esophagogram did not have a positive symptom association probability more often than those who did not have reflux at barium esophagography. Lastly, there were no differences in numbers of acid, weakly acidic or total reflux episodes between those with positive or negative barium esophagogram (p > 0.05). No correlations were found between the maximum proximal extent of gastro-esophageal reflux during esophagography and pH-impedance parameters.

CONCLUSIONS & INFERENCES

Presence or absence of gastro-esophageal reflux during barium esophagography does not correlate with incidence or extent of reflux observed during 24-h pH-impedance monitoring and is not of value for the diagnosis of GERD.

Short segment hiatal hernia: is it a clinically significant entity?

INTRODUCTION

Hiatal hernia (HH) is a well-known contributory factor of gastroesophageal reflux disease (GERD). However, studies on the clinical significance of simple small HH are lacking. We conducted a study to clarify the clinical significance of short segment HH (SSHH) in relation to GERD.

METHODS

4,592 consecutive cases (male/female: 2,076/2,516, median age: 49 years) examined with diagnostic esophagogastroduodenoscopy for the first time were enrolled. During the insertion of endoscope, presence of HH was determined and the length was measured, if present. The relationships between gender, age, presence of erosive esophagitis, and columnar-lined esophagus (CLE) and the lengths of HH were analyzed.

RESULTS

Among 4,592 cases, HH was present in 428 cases (9.3%); SSHH was found in 255 cases (5.6%) and long segment HH (LSHH) in 173 cases (3.8%). HH was more frequent among males and patients with LSHH tended to be older. Erosive esophagitis was observed in 4.8%, 22.0%, and 37.0% of no HH, SSHH, and LSHH group, respectively (p <0.05). CLE was observed in 14.4%, 36.5%, and 24.3% of no HH, SSHH, and LSHH group, respectively (p <0.05).

CONCLUSIONS

SSHH is not a clinically silent and "innocent entity," but rather a condition with a significant pathologic significance similar to LSHH in regard to GERD.

The effect of hiatal hernia on gastroesophageal reflux disease and influence on proximal and distal esophageal reflux

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a very common disorder that substantially affects the patient's quality of life.

AIM

Our aim was to detect the frequency of GERD in patients with hiatal hernia (HH), to compare the acid reflux pattern in patients with and without HH, and to search the relationship between the erosive gastroesophageal reflux (GER) and HH.

METHODS

Forty patients with HH diagnosed by at least two methods, and 121 patients with GERD as a control group were studied. The frequency of GERD in patients with HH, the acid reflux pattern, the relation of body mass index and erosive esophagitis with HH and control group was studied.

RESULTS

Among patients with HH 67.5% of patients had GER. On comparison of acid reflux pattern, the isolated distal esophageal reflux was seen more in patients with HH than in the control group (P < 0.0001). Erosive GERD was seen more in patients with HH than in the control group (P = 0.017). There was no difference in body mass indices between patients with HH and erosive gastroesophageal reflux disease and patients with HH and non-erosive GERD.

CONCLUSION

Hiatal hernia is very closely associated with GERD, and isolated distal esophageal reflux is seen more in patients with HH than in patients without HH. There is no effect of body mass index on GER in patients with HH.

Comparison of four proton pump inhibitors for the short-term treatment of esophagitis in elderly patients

AIM: To compare efficacy and tolerability of four proton pump inhibitors (PPIs) commonly used in the short-term therapy of esophagitis in elderly patients.

METHODS: A total of 320 patients over 65 years with endoscopically diagnosed esophagitis were randomly assigned to one of the following treatments for 8 wk: (1) omeprazole 20 mg/d; (2) lansoprazole 30 mg/d; (3) pantoprazole 40 mg/d, or (4) rabeprazole 20 mg/d. Major symptoms, compliance, and adverse events were recorded. After 8 wk, endoscopy and clinical evaluation were repeated.

RESULTS: Per protocol and intention to treat healing rates of esophagitis were: omeprazole = 81.0% and 75.0%, lansoprazole = 90.7% (P = 0.143 vs omeprazole) and 85.0%, pantoprazole = 93.5% (P = 0.04 vs omeprazole) and 90.0% (P = 0.02 vs omeprazole), rabeprazole = 94.6% (P = 0.02 vs omeprazole) and 88.8% (P = 0.04 vs omeprazole). Dividing patients according to the grades of esophagitis, omeprazole was significantly less effective than the three other PPIs in healing grade 1 esophagitis (healing rates: 81.8% vs 100%, 100% and 100%, respectively, P = 0.012). Pantoprazole and rabeprazole (100%) were more effective vs omeprazole (89.6%, P = 0.0001) and lansoprazole (82.4%, P = 0.0001) in decreasing heartburn. Pantoprazole and rabeprazole (92.2% and 90.1%, respectively) were also more effective vs lansoprazole (75.0%, P < 0.05) in decreasing acid regurgitation. Finally, pantoprazole and rabeprazole (95.2% and 100%) were also more effective vs lansoprazole (82.6%, P < 0.05) in decreasing epigastric pain.

CONCLUSION: In elderly patients, pantoprazole and rabeprazole were significantly more effective than omeprazole in healing esophagitis and than omeprazole or lansoprazole in improving symptoms. H pylori infection did not influence the healing rates of esophagitis after a short-term treatment with PPI.

Are there any differences between nutcracker esophagus with and without reflux?

"Nutcracker esophagus" (NE) is a primary esophageal motor disorder, first described in patients with noncardiac chest pain. In recent years NE has been associated with gastroesophageal reflux disease (GERD). In this study we compare patients with NE with and without GERD, as defined by pHmetry or endoscopy, with respect to clinical, endoscopic, radiologic, and manometric findings. Fifty-two patients with NE were studied. They were divided in two groups: GERD (17-32.6%) and non-GERD (35-67.4%) patients. Females predominated in both groups, with no significant difference in age (p>0.05). Chest pain was the chief complaint in both groups (p>0.05). Clinical findings in patients with and without reflux included chest pain (52.9% and 51.4%), dysphagia (58.8% and 42.8%), and heartburn (64.7% and 42.8%), followed by regurgitation, dyspepsia, ear, nose, and throat (ENT) complaints, respiratory symptoms, and odynophagia (p>0.05). Erosive esophagitis was found in three patients (5.7%). There were no differences between groups in the findings of barium swallow studies and all manometric findings were similar for both groups (p>0.05). We conclude that there were no differences in patients with NE with or without associated reflux disease. It is important to diagnose reflux properly so patients can be treated adequately.

Clinical analysis of gastroesophageal reflux after PEG

BACKGROUND

It is difficult to predict whether or not gastroesophageal reflux (GER), such as aspiration or vomiting, will occur after PEG.

OBJECTIVE

To identify factors that would support the prediction of aspiration after PEG.

DESIGN

Case-control study.

SETTING

Patients who underwent PEG from February 1998 to June 2005 in our hospital.

PATIENTS

The study included 178 patients.

INTERVENTIONS

Endoscopic observation was carried out during PEG tube placement and at PEG tube replacement to determine the presence of hiatus hernia and/or reflux esophagitis.

MAIN OUTCOME MEASUREMENTS

Gastric emptying and GER index (GERI) were measured by using a radioisotope technique.

RESULTS

The patients were divided into 2 groups: the non-GER (NGER) group (n = 108), who had no symptoms of GER, and the GER group (n = 70), who showed these symptoms. No significant differences were observed between the groups in age, sex, morbidity, the presence of reflux esophagitis at PEG tube placement, gastric emptying, or serum albumin levels. The presence of a hiatus hernia (P = .028) and reflux esophagitis grading Los Angeles classification C or D (P = .008) were significantly more frequent in the GER group compared with the NGER group. The GERI was also significantly higher in the GER group than in the NGER group (P < .0001).

CONCLUSIONS

The presence of hiatus hernia, severe reflux esophagitis, and a high GERI might be predictive factors of aspiration or vomiting after PEG tube placement.

Clinical features of reflux esophagitis in older people: a study of 840 consecutive patients

OBJECTIVES

To compare symptoms and other clinical characteristics of reflux esophagitis in patients of different ages.

DESIGN

Observational cross-sectional study of consecutive patients.

SETTING

Geriatric Unit, Casa Sollievo della Sofferenza Hospital, Istituto di Ricovero e Cura a Carattere Scientifico.

PARTICIPANTS

Eight hundred forty patients with endoscopically diagnosed erosive esophagitis divided into four groups according to age (young (<50, mean 36.7, n=114), adult (50-69, mean 59.1, n=126), elderly (70-84, mean 77.3, n=425), and very elderly (>or=85, mean 88.4, n=175)).

MEASUREMENTS

Gastrointestinal symptoms were evaluated using the Gastrointestinal Symptom Rating Scale questionnaire. Other symptoms were recorded when present as an indication for endoscopy. Severity of esophagitis, presence of Helicobacter pylori infection, presence and size of hiatus hernia, Barrett's esophagus, antrum or corpus gastric atrophy, and nonsteroidal antiinflammatory drug (NSAID) use were also evaluated.

RESULTS

Elderly and very elderly patients had a significantly lower prevalence of typical gastroesophageal reflux disease symptoms (heartburn or acid regurgitation (P<.001) and epigastric pain (P<.001)) than young and adult patients. Conversely, the prevalence of other symptoms (anorexia (P<.001), weight loss (P<.007), anemia (P<.001), vomiting (P<.001), and dysphagia (P<.001)) significantly increased with age. The prevalence of severe esophagitis (P<.001), hiatus hernia (P<.005), the size of hiatus hernia (P<.001), antrum and corpus gastric atrophy (P<.05) and NSAID use (P<.005) also significantly increased with age. Multivariate analysis demonstrated that older age (65-84, odds ratio (OR)=2.66, 95% confidence interval (CI)=1.38-5.12; >or=85, OR=4.57, 95% CI=2.15-9.71), hiatus hernia larger than 3 cm in diameter (OR=2.38, 95% CI=1.41-4.01), and male sex (OR=2.83, 95% CI=1.72-4.64) are independent risk factors for severe esophagitis, whereas H. pylori infection, gastric atrophy, NSAID use, and the presence of hiatus hernia were not.

CONCLUSION

Elderly patients with reflux esophagitis had less-typical and more-nonspecific symptoms than young or adult patients. Old age, male sex, and hiatus hernia size greater than 3 cm are significantly associated with severe esophagitis. Clinicians caring for older patients should be aware of the nonspecific presentation and potential severity of reflux esophagitis in this population.

Effect of Helicobacter pylori eradication on the outcome of reflux esophagitis and chronic gastritis in the elderly. A randomized, multicenter, eight-month study

BACKGROUND

The effect of Helicobacter pylori eradication on the clinical outcome of esophagitis in elderly patients is controversial.

AIM

To evaluate the effect of H. pylori eradication on clinical outcome of esophagitis and on chronic gastritis and its activity.

MATERIALS AND METHODS

Sixty-one symptomatic elderly patients with esophagitis and H. pylori infection were randomized into two groups. Group 1 (PPI-only, 30 patients) was treated with pantoprazole 40 mg daily for 2 months followed by pantoprazole 20 mg daily for a further 6 months; group 2 (PPI + eradication, 31 patients) was treated as group 1 plus a 1-week course of amoxicillin 1 g twice daily and clarithromycin 250 mg twice daily. Endoscopy with gastric biopsies, 13C-UBT and clinical visits were repeated after 2 and 8 months.

RESULTS

After 8 months, the intention-to-treat H. pylori eradication rates were 19.2% in group 1 vs. 80.7% in group 2 (p < 0.0001). No differences between group 1 and group 2 were observed in symptoms improvement (77 vs. 77%, p = n.s.) and healing rates of esophagitis (92.3 vs. 88.5%, p = n.s.). A significant decrease in the prevalence of moderate/severe chronic gastritis (from 52.2 to 4.7%, p = 0.002) and its activity (from 38 to 4.7%, p = 0.02) was observed in the antrum of patients of group 2, and not in patients of group 1. While a nonsignificant reduction in the chronic gastritis activity (from 28.6 to 4.7%, p = 0.09) was observed in the corpus of the eradicated patients of group 2, conversely a significant worsening of the chronic gastritis activity was found in the corpus of group 1 patients (from 25 to 60%, p = 0.05).

CONCLUSION

The eradication of H. pylori infection does not affect the clinical outcome of esophagitis, while it improves chronic gastritis and its activity in elderly patients on short- and long-term treatment with PPIs. These findings suggest that H. pylori infection should be eradicated in elderly patients with esophagitis who need maintenance treatment with PPI.

Intermittent spatial separation of diaphragm and lower esophageal sphincter favors acidic and weakly acidic reflux

BACKGROUND & AIMS

In small hiatal hernias, the size of the hernia is variable. Intermittent complete reduction can be observed with high-resolution manometry as a transition from a double-peak (hernia) to a single-peak (reduced) high-pressure zone. The aim of this study was to investigate whether intermittent separation of the diaphragm and lower esophageal sphincter (LES) favors the occurrence of gastroesophageal reflux.

METHODS

In 16 patients with a small hiatal hernia (3 cm), prolonged high-resolution manometry was performed. Acid and weakly acidic reflux episodes were detected with pH-impedance monitoring.

RESULTS

The single pressure peak profile (reduced hernia) was present for 814 minutes (56.5% of total time), and the double peak profile (unreduced hernia) was present for 626 minutes (43.5% of total time). In all patients, both pressure profiles were observed. The transition rate between the 2 profiles was 7.5 +/- 0.9 per hour. More reflux occurred when the LES and diaphragm were separated versus the reduced hernia state (23.1 +/- 5.1 vs 12.2 +/- 2.4 episodes per hour, respectively; P < .05). The proportions of acidic reflux episodes during the single and double pressure peaks were similar (70% and 67%, respectively). In the two-pressure-zone state, there was an increase in all reflux mechanisms except transient LES relaxation.

CONCLUSIONS

In patients with a small hiatal hernia, intermittent reduction of the hernia occurs frequently. Spatial separation of the diaphragm and LES in the nonreduced state results in a 2-fold increase in acidic and weakly acidic reflux due to mechanisms other than transient LES relaxation.

Endoscopic measurement of cardia circumference as an indicator of GERD

BACKGROUND

It is theorized that repeated gastric distention leads to dilatation of the cardia and the development of GERD. We hypothesize that cardia circumference correlates with the presence and the severity of GERD, and we developed software to measure cardia circumference from static endoscopic images. Our aims were to validate the software and to quantify cardia circumference along the spectrum of GERD.

METHODS

Software-based measurements were compared with actual measurements in animal and mechanical models. A retrospective review of an endoscopic database and patient charts produced 273 subjects, grouped as follows: controls, GERD, < or = 3-cm Barrett's esophagus, or > 3-cm Barrett's esophagus. A blinded abstractor measured cardia circumference by using images from the database.

RESULTS

Software and actual measurements correlated closely and were reproducible among observers. Median cardia circumference for each group was the following: control, 31.8 mm; GERD, 37.8 mm; < or = 3-cm Barrett's esophagus, 38.4 mm; and > 3-cm Barrett's esophagus, 45.0 mm (p < 0.001). By using 34.3 mm as a cutoff, cardia circumference was 85.3% sensitive and 89.6% specific for the diagnosis of GERD.

CONCLUSIONS

There was a direct relationship between cardia circumference and the presence of GERD. This finding augments our understanding of the anatomic contributions of the esophagogastric junction in the pathogenesis of GERD. Cardia measurement may prove to be a useful diagnostic tool.

Gastroesophageal reflux disease beyond infancy

BACKGROUND

Children beyond infancy (>12 months of age) rarely have gastroesophageal reflux disease (GERD). Underlying diseases may contribute to the persistence of GERD from infancy to childhood. This study compares the clinical course of children with GERD with and without underlying diseases.

METHODS

The authors studied the role of underlying diseases responsible for GERD in children beyond infancy by a retrospective analysis. From 1985 to 2000, GERD was confirmed in 34 children beyond infancy in the National Taiwan University (median age 2.5 years, range 1.1-9.7 years), according to the inclusion criteria of reflux symptoms and the fraction of pH < 4 above 5% in the 24-h esophageal pH study. The patients were divided into two groups: those without underlying diseases (n=10) and those with underlying diseases (n=24). The follow-up duration was 0.5-17.1 years (median 4.5 years).

RESULTS

The underlying diseases responsible for GERD in 24 children included neurological impairment (n=14), repaired esophageal atresia (n=2), hiatal hernia (n=3), repaired congenital diaphragmatic hernia (n=2), and congenital heart disease (n=3). At the end of the study, 9 of 10 children with GERD beyond infancy and without underlying diseases were free of symptoms without any need for further medical treatment. In contrast, 10 of 14 children with neurological disorders had persisting reflux symptoms (Kaplan-Meier analysis, P=0.02, log-rank test).

CONCLUSIONS

Neurological impairment and esophageal or diaphragmatic anatomic abnormalities were frequently associated with GERD beyond infancy. Children with underlying diseases, especially with neurological impairment, ran a refractory course, while those without underlying diseases enjoyed a longer symptom-free life.

The role of hiatus hernia in gastro-oesophageal reflux disease

This article gives an overview of the role of sliding hiatus hernia in gastro-oesophageal reflux disease (GORD). The crural diaphragm acts as an external sphincter of the anti-reflux barrier. Contractions of the crural diaphragm increase lower-oesophageal-sphincter (LOS) pressure during each inspiration and in situations of increased abdominal pressure, whereas these contractions are inhibited when gas and/or a bolus has to pass the gastro-oesophageal junction. A hiatus hernia is associated with GORD symptoms, increased oesophageal acid exposure, and oesophagitis and its severity. In patients with hiatus hernia, the incidence of reflux episodes is increased during periods with low LOS pressure, straining and swallowing. These findings underline the importance of the crural diaphragm, which, when surrounding the LOS, protects against gastro-oesophageal reflux.

Short- and long-term therapy for reflux oesophagitis in the elderly: a multi-centre, placebo-controlled study with pantoprazole

BACKGROUND

No placebo-controlled clinical trials have yet been published on the efficacy of therapy in older subjects with oesophagitis.

AIM

To evaluate the efficacy of pantoprazole in preventing the recurrence of oesophagitis in elderly subjects.

METHODS

One hundred and sixty-four patients aged 65 years and over with acute oesophagitis were treated openly with pantoprazole, 40 mg daily, for 8 weeks. Patients with documented healing of erosive oesophagitis were then treated with pantoprazole, 20 mg daily, for 6 months. Thereafter, cured patients were randomized to receive pantoprazole, 20 mg daily, or placebo for the following 6 months. Clinical evaluations were performed every 2 months, and endoscopy was repeated after 8 weeks and after 6 and 12 months and/or whenever symptoms suggested a relapse of oesophagitis.

RESULTS

After 8 weeks, the healing rates of oesophagitis were 81.1% (75.1-87.1%) and 93.7% (89.7-97.7%) by intention-to-treat and per protocol analyses, respectively. After 6 months, the corresponding values were 82% (75.4-88.5%) and 92.4% (87.6-97.2%), respectively. After 12 months, the per protocol and intention-to-treat healing rates of oesophagitis were 95.1% (88.5-100%) and 79.6% (68.3-90.9%), respectively, in the treatment group vs. 32.7% (19.9-45.4%) and 30.4% (18.3-42.4%), respectively, in the placebo group (P = 0.0001). Heartburn, acid regurgitation and chest pain were significantly associated with the relapse of oesophagitis (P = 0.0001), whereas hiatus hernia, Helicobacter pylori infection, concomitant diseases and treatments were not.

CONCLUSION

In the elderly, pantoprazole was highly effective in healing and reducing the relapse of oesophagitis; discontinuing active treatment after 6 months was associated with a significant increase in the relapse rate.

Long-term clinical outcome of elderly patients with reflux esophagitis: a six-month to three-year follow-up study

Although the prevalence of reflux esophagitis is known to increase with age, data on the long-term outcome of esophagitis in elderly patients are scarce. We sought to evaluate the clinical outcome of elderly patients with esophagitis 6 months to 3 years after diagnosis and to identify specific prognostic indicators of a poor outcome. This was a long-term (6 months to 3 years) follow-up study. Patients older than 65 years of age diagnosed as having reflux esophagitis healed after acute treatment (2 to 4 months) were included in the study. Clinical examinations and upper gastrointestinal endoscopy were performed every 6 months for the first year and annually thereafter. After healing, no therapy was prescribed; in the event of symptom recurrence, a maintenance therapy consisting either of H2 blockers or proton pump inhibitors (PPI) was prescribed. At baseline and during follow-up, the following clinical parameters were recorded: gender, age, the presence of symptoms (heartburn, acid regurgitation, epigastric/chest pain), type and dose of the maintenance therapy, nonsteroidal antiinflammatory drug use; gastric Helicobacter pylori infection, diagnosis of hiatal hernia, and/or Barrett's esophagus. The chi-square test, the Kaplan-Meier test, and Cox's proportional hazards regression analysis were used for statistical analyses. Included in the final analysis were 138 patients (M/F, 81/57; mean age, 79.7 years; range, 66-97). The numbers of patients in need of maintenance therapy were 47 of 69 (68.1%) after 6 months, 29 of 58 (50%) after 12 months, 17 of 39 (43.6%) after 24 months, and 12 of 26 (46.1%) after 36 months of follow-up. A significantly higher esophagitis relapse rate was found in patients not treated compared with subjects who were in maintenance therapy: 59% versus 8.5% (P <.0001) at 6 months, 65.5% versus 20.7% at 12 months (P <.002), 63.6% versus 11.7% at 24 months (P =.003), and 57.1% versus 8.3% at 36 months (P =.02). No significant difference in relapse rate was found in patients treated with H2 blockers versus PPIs (21.7% versus 10%). The Cox model demonstrated that no maintenance treatment (P =.00001), the presence of typical symptoms (P =.00001), the presence of hiatal hernia (P =.03), and a high severity grade of esophagitis at baseline (P =.009) were risk factors for relapse of esophagitis. In elderly subjects, esophagitis relapse occurs in a high percentage of cases, particularly in patients not treated with antisecretory drugs. The presence of typical symptoms, hiatal hernia, and a severe grade of esophagitis are risk factors for relapse. The most effective measure for minimizing the occurrence of relapse is a maintenance therapy with antisecretory drugs.

Increased gastric acid secretion after Helicobacter pylori eradication may be a factor for developing reflux oesophagitis

BACKGROUND

The role of acid secretion in reflux oesophagitis which may develop after H. pylori eradication is not well known.

AIM

To investigate the participation of altered gastric acid secretion and the presence of hiatal hernia in the development of reflux oesophagitis after eradication therapy for H. pylori.

SUBJECTS AND METHODS

A total of 105 patients with H. pylori infection, but without reflux oesophagitis at the time of eradication therapy, were followed prospectively for 7 months after the clearance of this microorganism. Gastric acid secretion was assessed by endoscopic gastrin test, and the presence of hiatal hernia by endoscopy.

RESULTS

Reflux oesophagitis developed in 11 out of 105 (10.5%) patients when examined at 7 months after the eradication therapy. The incidence was correlated significantly with the increase in gastric acid secretion after the eradication of H. pylori, and was significantly higher in the patients with hiatal hernia (20%) than in those without it (0%).

CONCLUSIONS

Increased acid secretion after H. pylori eradication is an important risk factor of reflux oesophagitis, especially in patients with hiatal hernia.

Excess gastroesophageal reflux in patients with hiatus hernia is caused by mechanisms other than transient LES relaxations

BACKGROUND & AIMS

Esophageal acid exposure is higher in gastroesophageal reflux disease (GERD) patients with hiatus hernia than in those without. We investigated the effect of a sliding hiatus hernia on the mechanisms underlying spontaneous gastroesophageal reflux over 24 hours.

METHODS

Twelve GERD patients with and 10 GERD patients without hiatus hernia were studied for 24 hours. Combined esophageal pH and manometric recordings of the pharynx, lower esophageal sphincter (LES), and stomach were performed using a multiple-lumen assembly incorporating a Dent sleeve connected to a portable water-perfused manometric system and a pH glass electrode.

RESULTS

Patients with hiatus hernia had greater esophageal acid exposure (7.6% vs. 3.3%; P < 0.01) and more reflux episodes (3.1 vs. 1.8/h; P < 0.001) than those without. LES pressure, the incidence of transient LES relaxations (TLESRs), and the proportion of TLESRs associated with acid reflux were comparable in both groups. Both groups had equal numbers of reflux episodes associated with TLESRs and swallow-associated prolonged LES relaxations. Patients with hiatus hernia had more reflux associated with low LES pressure, swallow-associated normal LES relaxations, and straining during periods with low LES pressure.

CONCLUSIONS

The excess reflux in GERD patients with hiatus hernia compared with those without is caused by malfunction of the gastroesophageal barrier during low LES pressure, swallow-associated normal LES relaxations, deep inspiration, and straining.

Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia

BACKGROUND & AIMS

This study aimed to determine if hiatal hernia influences vulnerability to reflux and transient lower esophageal sphincter relaxation (tLESR) during gastric distention in patients with gastroesophageal reflux disease (GERD).

METHODS

Eight normal subjects and 15 patients with GERD were studied. A metal clip attached to the squamocolumnar junction (SCJ) was beneath the hiatus in all control subjects. Eight GERD patients with >/=1-cm SCJ-hiatus separation were considered hernia patients, and 7 with <1-cm separation were considered nonhernia patients. Manometry and esophageal pH were recorded for 30 minutes, after which the stomach was loaded with acid dextrose and the recording continued for 2 hours with intragastric air infusion of 15 mL/min.

RESULTS

Baseline reflux was comparable among groups. Gastric distention increased the frequency of reflux by the tLESR mechanism in all groups. Controls and nonhernia patients had median increases of 4.0 and 4.5 in tLESR frequency, respectively, and hernia patients had a median increase of 9.5/h. tLESR frequency was highly correlated with the SCJ-hiatus separation (r = 0.76; P < 0.001).

CONCLUSIONS

Gastric air infusion was a potent stimulus for tLESR and reflux. The resultant tLESR frequency was directly proportional to the separation between the SCJ and hiatus, suggesting that the perturbed anatomy associated with hiatal hernia predisposed to eliciting tLESRs in patients with GERD.

Pathogenetic factors affecting gastroesophageal reflux in patients with esophagitis and concomitant duodenal ulcer: a multivariate analysis

AIM: To assess the relationship between gastric acid output (GAO) and both pattern of gastroesophageal reflux (GER) and esophageal lesions, and to evaluate the role of GAO and other potential pathogenetic factors in the development of esophagitis.

METHODS: Gastric acid secretory testing and 24-h intraesophageal pH monitoring were performed in 31 patients with esophagitis and concomitant duodenal ulcer (E + DU) and compared with those of 72 patients with esophagitis (E) alone.

RESULTS: The GAO in patients with E + DU was significantly higher than in patients with E (P < 0.05). There was no significant difference between the two groups of patients as to endoscopicl findings and parameters of GER (P > 0.05). A multiple regression analysis with stepwise deletion showed that the presence of hiatal hernia (HH), GER in upright position and age appeared to correlate significantly with the presence of esophagitis.

CONCLUSIONS: No parallel relationship between GAO and severity of GER or esophageal lesions exists in patients with E + DU, and that GAO is not a major pathogenetic factor in GER disease.

Study of the influence of hiatus hernia on gastroesophageal reflux

AIM: To explore whether the presence of a sliding hiatus hernia influences gastroesophageal reflux.

METHODS: Endoscopy and 24 h pH monitoring were performed for 197 outpatients with gastroesophageal reflux symptoms.

RESULTS: Of the 197 patients with symptoms of gastroesophageal reflux, patients with hiatus hernia accounted for 36%. The incidence of esophagitis in patients with hiatus hernia was significantly higher than that in patients without hiatus hernia. The results of 24 h pH monitoring showed that 84 patients had physiological reflux, 37 had pathological reflux without esophagitis, 64 had reflux esophagitis and 12 had physiological reflux concomitant with esophagitis. All the patients with hiatus hernia had a longer percentage time with supine reflux and a higher frequency of episodes lasting over 5 min at night compared to those without hiatus hernia. The incidence of combined daytime and nocturnal reflux in patients with hiatus hernia was significantly higher than that in patients without hiatus hernia.

CONCLUSION: Pathological reflux and reflux esophagitis in some patients with symptoms of gastroesophageal reflux represent two different stages of gastroesophageal reflux disease. Pathological reflux is the first stage, in which the lower esophageal sphincter is incompetent but the esophageal mucosal resistance effectively prevents regurgitated acid from damaging the esophageal mucosa. Reflux esophagitis represents the second stage, in which the aggression of the regurgitated acid is so strong that the esophageal mucosa fails to resist it and the epithelium of the esophagus is damaged. Patients with hiatus hernia have a high incidence of combined daytime and nocturnal reflux, with the latter being responsible for esophagitis.

The diagnosis and management of gastroesophageal reflux disease

GERD is a common clinical problem. Generally, its clinical presentation and management are straightforward. Greater awareness of the numerous extraesophageal manifestations of the disease aids patients and physicians in appropriate recognition and treatment. Medical therapy is effective in the majority of cases but often requires long-term medication for acceptable symptom control. A small, but significant proportion of patients presents with or develops complications of GERD, most importantly Barrett's esophagus. Although the logistics of long-term surveillance of persons with Barrett's esophagus is unclear, the association of this metaplastic change with esophageal adenocarcinoma underscores the importance of regular follow-up.

Gastro-oesophageal reflux disease in The Netherlands. Results of a multicentre pH study

Information on the relationships between gastro-oesophageal reflux (GOR), reflux symptoms, hiatal hernia (HH) and oesophagitis, and the response to antisecretory treatment is lacking. In a multicentre study endoscopy, ambulatory 24-h pH monitoring and symptom assessment were carried out in 142 patients with symptomatic reflux disease before and during treatment with ranitidine. Using a randomized, double-blind design, patients took ranitidine 150 mg bid or 300 mg bid. Macroscopic oesophagitis (grade I or II) was found in 85 patients; the remaining 57 patients had normal oesophageal mucosa. A significant correlation was found between the presence of an HH and the presence of oesophagitis. Symptom scores were similar in patients with and without oesophagitis, and in patients with and without HH. Patients with oesophagitis had significantly greater oesophageal acid exposure during the night, and in the total 24-h period, but not during the day. Likewise, patients with HH had greater acid exposure during the night (p < 0.008). Both doses of ranitidine significantly decreased oesophageal acid exposure and the effect was independent of baseline acid exposure. Reflux symptoms cannot be used to differentiate between presence or absence of oesophagitis and/or HH. Reflux patients without oesophagitis have less night-time reflux. Ranitidine dose-dependently decreases oesophageal acid exposure, and the effect is independent of baseline reflux.

Gastric acid secretion and pattern of gastroesophageal reflux in patients with esophagitis and concomitant duodenal ulcer. A multivariate analysis of pathogenetic factors

This study was designed to assess the relationship between gastric acid output (GAO) and both pattern of gastroesophageal reflux (GER) and severity of esophageal lesions. Gastric acid secretory testing and 24-h intraesophageal pH-monitoring were performed in 31 patients with esophagitis and concomitant duodenal ulcer (E+DU) and compared with those of 72 patients with esophagitis (E). The second aim of this study was to evaluate the role of GAO and other potential pathogenetic factors in the development of esophagitis. The results of the study showed that GAO in patients with E+DU was significantly higher than in patients with E (p < 0.05). There was no significant difference between the two groups of patients with regard to endoscopic findings or GER variables (p < 0.05). Multiple regression analysis with stepwise deletion showed that the presence of hiatal hernia, GER in the upright position and age appear to correlate significantly with the presence of esophagitis. We conclude that no parallel relationship exists between GAO and severity of GER or esophageal lesions in patients with E+DU and that GAO is not a major pathogenetic factor in GER disease.

Study of 47 consecutive patients with peptic esophageal stricture compared with 3880 cases of reflux esophagitis

The purpose of this study, making use of systematic records on computer over a period of 12 years, was to compare the prevalence and the demographic characteristics of patients with peptic stricture with those having a reflux esophagitis. As compared with 3880 cases of erosive and/or ulcerative esophagitis, the percentage of peptic stricture patients was 1.21%. The latter were on average nine years older and more frequently had a hiatus hernia. Ten patients with peptic stricture had had severe esophagitis previously recorded in our department. Thirty-four peptic stricture patients (72.3%) had at least one condition reported as possibly provocative of stricture. This study stresses the point that the incidence of peptic esophageal stricture is probably far lower than had been reported previously. Consequently, management of low-grade reflux esophagitis should be aimed primarily at relieving symptoms rather than healing esophageal lesions to prevent stricture.

Relationship between endoscopic hiatus hernia and gastroesophageal reflux symptoms

Little is known about the relationship between hiatus hernia (HH) and gastroesophageal reflux symptoms (GERS). Nine hundred and thirty patients submitted to gastroscopy because of symptoms completed a self-administered questionnaire. Fourteen per cent showed esophagitis (ES) and 17% HH. Forty-nine per cent of the patients with HH had endoscopic ES, and 60% of those with ES had HH. The severity of ES was dependent (p less than 0.05) on both the presence and the size of HH. After exclusion of patients with peptic ulcer and malignancy, patients with and without HH and ES were compared with regard to the presence of single symptoms and a weighted GERS score based on symptoms proven to be typical for ES. Only borderline differences were found between patients with ES and HH and those with ES and no HH. The former group, however, presented with significantly (p less than 0.001) more GERS than the patients with HH only. Nevertheless, the patients with HH as the only pathologic finding had significantly (p less than 0.01) more GERS than the patients with no major endoscopic abnormality. This study indicates a close association between HH and gastroesophageal reflux disease and supports the clinical significance of an endoscopically detected HH.

Effects of Buscopan on gastro-oesophageal reflux and hiatus hernia

This prospective study was undertaken to establish whether Buscopan (hyosine butyl bromide) interferes with the detection of a hiatus hernia or induces gastro-oesophageal reflux. One hundred and four consecutive patients were included in the study who came for barium meal and swallow examinations over a period of 3 months. Ten patients were excluded from the study. The examinations were performed by the author. The manoeuvres to detect gastro-oesophageal reflux and hiatus hernia were performed before and after intravenous Buscopan. It was found that Buscopan does not induce gastro-oesophageal reflux in the majority of patients, or interfere with detection of a hiatus hernia. The conclusion of this study is that Buscopan can be given early on in the barium meal examination without a significant effect on hiatal function.

Reproducibility of gastroesophageal reflux scintigraphy and the standard acid reflux test

Patients with symptoms compatible with gastroesophageal reflux (GER) disease and asymptomatic controls were evaluated three times for GER by gastroesophageal reflux scintigraphy (GES) at intervals ranging from 6 h to 15 days and after various periods of fasting. Similarly, in patients and controls, pH monitoring at the distal esophagus was conducted three times by applying the standard acid reflux test (SART) at intervals ranging from 4 h to 3 days after different fasting periods. In 18 of 19 patients and 14 of 15 controls the results of SART were identical on all three occasions. A similar agreement was found for GES in 23 of 25 patients and 20 of 21 controls. The reproducibility of the induced type of reflux after ingestion of acidified orange juice was significantly better than that of the spontaneous types or the induced type of reflux after ingestion of saline. It is concluded that the reproducibility of GES and SART is similarly good.