Acid and pepsin secretion in patients with esophagitis refractory to treatment with H2 antagonists

Is there any acid peptic disease that is refractory to proton pump inhibitors?

Non-healing and delayed healing during acid inhibition treatment depend on the extent to which acid and 'non-acid' factors are causative in the particular acid peptic disease, and on the effectiveness and duration of acid suppression. Refractoriness (defined arbitrarily) occurs less often with proton pump inhibitors than with H2-receptor antagonists as the former decrease acid more effectively; H2-receptor antagonist-refractory disease usually responds to treatment with proton pump inhibitors. In Rotherham, 5-10% of duodenal ulcer and gastric ulcer patients are refractory (not healed after > or = 3 months of standard-dose H2-receptor antagonist). In patients with oesophagitis 15% are refractory to high-dose H2-receptor antagonist (for example, 3.2 g cimetidine daily) and 5% to standard-dose proton pump inhibitors (for example, 20 mg omeprazole daily). In controlled clinical trials of patients with refractory duodenal ulcer, healing at 8 weeks with 40 mg omeprazole o.m. vs. continued standard-dose H2-receptor antagonist was 98% vs. 60%; and with 40 mg omeprazole vs. continued high-dose H2-receptor antagonist (2 g + 3 g cimetidine, that is, ultra-refractory disease) was 92% vs. 67%. After healing, in open studies, relapse with maintenance 400-800 mg cimetidine nocte was 45-69% at one year, but 0% with 40 mg omeprazole administered for up to 6.5 years. For 53 patients with refractory gastric ulcer, in an open study, healing with omeprazole 40 mg o.m. occurred in 94% at 8 weeks, and none relapsed on long-term maintenance treatment at this dose. In controlled trials of patients with refractory oesophagitis, healing at 12 weeks with 40 mg omeprazole o.m. vs. high-dose ranitidine (300 mg b.d.) was 90% vs. 47%, and with maintenance 20 mg omeprazole o.m. vs. 150 mg ranitidine b.d., relapse at 1 year was 32% vs. 88%. In conclusion, acid peptic disease refractory to H2-receptor antagonists is uncommon and treatment with proton pump inhibitors is effective. Refractoriness to proton pump inhibitors is rare.

Association of obesity with hiatal hernia and esophagitis

OBJECTIVE

Although weight loss is commonly recommended for symptoms of gastroesophageal reflux, a relationship between excessive body weight and esophageal reflux has not been established. The aim of this study was to determine whether obesity is associated with the presence of a hiatal hernia (HH) and/or an endoscopic diagnosis of esophagitis.

METHODS

Retrospective case control studies were done using 1389 patients who underwent gastric analysis and upper GI endoscopy between 1974 and 1995. After excluding patients with Zollinger-Ellison syndrome, 189 cases of esophagitis with 1024 controls were identified. In a separate analysis of the database, 151 cases of HH with 1053 controls were also identified. Patients were classified by body mass index (BMI) as: thin (BMI <20 kg/m2), normal (BMI 20-25), mildly obese (BMI 25-30), and obese (BMI >30).

RESULTS

Excessive body weight was significantly associated with the presence of HH, the probability of HH increasing with each level of BMI (p < 0.01), as well as with esophagitis (OR 1.8; 95% CI 1.4-2.1). HH was independently associated with esophagitis (OR 4.2 95% CI 2.9-6.1); when controlled for the effect of HH, the association between BMI and esophagitis diminished but remained significant. In the population as a whole, for the presence of esophagitis multiple logistic regression indicates BMI and hiatal hernia were significant factors but gender and race did not appear to be.

CONCLUSIONS

Excessive body weight is a significant independent risk factor for hiatal hernia and is significantly associated with esophagitis, largely through an increased incidence of hiatal hernia. Whites are more likely to have the combination of esophagitis and hiatal hernia than are blacks.

Gastric secretion of acid and pepsin in patients with esophageal stricture and appropriate controls

Most cases of esophageal stricture are associated with acid/peptic reflux esophagitis. While patients with strictures commonly have disordered lower esophageal sphincters and poor clearance and neutralization mechanisms, it is not known whether they also have abnormal gastric secretion. This study examined fasting, basal, and stimulated acid and pepsin secretion. With an endoscopic diagnosis of esophagitis, patients with stricture (< 12.5 mm) were matched for age, sex, concurrent gastrointestinal disease (duodenal ulcer, N = 9), Zollinger-Ellison syndrome (N = 6), and postgastric surgery state (N = 5), as well as the absence of ulcer disease (non-DU, N = 37). Fasting, basal, and pentagastrin-stimulated acid and pepsin secretion were measured. Overall, the 57 stricture patients had the same acid and pepsin secretion as their matched controls with esophagitis; the same was true for each of the subgroups (ZES, DU, non-DU, and postsurgical). Stricture patients weighed less and had a lower body mass index (P < 0.01). Patients with esophageal peptic stricture have the same acid and pepsin output as control patients matched for sex, age, background gastrointestinal disease, and the presence of esophagitis.

Gastric acid and pepsin secretion in patients with Barrett's esophagus and appropriate controls

The objective of this study was to determine whether gastric secretion of acid and pepsin is different in the subset of esophagitis patients who also have Barrett's esophagus. Basal and stimulated gastric secretions were studied for 1 hr in the unstimulated state and 1 hr after pentagastrin 6 microg/kg subcutaneous injection. Because Barrett's patients are predominantly male, the 30 patients were matched with patients who had esophagitis, but not Barrett's, for sex (26 men, 4 women) and age as well as for background gastrointestinal disease (duodenal ulcer in 10, no ulcer disease in 17 and Zollinger-Ellison hypersecretors in 3). Patients with Barrett's weighed more than controls (P < 0.05). Acid and pepsin output in the basal and stimulated state were no different in Barrett's and their appropriately matched controls. Overnight fasting residue--volume, pH, acid and pepsin concentrations, and bile content--were also alike. The severity of esophagitis or prevalence of esophageal ulcer or stricture was not different between those with and without Barrett's and in neither was the grade of esophagitis related to acid or pepsin output. It is concluded that Barrett's esophagus patients do not have gastric secretions different from appropriately matched controls with esophagitis alone. When present, esophagitis due to reflux in Barrett's epithelium should be treated on its merits by appropriate reduction of acid exposure.

The pathophysiology of gastro-oesophageal reflux disease: an overview

Gastro-oesophageal reflux disease (GORD) is a multifactorial disease. Although it is primarily a motility disorder, several other disturbances can interfere and contribute to determine the severity of symptoms and the degree of lesions. In normal subjects, as in patients with pathological reflux, nearly all the episodes of reflux obey one of the following three mechanisms: (a) a transient complete relaxation of the lower oesophageal sphincter (TLOSR), (b) a transient increase in intra-abdominal pressure which overcomes the resistance of the antireflux barrier ('stress reflux') and, (c) a spontaneous reflux through a permanently hypotonic sphincter. Gastric distension is the major factor that can induce TLOSRs. Whereas, at rest, the diaphragm probably plays little role in cardial competence, diaphragmatic contraction may help prevent reflux in conditions resulting in increased abdominal pressure such as during physical activity and abdominal staining. The presence of a hiatal hernia increases susceptibility to reflux. A delayed gastric emptying may also facilitate reflux and represents a factor of resistance to antireflux therapy. Most studies in humans have shown that motor abnormalities remain unchanged after healing of oesophagitis. Acid and pepsin are the most noxious agents of the upper gastrointestinal secretions that can participate in the pathogenesis of oesophagitis. However, there is no evidence that patients with reflux have greater acid secretion than subjects without reflux. The clearance function is a two-stage phenomenon requiring first a reduction in volume by peristalsis and then chemical neutralization by saliva. Primary peristalsis is mainly responsible for the clearance of acid in both the upright and the supine positions. It takes longer to clear acid in patients with non-reducing hiatal hernia. The layer of mucus which carpets the mucosa comes from the saliva and also from the submucosal glands of the oesophagus. The paracellular pathway is the major route by which mucosal HCl enters and then damages the oesophageal epithelium. Only a minority of acid reflux episodes are accompanied by symptoms. The acid exposure during the time period that precedes a reflux episode (i.e. the acid burden) is a key factor determining whether that reflux episode will be symptomatic or asymptomatic.