Gastroesophageal reflux disease. Scintigraphic, endoscopic, and histologic considerations

Questionnaire based gastroesophageal reflux disease (GERD) assessment scales

Questionnaire based assessment scales for gastroesophageal reflux disease (GERD) have been utilized for assessment of the patient's symptomatology, assessment of symptom severity and frequency, assessment of health-related quality of life and for assessment of response to treatment. A multitude of unidimensional and multidimensional questionnaires exist for making symptom assessment and monitoring quality of life in GERD. Many of the scales meet some of the parameters of an ideal evaluative GERD specific assessment instrument. Yet, there are certain shortcomings and challenges which are faced in development of GERD questionnaires. This review discusses the features of an ideal symptom assessment instrument, examines the strengths and weaknesses of currently available questionnaires.

Review article: the nature of oesophageal injury in gastro-oesophageal reflux disease

The purpose of this review was to explore issues relating to the nature of oesophageal injury in gastro-oesophageal reflux disease. Several structural and functional elements of the oesophageal epithelium provide for an inherent resistance against refluxed material. It is only when this defence is overcome that reflux-induced damage ensues. The light microscopic changes in reflux oesophagitis are manifold. Early changes are confined to the epithelium and consist of reactive changes and inflammatory cell infiltration. When the epithelial integrity can no longer be maintained, erosions and ulcers develop. Recently, dilatation of the intercellular spaces was described as a sensitive early marker for gastro-oesophageal reflux disease. This parameter was first identified by electron microscopy but can also be assessed by light microscopy in routinely stained tissue sections. Some of the changes occurring in early gastro-oesophageal reflux disease can be reproduced by incubating oesophageal mucosal biopsies in gastrointestinal fluids or their components. Activated pepsin, trypsin and conjugated bile acids at an acidic pH have been identified as probable causes of reflux-induced damage.

Impact of 24-h esophageal pH monitoring on the diagnosis of gastroesophageal reflux disease: defining the gold standard

BACKGROUND AND AIMS

The tests that are currently available for the diagnosis of gastroesophageal reflux disease (GERD) lack the desired diagnostic accuracy. To date, only pH monitoring has been shown to have a good sensitivity and specificity, but recent studies have failed to confirm this. Thus there is a need to find a test with acceptable sensitivity and specificity for diagnosing GERD. The present study aimed to find a single test or a combination of tests that could serve as a gold standard for the diagnosis of GERD and to identify an evidence-based diagnostic work-up for GERD in clinical and research settings.

METHODS

A prospectively conducted masked study was carried out in which 109 GERD patients were recruited on the basis of symptom score evaluation (heartburn and/or regurgitation). After informed consent was given, the patients underwent various tests, including esophagogastroduodenoscopy with biopsy from the lower esophageal mucosa during the first visit, followed by omeprazole challenge test (OCT), radionuclide scintigraphy, barium swallow and finally 24-h esophageal pH monitoring. A positive concordance of three or more tests was taken as the gold standard.

RESULTS

The results of all six tests were available for 70 patients. As a single diagnostic test, pH testing had the best combination of sensitivity and specificity (Youden's J = 0.69). Even in cases of endoscopy-negative reflux disease, pH monitoring was the most sensitive and specific test (93.3% and 90.4%, respectively; J = 0.83). OCT, endoscopy and histopathology also had good sensitivity (84.4%, 64.4%, 82.2%, respectively). A combination of OCT, endoscopy and histopathology achieved a sensitivity of 100%.

CONCLUSIONS

A combination of OCT, endoscopy and histology will identify all cases of GERD. As these investigations are easily available, they should form the diagnostic work-up in clinical situations. 24-h esophageal pH testing, despite being the gold standard, has no utility in routine clinical settings and hence its availability should be limited to tertiary care settings.

Optimal management of patients with non-ulcer dyspepsia: considerations for the treatment of the elderly

Optimal therapy for patients with non-ulcer dyspepsia still remains elusive. Increasing consensus on the definition of non-ulcer dyspepsia may improve the design of clinical trials and result in more effective therapies for this common condition. This paper reviews the investigation, pathophysiology and therapy of non-ulcer dyspepsia in order to formulate management strategies in the elderly. The best outcome for the patient can be achieved by detailed evaluation, leading to therapy targeted to obvious precipitating factors such as dyspepsia-inducing medications and other aggravating factors such as slow-transit constipation. Prokinetics and, to a lesser extent, H(2) receptor antagonists are the main medications of choice. Cisapride, the best studied prokinetic, has been withdrawn from the market in certain countries because some patients experienced dangerous cardiac arrhythmias, especially when cisapride was given with potent inhibitors of cytochrome P450 3A4. Time spent on reassurance and judicious use of antidepressants for the right patient can help improve symptoms. In the elderly, however, persistent symptoms should be re-evaluated because of the increased incidence of malignancy.

Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease

OBJECTIVE

To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD).

STUDY DESIGN

Retrospective chart review

METHODS

Operative notes of 155 children undergoing direct laryngoscopy and bronchoscopy between 1996 and 1999 for airway symptoms for whom there was a suspicion of EERD were examined. Gastroesophageal reflux disease (GERD) was considered present if at least one test was positive (including upper GI series, pH probe, gastric scintiscan, or esophageal biopsy).

RESULTS

A total of 130 (84%) patients had GERD diagnosed. Ninety percent had at least one laryngotracheal abnormality: 83% had an abnormal larynx and 66% had an abnormal trachea. Laryngeal abnormalities in GERD included postglottic edema, 69%; arytenoid edema, 30%; large lingual tonsil, 16%; vocal fold edema, 12%; vocal fold nodule, 12%; ventricular obliteration, 5%; and hypopharyngeal cobblestoning, 3%. Tracheobronchial abnormalities in GERD included tracheal cobblestoning, 33%; blunting of carina, 12.5%; subglottic stenosis, 11%; increased secretions, 11%; and generalized edema or erythema, 5%. The best sensitivity or specificity was obtained by combining postglottic edema, arytenoid edema, and vocal fold edema, resulting in a sensitivity of 75% and a specificity of 67%. Positive predictive value was 100% for the combination of postglottic edema and any vocal fold or ventricular abnormality.

CONCLUSION

Laryngoscopy and bronchoscopy can reveal findings with a high positive predictive value for the presence of GERD. Endoscopy of the upper airway in children with clinical signs and symptoms of EERD is a promising tool for diagnosis.

Dyspepsia: current understanding and management

Dyspepsia, defined as "pain or discomfort centered in the upper abdomen" is reported by one in four adults in Western societies. The most important causes are non-ulcer (functional) dyspepsia, peptic ulcer, gastroesophageal reflux, and, rarely, gastric cancer. Persons with heartburn alone are not considered to have dyspepsia. The division of dyspepsia into symptom-based subgroups (ulcer-like, dysmotility-like, reflux-like, and unspecified dyspepsia) has proven to be of doubtful value for the clinician, as it has a low predictive value for identifying the causes of dyspepsia. Upper endoscopy remains the "gold standard" test; ultrasound and blood tests have a low yield. The role of Helicobacter pylori in peptic ulcer disease is well known, but the clinical role of the infection in non-ulcer dyspepsia remains very controversial. In uninvestigated dyspeptic patients who are H. pylori infected based on a non-invasive test, empiric anti-H. pylori therapy is a reasonable and probably cost-effective option. In documented non-ulcer dyspepsia, prokinetics are superior to placebo while antisecretory therapy is of less certain efficacy.

Patterns of food and acid reflux in patients with low-grade oesophagitis--the role of an anti-reflux agent

BACKGROUND

Food and acid have been shown to be refluxed independently of each other in healthy volunteers, and anti-reflux agents decrease the reflux of both parameters. Until now this phenomenon had not been studied in patients with low-grade oesophagitis, who are the group most likely to use anti-reflux medication.

AIM

To assess patterns of gastro-oesophageal reflux of acid and food in 12 ambulant patients with endoscopically proven oesophagitis of between grades I and II, but who were otherwise healthy. Also to assess the effectiveness of a single dose of an alginate-containing anti-reflux agent in controlling food and acid reflux in this patient group.

METHODS

Oesophageal pH monitoring and external ambulatory gamma detection were used to study food and acid reflux. A pH electrode was positioned 5 cm above the cardia and the gamma detector was positioned externally over the pH electrode. The patients then received a technetium-99m labelled meal designed to provoke reflux. Thirty minutes later the patients were given a 20 ml dose of alginate (Liquid Gaviscon), or 20 ml of tap water. Incidence of reflux was monitored for approximately 4 h from the end of the meal. Allocation to treatment group was randomized, with patients receiving the alternative treatment on the second study day after approximately a 7-day washout period.

RESULTS

The mean percentage time oesophageal pH remained below 4 was 16.3 min for the control group and 5.4 min for the treatment group (P = 0.03). Food reflux was detected 23.7% of the time in the control group compared to 12% of the time in the treatment group (P = 0.02). The anti-reflux agent was also successful in decreasing the number of events, but the duration of the reflux events was not significantly different.

CONCLUSIONS

Patients with grades I and II oesophagitis reflux food and acid independently, and are predominantly either food refluxers or acid refluxers, but not both. Liquid alginate decreases the number of both food and acid reflux events, but does not change their duration.

Vertical lines in distal esophageal mucosa (VLEM): a true endoscopic manifestation of esophagitis in children?

BACKGROUND

We observed an endoscopic abnormally in a group of children with histological esophagitis. We termed this finding "vertical lines in esophageal mucosa" (VLEM). We examined the relationship between the presence of VLEM and significant histologic changes in esophageal mucosal biopsies.

METHODS

Between January 1, 1992, and August 31, 1994, the senior author (JFF) performed 255 esophageal biopsies. The procedure reports, available endoscopic photographs, and histology reports were reviewed to establish the endoscopic and histologic appearance of the esophageal mucosa. Intraepithelial cells were counted in a blind review of 42 randomly selected biopsies.

RESULTS

The esophageal mucosa had a normal appearance on 160 endoscopic studies (Group 1) and VLEM were the only mucosal abnormalities in 41 endoscopies (Group 2). Histology was normal in 92 of 160 biopsies (57.5%) from Group 1, and 1 of 41 biopsies (2.4%) from Group 2. Most patients in Group 2 had eosinophilic esophagitis (34 of 41, 83%, specificity 0.85, sensitivity 0.5, p > 0.001) which was of moderate to severe intensity (31 of 34, 91.2%, specificity 0.88, sensitivity 0.73, p < 0.001).

CONCLUSIONS

Histology usually demonstrated moderate to severe inflammation when VLEM were present. VLEM may be a highly specific endoscopic feature of esophagitis in children.

Epidemiology of gastro-esophageal reflux disease

Gastro-esophageal reflux disease encompasses a spectrum of disorders in which gastric reflux leads to symptoms and/or damage to the esophageal mucosa. Although a common problem in clinical practice, our understanding of the pathophysiology of the condition has not been matched by our knowledge of its epidemiology and natural history. This review examines some of the difficulties inherent in epidemiological studies with particular emphasis on the nature and variety of reflux symptoms and their relationship to esophagitis, the natural history and complications of reflux disease, Barrett's esophagus, and the possible role of gastroesophageal reflux in lung disease, especially asthma.

Simultaneous esophageal pH monitoring and scintigraphy during the postprandial period in patients with severe reflux esophagitis

To compare reflux events detected by intraesophageal pH monitoring with that of scintigraphy, we simultaneously performed both techniques along with esophageal manometry in nine patients with severe reflux esophagitis. Two hundred eighteen reflux events were detected in the recumbent posture after a meal during a 40-min interval. Both techniques simultaneously detected only 23% of all reflux events. Scintigraphy alone detected 61% of all reflux events as opposed to 16% for pH monitoring. Of those reflux events diagnosed only by scintigraphy, more occurred while the intraesophageal pH was less than 4 (ie, during an acid-clearing interval) than while the intraesophageal pH was greater than 4 (ie, when intragastric contents were neutralized by the meal). Most reflux events occurred during periods of stable, but low LES pressure. While reflux events diagnosed by scintigraphy significantly decreased during the second of two 20-min postprandial intervals, those by pH monitoring tended to increase. That simultaneous scintigraphy and pH monitoring agreed on less than 1/3 of all reflux events not only underscores the fact that both techniques measured different physical components of the esophageal refluxate (ie, volume vs acid concentration, respectively), but also were influenced by different physiologic events such as the ingestion of a meal, gastric emptying, and esophageal acid clearance.

Detection of gastroesophageal reflux in the head and neck: the role of scintigraphy

Patients with gastroesophageal reflux (GER) present to the head and neck specialist with a myriad of nonspecific complaints that may be manifestations of pharyngoesophageal or upper airway involvement. Numerous diagnostic tests for GER have been used in the past with varying success. In the present study, gastroesophageal scintigraphy using 99mtechnetium-sulfur colloid was used to evaluate 28 patients with head and neck manifestations of GER. The role of gastroesophageal scintigraphy as an accurate and noninvasive method of detecting GER is discussed in the context of other current diagnostic modalities.

Cimetidine responders in non-ulcer dyspepsia

The effect of cimetidine and placebo was examined in 123 patients with non-ulcer dyspepsia (NUD) by means of a 12-day multi-crossover model with 5 regular interchanges between cimetidine and placebo. The evaluation of effect in individual patients was based on the number of times cimetidine was associated with less symptoms than the preceding or following placebo period. If cimetidine had no effect, the probability of being defined as a cimetidine responder was 25%. In general, cimetidine was associated with less symptoms than placebo (p less than 0.0001). Forty patients were identified as cimetidine responders (R) and the remaining patients were termed non-responders (NR). Symptoms compatible with gastroesophageal reflux were significantly more frequent in R than in NR, whereas the opposite was true for symptoms of the irritable colon syndrome. The ability of symptoms selected by stepwise logistic regression to predict response to cimetidine showed at best a sensitivity of 75% and a specificity of about 65%. No differences were found between R and NR with regard to acid secretion, endoscopic and histologic findings, or the result of an acid perfusion test. The present study supports the existence of a subgroup of cimetidine responders among patients with NUD characterized by symptoms suggestive of gastroesophageal reflux disease in the absence of confirmatory objective evidence.

Symptoms and endoscopic findings in the diagnosis of gastroesophageal reflux disease

Two hundred and twenty patients with symptoms suggestive of pathologic gastroesophageal reflux were investigated to elucidate the ability of symptoms and endoscopic findings in establishing a diagnosis of reflux disease as measured by ambulatory 24-h pH-monitoring. Daily occurrence of heartburn or acid regurgitation had positive predictive values of 59% and 66%, respectively. pH-monitoring showed pathologic reflux in 75% of patients with esophageal mucosal erosions. Endoscopic erythema of the distal esophagus predicted reflux disease in only 53%. Symptom registration during ambulatory 24-h pH-monitoring showed that about half of the symptomatic events reported by patients with pathologic reflux occurred within 5 min of a reflux episode. The corresponding figure for patients with normal pH-monitoring was less than 20%. We conclude that it is difficult to establish a diagnosis of gastroesophageal reflux disease by patient history alone, that erythema at endoscopy correlates poorly with pathologic reflux, and that reflux disease may be present even with normal endoscopy findings.

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.