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Geeraerts A, Guadagnoli L, Pauwels A, Geysen H, Neyens T, Van Oudenhove L, Vanuytsel T, Tack J. Psychological symptoms do not discriminate between reflux phenotypes along the organic-functional refractory GERD spectrum. Gut 2023; 72:1819-1827. [PMID: 37336632 DOI: 10.1136/gutjnl-2023-329673] [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: 02/08/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Historically, psychological processes are associated with disorders at the functional end of the gastro-oesophageal reflux disease (GERD) spectrum. However, recent research suggests that psychological symptoms are relevant across the entire GERD spectrum. We aim to investigate whether psychological symptoms are associated with reflux phenotype (True GERD, Borderline GERD, reflux hypersensitivity, functional heartburn) along the GERD spectrum in a cohort of refractory reflux patients. DESIGN Consecutive adult patients with refractory reflux symptoms underwent standard 24-hour pH-impedance monitoring and completed questionnaires assessing demographic, clinical and psychological information. Bayesian one-way analysis of variance assessed whether psychological variables differed across reflux phenotypes. Next, we applied multinomial and ordinal logistic regressions with clinical, demographic and psychological variables set as independent variables and reflux phenotype as the outcome variable. The complementary machine-learning approach entered all demographic, clinical and psychological variables into models, with reflux phenotype set nominally and ordinally. Cross-validated model performance was used to select the best model. RESULTS 393 participants (mean (SD) age=48.5 (14.1); 60% female) were included. The Bayesian analyses found no difference in psychological variables across reflux phenotypes. Similarly, age, gender and proton pump inhibitor use were the only significant variables in the multinomial logistic regression and body mass index was significant in both regressions. Machine-learning analyses revealed poorly performing models with high misclassification rates (67-68%) in both models. CONCLUSION Psychological symptoms do not differ between nor predict reflux phenotype membership in refractory reflux patients. Findings suggest that psychological symptoms are relevant across the spectrum of GERD, rather than specific to functional oesophageal disorders.
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Affiliation(s)
- Annelies Geeraerts
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - 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
| | - Ans Pauwels
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Hannelore Geysen
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Thomas Neyens
- Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health & Primary Care, KU Leuven, Leuven, Belgium
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Lukas Van Oudenhove
- 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
- Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- Department of Gastroenterology, UZ Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- Department of Gastroenterology, UZ Leuven, Leuven, Belgium
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2
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Oshima T, Igarashi A, Nakano H, Deguchi H, Fujimori I, Fernandez J. Network Meta-analysis Comparing Vonoprazan and Proton Pump Inhibitors for Heartburn Symptoms in Erosive Esophagitis. J Clin Gastroenterol 2022; 56:493-504. [PMID: 35470298 DOI: 10.1097/mcg.0000000000001707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
GOALS This systematic review and network meta-analysis aimed to assess the relative efficacy of vonoprazan and proton pump inhibitors (PPIs) on early heartburn symptom resolution in patients with erosive esophagitis. BACKGROUND Limited available data directly compare the efficacy of vonoprazan, a first-in-class potassium-competitive acid blocker, with PPIs in erosive esophagitis. STUDY We conducted a systematic literature review (in MEDLINE and CENTRAL) and subsequent network meta-analysis according to Cochrane and PRISMA guidelines. Double-blind, randomized controlled trials in adults with erosive esophagitis treated with vonoprazan or a PPI were included in the analysis. Primary outcomes were heartburn symptom resolution rate on Day 1 and Day 7. The study was performed with all available data, using a random effects model within a Bayesian framework. RESULTS Overall, 10 randomized controlled trials were included in the network meta-analysis. For heartburn resolution rate on Day 1 (9 of 10 trials), vonoprazan 20 mg once daily (QD) was superior to placebo (median odds ratio=16.75, 95% credible interval: 2.16-207.80). Point estimates numerically favored vonoprazan 20 mg QD over other comparators. For heartburn resolution rate on Day 7 (10 of 10 trials), vonoprazan 20 mg QD was superior to placebo and other comparators except rabeprazole 20 mg QD. Point estimates numerically favored vonoprazan 20 mg QD over rabeprazole 20 mg QD. CONCLUSIONS In this study, vonoprazan 20 mg QD was equally effective in heartburn resolution on Day 1, and equally or more effective on Day 7 versus PPIs in adults with erosive esophagitis.
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Affiliation(s)
- Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya
| | - Ataru Igarashi
- Unit of Public Health and Preventive Medicine, Yokohama City University School of Medicine, Yokohama
- Department of Health Economics and Outcomes Research, Graduate School of Pharmaceutical Sciences, The University of Tokyo
| | - Hiroya Nakano
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Hisato Deguchi
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Ikuo Fujimori
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Jovelle Fernandez
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
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Ong JS, An J, Han X, Law MH, Nandakumar P, Schumacher J, Gockel I, Bohmer A, Jankowski J, Palles C, Olsen CM, Neale RE, Fitzgerald R, Thrift AP, Vaughan TL, Buas MF, Hinds DA, Gharahkhani P, Kendall BJ, MacGregor S. Multitrait genetic association analysis identifies 50 new risk loci for gastro-oesophageal reflux, seven new loci for Barrett's oesophagus and provides insights into clinical heterogeneity in reflux diagnosis. Gut 2022; 71:1053-1061. [PMID: 34187846 PMCID: PMC9120377 DOI: 10.1136/gutjnl-2020-323906] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 06/13/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Gastro-oesophageal reflux disease (GERD) has heterogeneous aetiology primarily attributable to its symptom-based definitions. GERD genome-wide association studies (GWASs) have shown strong genetic overlaps with established risk factors such as obesity and depression. We hypothesised that the shared genetic architecture between GERD and these risk factors can be leveraged to (1) identify new GERD and Barrett's oesophagus (BE) risk loci and (2) explore potentially heterogeneous pathways leading to GERD and oesophageal complications. DESIGN We applied multitrait GWAS models combining GERD (78 707 cases; 288 734 controls) and genetically correlated traits including education attainment, depression and body mass index. We also used multitrait analysis to identify BE risk loci. Top hits were replicated in 23andMe (462 753 GERD cases, 24 099 BE cases, 1 484 025 controls). We additionally dissected the GERD loci into obesity-driven and depression-driven subgroups. These subgroups were investigated to determine how they relate to tissue-specific gene expression and to risk of serious oesophageal disease (BE and/or oesophageal adenocarcinoma, EA). RESULTS We identified 88 loci associated with GERD, with 59 replicating in 23andMe after multiple testing corrections. Our BE analysis identified seven novel loci. Additionally we showed that only the obesity-driven GERD loci (but not the depression-driven loci) were associated with genes enriched in oesophageal tissues and successfully predicted BE/EA. CONCLUSION Our multitrait model identified many novel risk loci for GERD and BE. We present strong evidence for a genetic underpinning of disease heterogeneity in GERD and show that GERD loci associated with depressive symptoms are not strong predictors of BE/EA relative to obesity-driven GERD loci.
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Affiliation(s)
- Jue-Sheng Ong
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Jiyuan An
- School of Biology & Environmental Science, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Xikun Han
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Matthew H Law
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Johannes Schumacher
- Institute of Human Genetics, Philipps University of Marburg, Marburg, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Anne Bohmer
- Institute of Human Genetics, University of Bonn, Bonn, Germany
| | - Janusz Jankowski
- Centre for Medicine and Health Sciences, University of United Arab Emirates, Al Ain, Abu Dhabi, UAE
- UCL Medical School, University College London, London, UK
| | - Claire Palles
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Catherine M Olsen
- Department of Population Health, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Rachel E Neale
- Department of Population Health, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | | | - Aaron P Thrift
- Department of Medicine, and Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas L Vaughan
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Matthew F Buas
- Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | | | - Puya Gharahkhani
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Bradley J Kendall
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Stuart MacGregor
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
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Szczesniak MM, Omari TI, Lam TY, Wong M, Mok VCT, Wu JCY, Chiu PWY, Yuen MTY, Tsang RK, Cock C, Sung JJ, Wu P. Evaluation of oropharyngeal deglutitive pressure dynamics in patients with Parkinson's disease. Am J Physiol Gastrointest Liver Physiol 2022; 322:G421-G430. [PMID: 35138164 DOI: 10.1152/ajpgi.00314.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In Parkinson's disease (PD), oropharyngeal dysphagia is common and clinically relevant. The neurophysiology of dysphagia in PD is complex and incompletely understood. The aim of the study was to determine the changes in oropharyngeal deglutitive pressure dynamics in PD and to correlate these with clinical characteristics including dysphagia and PD severity. In prospective consecutive series of 64 patients with PD [mean age: 66.9 ± 8.3 (SD)], we evaluated dysphagia severity clinically as well as with Sydney Swallow Questionnaire (SSQ) and Swallow Quality-of-Life Questionnaire (SWAL-QOL). PD severity was assessed with Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS). We used high-resolution pharyngeal impedance manometry (HRPIM) to objectively evaluate swallow function and compared data from 23 age-matched healthy controls [mean age 62.3 ± 9.1 (SD)]. Metrics assessed were upper esophageal sphincter (UES), integrated relaxation pressure (IRP), relaxation time (RT), maximum opening (MaxAdm), and pharyngeal intrabolus pressure (IBP) and pharyngeal contractility (PhCI). Mean MDS-UPDRS score was positively associated with dysphagia severity on SSQ and SWAL-QOL. HRPIM in PD compared with controls showed impaired UES relaxation parameters, with shorter RT, and elevated IRP and IBP. MaxAdm was not affected. The overall pharyngeal contractility was significantly higher in PD. Only the IBP and IRP were associated with PD severity and only IBP was significantly associated with dysphagia severity. UES dysfunction leading to increased flow resistance is common in patients with PD and correlates with dysphagia severity. Increased flow resistance may suggest impaired UES relaxation and/or impaired neuromodulation to bolus volume.NEW & NOTEWORTHY In Parkinson's disease, objective assessment of swallow function with high-resolution impedance manometry identifies upper esophageal sphincter dysfunction leading to increased flow resistance.
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Affiliation(s)
- Michal M Szczesniak
- St George and Sutherland Clinical School, University of NSW, Sydney, Australia.,Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, Australia
| | - Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Thomas Y Lam
- Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Marc Wong
- Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Vincent C T Mok
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism, Division of Neurology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Justin C Y Wu
- Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Philip W Y Chiu
- Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Margaret T Y Yuen
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China.,Division of Otorhinolaryngology, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Raymond K Tsang
- Division of Otorhinolaryngology, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Charles Cock
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Joseph J Sung
- Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Peter Wu
- St George and Sutherland Clinical School, University of NSW, Sydney, Australia.,Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, Australia.,Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, People's Republic of China
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5
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Wong MW, Liu TT, Yi CH, Lei WY, Hung JS, Cock C, Omari T, Gyawali CP, Liang SW, Lin L, Chen CL. Oesophageal hypervigilance and visceral anxiety relate to reflux symptom severity and psychological distress but not to acid reflux parameters. Aliment Pharmacol Ther 2021; 54:923-930. [PMID: 34383968 DOI: 10.1111/apt.16561] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/21/2021] [Accepted: 07/21/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The pathogenesis of gastro-oesophageal reflux disease (GERD) is complex and multifactorial. The oesophageal hypervigilance and anxiety scale (EHAS) is a novel cognitive-affective evaluation of visceral sensitivity. AIMS To investigate the interrelationship between EHAS and reflux symptom severity, psychological stress, acid reflux burden, phenotypes, and oesophageal mucosal integrity in patients with GERD. METHODS Patients with chronic reflux symptoms and negative endoscopy underwent 24-hour impedance-pH monitoring for phenotyping, acid reflux burden, and mucosal integrity with mean nocturnal baseline impedance (MNBI) calculation. Validated scores for patient-reported outcomes, including EHAS, GERD questionnaire (GERDQ), State-Trait Anxiety Inventory score, and Taiwanese Depression Questionnaire score, were recorded. RESULTS We enrolled 105 patients, aged 21-64 years (mean, 48.8), of whom 58.1% were female; 27 had non-erosive reflux disease, 43 had reflux hypersensitivity and 35 had functional heartburn. There were no significant differences in sex, EHAS, GERDQ, questionnaires of depression or anxiety among GERD phenotypes. EHAS was significantly correlated with GERDQ, questionnaires of depression and anxiety (P < 0.05). However, there were no significant correlations between GERDQ and questionnaires of depression or anxiety. Regarding patient-reported outcomes, GERDQ positively correlated with acid exposure time and negatively correlated with MNBI (P < 0.05). CONCLUSIONS EHAS associates with reflux symptom severity and psychological stress but not with acid reflux burden or mucosal integrity. Thus, EHAS assessment shows promise in assessment of subjective patient outcome and satisfaction with treatment, a hitherto unmet clinical need.
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Affiliation(s)
- Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Charles Cock
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Taher Omari
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Lin Lin
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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6
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Patel D, Fass R, Vaezi M. Untangling Nonerosive Reflux Disease From Functional Heartburn. Clin Gastroenterol Hepatol 2021; 19:1314-1326. [PMID: 32246998 DOI: 10.1016/j.cgh.2020.03.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have nonerosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common phenotype of gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. A diagnosis of NERD requires endoscopy and reflux testing, whereas a diagnosis of functional heartburn also requires esophageal manometry. NERD is treated most commonly with medical, endoscopic, and surgical antireflux approaches, whereas functional heartburn as well as NERD can be treated with neuromodulators, psychological intervention, and complementary medicine options.
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Affiliation(s)
- Dhyanesh Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth System, Case Western Reserve University, Cleveland, Ohio
| | - Michael Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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7
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Carlson DA, Gyawali CP, Roman S, Vela M, Taft TH, Crowell MD, Ravi K, Triggs JR, Quader F, Prescott J, Lin FTJ, Mion F, Biasutto D, Keefer L, Kahrilas PJ, Pandolfino JE. Esophageal Hypervigilance and Visceral Anxiety Are Contributors to Symptom Severity Among Patients Evaluated With High-Resolution Esophageal Manometry. Am J Gastroenterol 2020; 115:367-375. [PMID: 31990697 PMCID: PMC7071929 DOI: 10.14309/ajg.0000000000000536] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Symptoms are inconsistently associated with esophageal motor findings on high-resolution manometry (HRM). We aimed to evaluate predictors of dysphagia severity, including esophageal hypervigilance and visceral anxiety, among patients evaluated with HRM. METHODS Adult patients undergoing HRM at 4 academic medical centers (United States and France) were prospectively evaluated. HRM was completed and analyzed per the Chicago Classification v3.0. Validated symptom scores, including the Brief Esophageal Dysphagia Questionnaire and Esophageal Hypervigilance and Anxiety Scale, were completed at the time of HRM. RESULTS Two hundred thirty-six patients, aged 18-85 (mean 53) years, 65% female, were included. Approximately 59 (25%) patients had a major motor disorder on HRM: 19 achalasia, 24 esophagogastric junction outflow obstruction, 12 absent contractility, and 4 jackhammer. Approximately 177 (75%) patients did not have a major motor disorder: 71 ineffective esophageal motility and 106 normal motility. Having a major motor disorder was a significant predictor of dysphagia severity (Radj = 0.049, P < 0.001), but the Esophageal Hypervigilance and Anxiety Scale score carried a predictive relationship of Brief Esophageal Dysphagia Questionnaire that was 2-fold higher than having a major motor disorder: Radj = 0.118 (P < 0.001). This finding remained when evaluated by the major motor disorder group. HRM metrics were nonsignificant. DISCUSSION In a prospective, international multicenter study, we found that esophageal hypervigilance and visceral anxiety were the strongest predictors of dysphagia severity among patients evaluated with HRM. Thus, an assessment of esophageal hypervigilance and visceral anxiety is important to incorporate when evaluating symptom severity in clinical practice and research studies.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sabine Roman
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, F-69437 LYON, France; Université de Lyon, Lyon I University, Digestive Physiology, F-69008 LYON, France; Université de Lyon, Inserm U1032, LabTAU, F-69008 LYON, France
| | - Marcelo Vela
- Division of Gastroenterology, Mayo Clinic, Scottsdale, AZ, USA
| | - Tiffany H Taft
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Karthik Ravi
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Joseph R. Triggs
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Farhan Quader
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jacqueline Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Frederick TJ Lin
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Francois Mion
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, F-69437 LYON, France; Université de Lyon, Lyon I University, Digestive Physiology, F-69008 LYON, France; Université de Lyon, Inserm U1032, LabTAU, F-69008 LYON, France
| | - Dario Biasutto
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, F-69437 LYON, France; Université de Lyon, Lyon I University, Digestive Physiology, F-69008 LYON, France; Université de Lyon, Inserm U1032, LabTAU, F-69008 LYON, France
| | - Laurie Keefer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter J. Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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8
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Forootan M, Zojaji H, Ehsani MJ, Darvishi M. Advances in the Diagnosis of GERD Using the Esophageal pH Monitoring, Gastro-Esophageal Impedance-pH Monitoring, And Pitfalls. Open Access Maced J Med Sci 2018; 6:1934-1940. [PMID: 30455777 PMCID: PMC6236049 DOI: 10.3889/oamjms.2018.410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 01/28/2023] Open
Abstract
PH monitoring is not capable of detecting all types of reflux, especially when the amount of acid is very low or not at all in the refluxate. Multichannel intraluminal impedance-pH monitoring (MII-pH) is used as a new method to assess bolus transport. The types of reflexes including acid, weak acid and weak alkaline MII-pH is capable of distinguishing more reflux episodes based upon use of physical and chemical parameters of the refluxate, leads to a diagnosis of normal acid reflux from abnormal nonacidic reflux. 24-h oesophagal pH monitoring can be effectively used to assess the potential relationship between symptoms and refluxes. MII-pH is capable of distinguishing more reflux episodes based upon use of physical and chemical parameters of the refluxate, leads to a diagnosis of normal acid reflux from abnormal nonacidic reflux. It can be used to confirm gastro-oesophagal reflux episodes, where has a sensitivity and specificity for diagnosing GERD in comparison with endoscopy or pH-metry.
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Affiliation(s)
- Mojgan Forootan
- Department of Gastroenterology, Gastrointestinal and liver Diseases Research Center (RCGLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Homayoun Zojaji
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Ehsani
- Department of Gastroenterology and Hepatology, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), Department of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran
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9
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Gao F, Gao Y, Chen X, Qian J, Zhang J. Comparison of Esophageal Function Tests in Chinese Patients with Functional Heartburn and Reflux Hypersensitivity. Gastroenterol Res Pract 2017; 2017:3596148. [PMID: 29018480 PMCID: PMC5606052 DOI: 10.1155/2017/3596148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/16/2017] [Accepted: 08/08/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To investigate the differences in the results of esophageal function tests for functional heartburn (FH) and reflux hypersensitivity (RH). METHODS Patients with FH and RH and healthy volunteers (HVs) from the Department of Gastroenterology, Beijing Anzhen Hospital and Beijing Chao-Yang hospital, who underwent high-resolution manometry and impedance (HRIM), and 24-hour multichannel intraluminal impedance and pH recording (MII/pH) between 2014 and 2016, were enrolled in this study. RESULTS 36 HV, 147 FH patients, and 91 RH patients were enrolled. The postreflux swallow-induced peristaltic wave index (PSPW index) and mean nocturnal baseline impedance (MNBI) values were significantly lower in RH than in FH and HV. The ineffective esophageal motility (IEM), fragmented peristalsis rates, total bolus exposure, proximal total reflux events, and distal total reflux events were significantly greater in RH than in FH and HV. CONCLUSIONS Compared to HV and FH patients, RH patients exhibited greater IEM and fragmented peristalsis rates, a greater total bolus exposure, more proximal total and distal total reflux events, and reduced chemical clearance and mucosal integrity. By using the above described parameters, HRIM and MII/pH assays could be used to correctly classify RH and FH and hence allow physicians to provide adequate relief from associated symptoms.
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Affiliation(s)
- Feng Gao
- Digestive Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Yan Gao
- Digestive Department, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Xue Chen
- Digestive Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Jie Qian
- Digestive Department, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Jie Zhang
- Digestive Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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Ambulatory 24-hour multichannel intraluminal impedance-pH monitoring and high resolution endoscopy distinguish patients with non-erosive reflux disease from those with functional heartburn. PLoS One 2017; 12:e0175263. [PMID: 28384225 PMCID: PMC5383280 DOI: 10.1371/journal.pone.0175263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/23/2017] [Indexed: 12/13/2022] Open
Abstract
AIMS To assess the contribution of 24-h esophageal multichannel intraluminal impedance and pH (MII-pH) monitoring and high resolution endoscopy (HRE) with i-scan imaging in differentiating non erosive reflux disease (NERD) from functional heartburn (FH). METHODS This is a retrospective cohort study of patients with heartburn from the Endoscopy Unit. NERD patients and FH patients were defined by 24-h MII-pH monitoring and white light endoscopy. Minimal mucosal changes were assessed by HRE with i-scan imaging. RESULTS Total of 156 consecutive patients with heartburn but without esophageal mucosal erosions were studied. Forty-eight of these subjects had NERD, with increased acid exposure time (AET) and positive SAP and/or SI. Eighteen had FH with normal AET and negative SAP and SI. When compared to FH patients and healthy controls, NERD patients had significantly increased number of total acid reflux episodes, as well as increased number of weakly acidic reflux episodes (p<0.01). The rate of proximal reflux episodes in NERD patients was higher than that of FH patients and healthy controls (p<0.01). Irregular or blurring of the Z-line (58.3%) and white mucosal turbidity (47.9%) were the most common endoscopic findings of minimal mucosal changes observed in this study. NERD patients had more prevalent minimal changes than FH patients and the controls (87.5%vs. 66.6%vs. 61.9%; p = 0.004) with sensitivity of 87.5%. Histopathological evaluation showed that NERD patients had significantly higher average scores of intercellular spaces dilation (2.82±0.9 vs. 1.2±0.6, p = 0.005) and papillae elongation (2.65±1.0 vs. 1.5±0.8, p = 0.014), but not for basal cell proliferation (1.6±1.3 vs. 1.0±0.9, p = 0.070). The histological scores of the NERD patients were 7.1±1.2, which were higher than those of FH patients (3.4±1.0, p = 0.004). CONCLUSIONS Minimal mucosal changes could be useful markers to support clinical diagnosis of NERD. Combination of 24-h MII-pH monitoring and i-scan high resolution endoscopy can distinguish patients with NERD from those with FH.
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Bilgi MM, Vardar R, Yıldırım E, Veznedaroğlu B, Bor S. Prevalence of Psychiatric Comorbidity in Symptomatic Gastroesophageal Reflux Subgroups. Dig Dis Sci 2017; 62:984-993. [PMID: 27565506 DOI: 10.1007/s10620-016-4273-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 08/08/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Limited data exist regarding the psychosocial aspects of gastroesophageal reflux disease (GERD). Some GERD subgroups, such as functional heartburn and hypersensitive esophagus, might show different psychiatric comorbidities than others. AIM We aimed to evaluate the psychiatric comorbidities of GERD subgroups using a cross-sectional design. METHODS A group of GERD patients at a tertiary outpatient clinic were evaluated via upper GIS (gastrointestinal system) endoscopy, esophageal manometry, and 24-h impedance-pH monitoring. Thirty-nine patients diagnosed with erosive reflux disease, 44 with non-erosive reflux disease, 20 with functional heartburn, 11 with hypersensitive esophagus, and 44 healthy controls participated. Psychiatric diagnoses were made using the Structured Clinical Interview for Diagnostics and Statistical Manual of Mental Disorders IV. Psychometric measurements of the patients were performed using the Somatosensory Amplification Scale, Beck Depression Inventory, State-Trait Anxiety Inventory, and Short-Form 36. Healthy controls were evaluated with the same psychometric scales except for the Short-Form 36. RESULTS All of the GERD subgroups were significantly more depressed than the control group. Depressive disorders were significantly more prevalent in the functional heartburn group than in the non-erosive reflux disease and erosive reflux disease groups. The trait anxiety level of the functional heartburn group was significantly higher than those of the control and non-erosive reflux disease groups. The quality of life scores of the GERD subgroups were significantly lower than the population standards. CONCLUSIONS Depressive disorders were frequently comorbid in the GERD subgroups studied (30-65 %). It is essential to consider the high prevalence rates of comorbid depression when managing GERD.
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Affiliation(s)
- Mustafa Melih Bilgi
- Izmir Bozyaka Educational and Research Hospital, Izmir, Turkey. .,Ege Reflux Group, Izmir, Turkey. .,Karabaglar State Clinics, 4025 Sok., Yunus Emre Mah., Karabaglar, Izmir, Turkey.
| | - Rukiye Vardar
- Division of Gastroenterology, School of Medicine, Ege University, Bornova, Izmir, Turkey.,Ege Reflux Group, Izmir, Turkey
| | - Esra Yıldırım
- Division of Gastroenterology, School of Medicine, Ege University, Bornova, Izmir, Turkey.,Ege Reflux Group, Izmir, Turkey
| | - Baybars Veznedaroğlu
- Department of Psychiatry, School of Medicine, Ege University, Bornova, Izmir, Turkey
| | - Serhat Bor
- Division of Gastroenterology, School of Medicine, Ege University, Bornova, Izmir, Turkey.,Ege Reflux Group, Izmir, Turkey
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12
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Aziz Q, Fass R, Gyawali CP, Miwa H, Pandolfino JE, Zerbib F. Functional Esophageal Disorders. Gastroenterology 2016; 150:S0016-5085(16)00178-5. [PMID: 27144625 DOI: 10.1053/j.gastro.2016.02.012] [Citation(s) in RCA: 316] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/09/2016] [Indexed: 02/06/2023]
Abstract
Functional esophageal disorders consist of a disease category that present with esophageal symptoms (heartburn, chest pain, dysphagia, globus) not explained by mechanical obstruction (stricture, tumor, eosinophilic esophagitis), major motor disorders (achalasia, EGJ outflow obstruction, absent contractility, distal esophageal spasm, jackhammer esophagus), or gastroesophageal reflux disease (GERD). While mechanisms responsible are unclear, it is theorized that visceral hypersensitivity and hypervigilance play an important role in symptom generation, in the context of normal or borderline function. Treatments directed at improving borderline motor dysfunction or reducing reflux burden to sub-normal levels have limited success in symptom improvement. In contrast, strategies focused on modulating peripheral triggering and central perception are mechanistically viable and clinically meaningful. However, outcome data from these treatment options are limited. Future research needs to focus on understanding mechanisms underlying visceral hypersensitivity and hypervigilance so that appropriate targets and therapies can be developed.
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Affiliation(s)
- Qasim Aziz
- Barts and The London School of Medicine and Dentistry, Professor, Wingate Institute of Neurogastroneterology, Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London UK, London UK
| | - Ronnie Fass
- MetroHalth Medical Center, The Esophageal and Swallowing Center, Professor, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Professor, University Washington University School of Medicine, St. Louis, MO, USA
| | - Hiroto Miwa
- Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - John E Pandolfino
- Chief and Professor, Division of Medicine-Gastroenterology and Hepatology, Feinberg School of Medicine Center, Northwestern University, Chicago, Illinois, USA.
| | - Frank Zerbib
- CHU de Bordeaux, Professor, Gastroenterology Department, Université de Bordeaux, Bordeaux, France
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13
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Established and Emerging Treatment Options for Functional Heartburn and Chest Pain. ACTA ACUST UNITED AC 2016; 14:19-27. [DOI: 10.1007/s11938-016-0081-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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14
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Diagnosis and Management of Functional Heartburn. Am J Gastroenterol 2016; 111:53-61; quiz 62. [PMID: 26729546 DOI: 10.1038/ajg.2015.376] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/14/2015] [Indexed: 02/06/2023]
Abstract
Heartburn is among the most common gastrointestinal symptoms presenting to both generalist physicians and gastroenterologists. Heartburn that does not respond to traditional acid suppression is a diagnostic and therapeutic dilemma. In the era of high utilization of proton pump inhibitors, a substantial proportion of patients presenting to the gastroenterologist with chronic symptoms of heartburn do not have a reflux-mediated disease. Subjects without objective evidence of reflux as a cause of their symptoms have "functional heartburn". The diagnostic role of endoscopy, reflux and motility testing in functional heartburn (FH) patients is discussed. Lifestyle modifications, pharmacological interventions, and alternative therapies for FH are also presented. Recognition of patients with FH allows earlier assignment of these patients to different treatment algorithms, which may allow greater likelihood of success of treatment, diminished resource utilization and improved quality of life. Further data on this large and understudied group of patients is necessary to allow improvement in treatment algorithms and a more evidence-based approach to care of these patients.
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15
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Kessing BF, Bredenoord AJ, Saleh CMG, Smout AJPM. Effects of anxiety and depression in patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2015; 13:1089-95.e1. [PMID: 25496817 DOI: 10.1016/j.cgh.2014.11.034] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 11/09/2014] [Accepted: 11/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Increased levels of anxiety and depression have been associated with esophageal hyperalgesia and an increased risk of gastroesophageal reflux disease (GERD). We investigated the effects of anxiety and depression on GERD symptoms and the perception of reflux episodes in a well-characterized group of patients. METHODS We performed a prospective study of 225 consecutive patients who had symptoms of GERD evaluated. Patients underwent ambulatory 24-hour pH impedance monitoring, and levels of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale. RESULTS GERD was diagnosed in 147 patients (78 patients had functional heartburn); 36 patients were hypersensitive to gastroesophageal reflux. Among patients with GERD, increased levels of anxiety were associated with more severe retrosternal pain and retrosternal burning. Furthermore, increased levels of anxiety and depression each were associated with lower scores of the mental component of quality of life questionnaire. Levels of anxiety or depression were not associated with the number of reflux symptoms reported during 24-hour pH impedance monitoring or with the number of symptoms associated with a reflux event. Among GERD patients with hypersensitivity to reflux, levels of anxiety and depression and decreases in quality of life were similar to those of other patients with GERD. Patients with functional heartburn had higher levels of anxiety than patients with GERD. CONCLUSIONS In patients with GERD, increased levels of anxiety are associated with increased severity of retrosternal pain and heartburn and reduced quality of life. Patients with GERD with hypersensitivity to gastroesophageal reflux have similar levels of anxiety and similar quality-of-life scores as other patients with GERD.
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Affiliation(s)
- Boudewijn F Kessing
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Caroline M G Saleh
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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16
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Khan MQ, Alaraj A, Alsohaibani F, Al-Kahtani K, Jbarah S, Al-Ashgar H. Diagnostic Utility of Impedance-pH Monitoring in Refractory Non-erosive Reflux Disease. J Neurogastroenterol Motil 2014; 20:497-505. [PMID: 25273120 PMCID: PMC4204403 DOI: 10.5056/jnm14038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Approximately one-third of non-erosive reflux disease (NERD) patients are refractory to proton pump inhibitors (PPI) and face a therapeutic challenge. Therefore, it is important to differentiate between pathological and non-pathological reflux utilizing multichannel intraluminal impedance-pH (MII-pH) to analyze symptom-reflux association and diagnose true NERD versus hyper-sensitive esophagus (HE) and functional heartburn (FH). Herein, we evaluated the diagnostic yield of MII-pH in refractory NERD and sub-classified it based on quantity and quality of acid/non-acid reflux and reflux-symptom association. Methods Sixty symptomatic NERD patients on twice daily PPI for > 2 months were prospectively evaluated by MII-pH. Distal and proximal refluxes, bolus exposure time (BET), esophageal acid exposure time, symptom index (SI) and symptom association probability (SAP) were measured. Results Thirty-two (53%) patients had BET > 1.4% (MII-pH positive-true NERD), while 28 (47%) had BET < 1.4% (MII-pH negative NERD) where SI and SAP were negative in 15/60 (25%; categorized as FH) and SI or SAP were positive in 13/60 (22%; identified as HE). Thirty-eight (63%) patients reported significant SI or SAP parameters where > 80% of symptoms were associated with non-acid reflux. The number of distal refluxes in true NERD versus FH or HE were significantly different, but not between FH and HE. Conclusions Approximately 60% of refractory PPI NERD patients had positive reflux-symptom association, primarily due to non-acid reflux. Nearly half of NERD patients on PPI had normal MII-pH monitoring, sub-divided further into FH and HE equally.
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Affiliation(s)
- Mohammed Q Khan
- Section of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ali Alaraj
- Section of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahad Alsohaibani
- Section of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khalid Al-Kahtani
- Section of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sahar Jbarah
- Section of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hamad Al-Ashgar
- Section of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Jo SY, Kim N, Lim JH, Shin CM, Park YS, Lee DH, Jung HC. Comparison of gastroesophageal reflux disease symptoms and proton pump inhibitor response using gastroesophageal reflux disease impact scale questionnaire. J Neurogastroenterol Motil 2013; 19:61-9. [PMID: 23350049 PMCID: PMC3548129 DOI: 10.5056/jnm.2013.19.1.61] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 11/29/2012] [Accepted: 12/01/2012] [Indexed: 12/13/2022] Open
Abstract
Background/Aims To compare gastroesophageal reflux disease (GERD) symptoms and response to proton pump inhibitor (PPI) in patients with erosive esophagitis (EE), non-erosive reflux disease (NERD) or functional heartburn (FH) using GERD impact scale (GIS) questionnaire. Methods Total 126 patients with GERD symptoms were diagnosed as EE (n = 62), NERD (n = 34) and FH (n = 30) by endoscopy, 24-hour esophageal pH testing and Bernstein test, prospectively. Analysis of risk factors and GIS questionnaire for GERD symptoms and quality of life were performed before and 8 weeks after PPI treatment. Results EE group had a higher proportion of men, frequent alcohol consumption, smoking, hiatal hernia, body mass index ≥ 25 kg/m2 and triglyceride levels (≥ 150 mg/dL) than the other groups (all P < 0.05). On the other hand, both psychiatric treatment and psychopharmacotherapy were more frequent in patients with FH than in those with EE and NERD (both P < 0.05). Among GERD symptoms, chest pain was more frequent in FH group than in EE and NERD groups (P < 0.05). Eating problems and limitation of productive daily activities occurred frequently in FH group and NERD group, respectively. GIS after 8 week PPI treatment showed improvement in all of the GERD symptoms in EE (all P < 0.05) and in acid regurgitation, epigastric pain and hoarseness in NERD group (all P < 0.05). In terms of quality of life, PPI treatment improved sleep disturbance in EE (P = 0.031) and limitation of productive activity in the NERD group (P = 0.001). Conclusions GIS questionnaire showed that different characteristics and symptoms improved after PPI therapy among patients with EE, NERD and FH, demonstrating the usefulness of the GIS questionnaire.
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Affiliation(s)
- So Young Jo
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
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Zerbib F, Bruley des Varannes S, Simon M, Galmiche JP. Functional heartburn: definition and management strategies. Curr Gastroenterol Rep 2012; 14:181-8. [PMID: 22451252 DOI: 10.1007/s11894-012-0255-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Functional heartburn (FH) is a functional gastro-intestinal disorder characterized by symptoms of heartburn not related to gastro-esophageal reflux. The absence of evidence of reflux-related symptoms relies on absence of esophagitis at endoscopy (including biopsies to exclude eosinophilic esophagitis), a normal esophageal acid exposure during esophageal pH-monitoring together with a negative symptom-reflux association analysis and an unsatisfactory response to proton pump inhibitor therapy. Addition of impedance measurement to pH-monitoring is likely to increase the number of patients with recognized reflux-related symptoms. The pathophysiology of functional heartburn remains largely unknown but involves disturbed esophageal perception and psychological factors such as depression, anxiety and somatization. The treatment of FH remains largely empirical and an individual approach is therefore recommended. The clinician should provide reassurance and refrain from performing too many invasive tests or therapeutic procedures. The use of pain modulators is recommended by most experts despite the lack of appropriate clinical trials to support it.
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Affiliation(s)
- Frank Zerbib
- Gastroenterology and Hepatology Department, Saint André Hospital, Centre Hospitalier Universitaire de Bordeaux.
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Gawron AJ, Rothe J, Fought AJ, Fareeduddin A, Toto E, Boris L, Kahrilas PJ, Pandolfino JE. Many patients continue using proton pump inhibitors after negative results from tests for reflux disease. Clin Gastroenterol Hepatol 2012; 10:620-5; quiz e57. [PMID: 22366177 PMCID: PMC3547497 DOI: 10.1016/j.cgh.2012.02.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 01/09/2012] [Accepted: 02/02/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ambulatory reflux testing is used to evaluate symptoms of gastroesophageal reflux disease (GERD) refractory to protein pump inhibitors (PPIs). We investigated the prevalence of PPI use in patients with negative results from Bravo pH or multichannel intraluminal impedance-pH (MII-pH) tests and factors that might predict the use of PPIs. METHODS We analyzed data from patients who had undergone Bravo pH monitoring or MII-pH testing at Northwestern University, without evidence of reflux disease. Demographics, endoscopy findings, pathology results, and provider recommendations were obtained via chart review. Eligible patients (n = 90) were contacted by telephone, and a cross-sectional survey was administered with questions about symptom severity, demographics, medication use, and health behaviors. Patients were compared by current PPI use, and statistical analyses were performed by using SAS version 9.2 software. RESULTS Thirty-eight patients (42.2%) reported current PPI use despite a negative result from a pH study. Only 17 patients (18.9%) recalled being instructed to stop taking PPIs; chart review showed documented instructions to stop PPI therapy for 15 patients (16.7%). There were no significant differences in demographic or clinical characteristics among patients compared by current PPI use. Patients taking a PPI were more likely than those not taking a PPI to report troublesome symptoms that affected their daily life, as measured by a questionnaire for the diagnosis of GERD (the GerdQ). CONCLUSIONS More than 42% of patients with negative results from pH monitoring studies continue PPI therapy despite physiological data that they do not have GERD.
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Affiliation(s)
- Andrew J Gawron
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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Affiliation(s)
- Emeran A Mayer
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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The hypersensitive esophagus: pathophysiology, evaluation, and treatment options. Curr Gastroenterol Rep 2011; 12:417-26. [PMID: 20669058 DOI: 10.1007/s11894-010-0122-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Visceral hypersensitivity plays a key role in the pathogenesis of esophageal functional disorders such as functional heartburn and chest pain of presumed esophageal origin (noncardiac chest pain). About 80% of patients with unexplained noncardiac chest pain exhibit lower esophageal sensory thresholds when compared to controls during esophageal sensory testing (ie, esophageal barostat, impedance planimetry). Such information has led to prescription of peripherally and/or centrally acting therapies for the management of these patients. This review summarizes and highlights recent and significant findings regarding the pathophysiology, evaluation, and treatment of the hypersensitive esophagus, a central factor in functional esophageal disorders.
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Kamiya T, Adachi H, Hirako M, Shikano M, Matsuhisa E, Wada T, Ogasawara N, Nojiri S, Kataoka H, Sasaki M, Ohara H, Joh T. Impaired gastric motility and its relationship to reflux symptoms in patients with nonerosive gastroesophageal reflux disease. J Gastroenterol 2009; 44:183-9. [PMID: 19214661 DOI: 10.1007/s00535-008-2289-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Accepted: 08/22/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND More than half of patients with refluxrelated symptoms have no endoscopic evidence of mucosal breaks. These patients are considered to have nonerosive gastroesophageal reflux disease (NERD). The pathogenesis of NERD may be multifactorial, but the role played by gastric motility in symptom generation in patients with NERD has not been examined. In this study, we elucidate gastric motility in patients with NERD and the efficacy of a prokinetic agent in the treatment of NERD. METHODS Gastric motility was evaluated with electrogastrography (EGG) and by measurement of gastric emptying using the acetaminophen method in 26 patients with NERD and in 11 matched healthy controls. NERD patients were treated with a prokinetic agent (mosapride 15 mg, orally three times daily) for a period of 4 weeks, after which gastric motility was measured again. RESULTS Compared with the healthy controls, the NERD patients showed a significantly lower percentage of normogastria, a lower power ratio in EGG, and delayed gastric emptying. Ten patients had normal gastric motor function (group A), and 16 showed abnormalities of either gastric myoelectrical activity or gastric emptying (group B). After treatment with mosapride, gastric motility improved significantly in both groups of patients compared with pretreatment values. The subjective assessment by the patient after the treatment was improved in 20.0% of group A versus 62.5% of group B patients (P < 0.05). CONCLUSIONS Gastric hypomotility appears to be an important factor in reflux symptom generation in some NERD patients.
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Affiliation(s)
- Takeshi Kamiya
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Mizuho-ku, Nagoya, 467-8601, Japan
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Hiatal hernia, lower esophageal sphincter incompetence, and effectiveness of Nissen fundoplication in the spectrum of gastroesophageal reflux disease. J Gastrointest Surg 2009; 13:602-10. [PMID: 19050984 DOI: 10.1007/s11605-008-0754-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Accepted: 10/28/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS Gastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett's esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies. In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett's esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication. METHODS From the records of patients who had undergone laparoscopic Nissen fundoplication after an abnormal pH study, we identified 50 symptomatic consecutive patients with each of the GERD stages: (1) NERD, (2) mild ERD, defined as esophagitis that was healed with acid suppression therapy, (3) severe ERD, defined as esophagitis that persisted despite medical therapy, and (4) BE. Exclusion criteria were normal distal esophageal acid exposure, esophageal pH monitoring performed elsewhere, antireflux surgery less than 1 year previously or previous fundoplication, and a named esophageal motility disorder or distal esophageal low amplitude hypomotility. Patients who could not be contacted for the study were also excluded. All patients completed a detailed preoperative questionnaire; underwent preoperative upper gastrointestinal endoscopy, stationary manometry, and distal esophageal pH monitoring; and were interviewed at least 1 year after operation. RESULTS One hundred sixty patients meeting the entry criteria were studied. The mean follow-up period was 36.7 months. The only significant preoperative symptom difference was that patients with BE had more moderately severe or severe dysphagia compared to patients with NERD. Patients with severe ERD or BE had a significantly higher prevalence of hiatal hernia, lower LES pressures, and more esophageal acid exposure. Hiatal hernia and hypotensive LES were present in most patients with severe ERD or BE but in only a minority of patients with NERD or mild ERD. Surgical therapy resulted in similarly excellent symptom outcomes for patients in all GERD categories. CONCLUSIONS Compared to mild ERD and NERD, severe ERD and BE are associated with significantly greater loss of the mechanical antireflux barrier as reflected in the presence of hiatal hernia and LES measurements. Restoration of the antireflux barrier and hernia reduction by laparoscopic Nissen fundoplication provides similarly excellent symptom control in all patients.
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Garrigues V, Ponce J. Aspectos menos conocidos de la enfermedad por reflujo gastroesofágico: pirosis funcional y reflujo no ácido. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:522-9. [DOI: 10.1157/13127096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
The introduction of proton pump inhibitors (PPIs) has facilitated the treatment of gastrooesophageal reflux disease (GORD) enormously; however, treatment of GORD still fails in a small proportion of patients. This small proportion of therapy-resistant patients encompasses a substantial part of the working load of physicians and has become a common clinical problem. A strong variability in acid-suppressive effect of PPI treatment exists depending on compliance, Helicobacter pylori status and genotype. Nocturnal acid breakthrough does not seem to be a major determinant of refractory GORD. Recent data, however, show that PPI-refractory GORD can result from nonacid reflux episodes. It is wise to reconsider the diagnosis of GORD in patients who are PPI-refractory. Most patients in whom a PPI is not effective do not have GORD, instead they suffer from other disorders such as functional dyspepsia. If after a thorough history is taken the suspicion of GORD is still high, the next step would be to perform upper endoscopy and reflux monitoring. In case patients truly have PPI-refractory GORD, therapy can be aimed at oesophageal hypersensitivity or a surgical solution can be sought.
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Fass R. Proton-pump inhibitor therapy in patients with gastro-oesophageal reflux disease: putative mechanisms of failure. Drugs 2007; 67:1521-30. [PMID: 17661525 DOI: 10.2165/00003495-200767110-00001] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Proton-pump inhibitor (PPI) failure in gastro-oesophageal reflux disease (GORD) patients has become the main reason for referral of these patients to gastroenterology specialists. It is estimated that 30% of GORD patients requiring a PPI once daily will experience treatment failure. Patients with non-erosive reflux disease are the most common GORD-related group in which once-daily PPI therapy fails. Various mechanisms have been suggested to underlie PPI failure in GORD patients. The most pertinent include weakly acidic reflux, duodenogastro-oesophageal reflux, visceral hyperalgesia, delayed gastric emptying, psychological co-morbidity and concomitant functional bowel disorders, as well as others. Because of the importance of PPI failure as a target for future drug development, further understanding of the most relevant underlying mechanisms is needed.
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Affiliation(s)
- Ronnie Fass
- Section of Gastroenterology, The Neuro-Enteric Clinical Research Group, Southern Arizona VA Health Care System, Tucson, Arizona 85723-0001, USA.
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Shapiro M, Green C, Bautista JM, Dekel R, Risner-Adler S, Whitacre R, Graver E, Fass R. Assessment of dietary nutrients that influence perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2007; 25:93-101. [PMID: 17229224 DOI: 10.1111/j.1365-2036.2006.03170.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux disease symptoms are most commonly reported postprandially, suggesting that some diet components are likely to induce symptoms more than others. AIMS To determine which of the various dietary nutrients is a strong predictive factor for symptom generation in association with an acid reflux event. METHODS Subjects with typical heartburn symptoms were evaluated by the gastro-oesophageal reflux disease Symptom Checklist, demographics questionnaire, upper endoscopy and pH testing. During the pH study, patients completed a detailed 24-h dietary intake record. This included time of meals, description of food components and the amount and type of food preparation. RESULTS Fifty gastro-oesophageal reflux disease patients completed all stages of the study. A total of 112 (78%) symptoms were considered as sensed reflux event. Body mass index did not correlate with having perceived reflux. Patients who consumed more cholesterol, saturated fatty acids and had more percentage calories from fat were significantly more likely to experience a perceived reflux event. Regression analysis and beta-coefficient were specifically significant for cholesterol. CONCLUSION Of all dietary nutrients, cholesterol enhances the most the perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease.
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Affiliation(s)
- M Shapiro
- Department of Medicine, Section of Gastroenterology, The Neuro-Enteric Clinical Research Group, Southern Arizona VA Health Care System, AZ 85723-0001, USA
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Galmiche JP, Clouse RE, Bálint A, Cook IJ, Kahrilas PJ, Paterson WG, Smout AJPM. Functional esophageal disorders. Gastroenterology 2006; 130:1459-65. [PMID: 16678559 DOI: 10.1053/j.gastro.2005.08.060] [Citation(s) in RCA: 359] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Accepted: 08/31/2005] [Indexed: 12/13/2022]
Abstract
Functional esophageal disorders represent processes accompanied by typical esophageal symptoms (heartburn, chest pain, dysphagia, globus) that are not explained by structural disorders, histopathology-based motor disturbances, or gastroesophageal reflux disease. Gastroesophageal reflux disease is the preferred diagnosis when reflux esophagitis or excessive esophageal acid exposure is present or when symptoms are closely related to acid reflux events or respond to antireflux therapy. A singular, well-defined pathogenetic mechanism is unavailable for any of these disorders; combinations of sensory and motor abnormalities involving both central and peripheral neural dysfunction have been invoked for some. Treatments remain empirical, although the efficacy of several interventions has been established in the case of functional chest pain. Management approaches that modulate central symptom perception or amplification often are required once local provoking factors (eg, noxious esophageal stimuli) have been eliminated. Future research directions include further determination of fundamental mechanisms responsible for symptoms, development of novel management strategies, and definition of the most cost-effective diagnostic and treatment approaches.
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Wiklund I, Carlsson R, Carlsson J, Glise H. Psychological factors as a predictor of treatment response in patients with heartburn: a pooled analysis of clinical trials. Scand J Gastroenterol 2006; 41:288-93. [PMID: 16497615 DOI: 10.1080/00365520500292970] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A pooled analysis, using data from three prospective, randomized, double-blind, placebo-controlled, clinical studies, was undertaken to determine the relationship between well-being and subsequent clinical response to acid suppressant therapy in 1887 adult patients with reflux symptoms (with/without endoscopically verified erosive esophagitis). MATERIAL AND METHODS Well-being was assessed at study entry using the Psychological General Well-Being (PGWB) Index. Patients were assessed for complete relief of heartburn (absence of symptoms in the preceding 7 days) after 4 weeks' treatment (omeprazole 10 or 20 mg once daily; ranitidine 150 mg twice daily). RESULTS Multiple logistic regression analysis identified baseline PGWB Index total score and anxiety score as independent prognostic indicators of treatment response in endoscopy-positive patients (n=1333). Thus, the likelihood of achieving complete heartburn relief was impaired by high baseline levels of anxiety or a low total well-being score. In the endoscopy-negative group, high levels of depression and low vitality scores affected treatment response adversely. Furthermore, age (for endoscopy-positive patients only) and body mass index (for endoscopy-negative patients only) showed an association with treatment outcome. Gender seemed to have no prognostic value on treatment outcome. CONCLUSIONS Patient well-being may be a useful prognostic indicator in patients presenting with reflux symptoms, with a high level of anxiety predicating against a response to acid suppressant therapy, particularly in those with normal endoscopic findings.
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Affiliation(s)
- Brian T Johnston
- Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland, UK.
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Triponez F, Dumonceau JM, Azagury D, Volonte F, Slim K, Mermillod B, Huber O, Morel P. Reflux, dysphagia, and gas bloat after laparoscopic fundoplication in patients with incidentally discovered hiatal hernia and in a control group. Surgery 2005; 137:235-42. [PMID: 15674207 DOI: 10.1016/j.surg.2004.07.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic fundoplication effectively controls reflux symptoms in patients with gastroesophageal reflux disease (GERD). However, symptom relapse and side effects, including dysphagia and gas bloat, may develop after surgery. The aim of the study was to assess these symptoms in patients who underwent laparoscopic fundoplication, as well as in control subjects and patients with hiatal hernia. METHODS A standardized, validated questionnaire on reflux, dysphagia, and gas bloat was filled out by 115 patients with a follow-up of 1 to 7 years after laparoscopic fundoplication, as well as by 105 subjects with an incidentally discovered hiatal hernia and 238 control subjects. RESULTS Patients who underwent fundoplication had better reflux scores than patients with hiatal hernia ( P = .0001) and similar scores to control subjects ( P = .11). They also had significantly more dysphagia and gas bloat than patients with hiatal hernia and controls ( P < .005 for all comparisons). Gas bloat and dysphagia were more severe in hiatal hernia patients than in controls ( P < 0.005). After fundoplication, the 25% of the patients with the shortest follow-up (1.5 +/- 0.2 years) and the 25% patients with the longest follow-up (5.8 +/- 0.6 years) had similar reflux, dysphagia, and gas bloat scores ( P = .43, .82, and .85, respectively). CONCLUSION In patients with severe GERD, laparoscopic fundoplication decreases reflux symptoms to levels found in control subjects. These results appear to be stable over time. However, patients who underwent fundoplication experience more dysphagia and gas bloat than controls and patients with hiatal hernia-symptoms that should be seen as a side effect of the procedure and of GERD itself.
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Affiliation(s)
- Frederic Triponez
- Clinic and Policlinic of Digestive Surgery, Department of Surgery, University Hospital of Geneva, Geneva, Switzerland.
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Abstract
OBJECTIVE Psychosocial stressors have been associated with exacerbations of symptoms in functional and inflammatory disorders of the gastrointestinal tract. The present longitudinal study tests the general hypothesis that life stressors can exacerbate symptoms in patients with chronic heartburn. METHODS Sixty subjects with current heartburn symptoms were recruited by community advertisement and assessed for presence of stressful life events retrospectively over the preceding 6 months and prospectively for 4 months. Symptom severity by daily diary, quality of life, and psychological symptoms of anxiety, depression, and vital exhaustion were also measured. RESULTS The presence of a severe, sustained life stress during the previous 6 months significantly predicted increased heartburn symptoms during the following 4 months. In addition, symptoms showed a strong, independent correlation with vital exhaustion. Affective and subjective stress ratings were not strongly related to heartburn severity; however, anxiety showed the strongest relationship to impaired quality of life and depression to heartburn medication use. CONCLUSIONS As with other chronic conditions such as irritable bowel syndrome (IBS), heartburn severity appears to be most responsive to major life events and not an accumulation of more minor stressors or fluctuations in mood. In addition, vital exhaustion, which may in part result from sustained stress, may represent the psychophysiological symptom complex most closely associated with heartburn exacerbation. Potential mechanisms for these results include increased level and frequency of esophageal acid exposure, inhibition of gastric emptying of acid, or stress-induced hypersensitivity.
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Affiliation(s)
- Bruce D Naliboff
- Center for Neurovisceral Sciences & Women's Health, Department of Medicine, UCLA, Los Angeles, CA, USA.
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Cicala M, Emerenziani S, Caviglia R, Guarino MPL, Vavassori P, Ribolsi M, Carotti S, Petitti T, Pallone F. Intra-oesophageal distribution and perception of acid reflux in patients with non-erosive gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2003; 18:605-13. [PMID: 12969087 DOI: 10.1046/j.1365-2036.2003.01702.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The majority of patients with gastro-oesophageal reflux disease do not present with erosive oesophagitis and make up a heterogeneous group. Patients with non-erosive gastro-oesophageal reflux disease are less responsive than patients with oesophagitis to acid-suppressive therapy. AIM To assess the role of acid reflux in gastro-oesophageal reflux disease symptoms. METHODS The spatio-temporal characteristics of reflux events were analysed and related to reflux perception in 45 patients with non-erosive gastro-oesophageal reflux disease and 20 patients with erosive oesophagitis. RESULTS Compared with healthy controls, all patients showed a higher intra-oesophageal proximal spread of acid, which was prominent in patients with non-erosive gastro-oesophageal reflux disease (> 50% of events lasting for 1-2 min). Irrespective of mucosal injury, the risk of reflux perception was very high when acid reached proximal sensors (odds ratio, 7.6; 95% confidence interval, 4.6-12.5), being maximal in patients with non-erosive gastro-oesophageal reflux disease with normal acid exposure time (odds ratio, 11; 95% confidence interval, 5.2-22.3). CONCLUSIONS Patients with non-erosive gastro-oesophageal reflux disease are characterized by a significantly higher proportion of proximal acid refluxes and a higher sensitivity to short-lasting refluxes when compared with patients with oesophagitis. The highest proximal acid exposure and highest perception occurred in patients with non-erosive gastro-oesophageal reflux disease presenting with a normal pH-metric profile. The assessment of acid distribution and its perception in the oesophageal body can better identify reflux patients who should benefit from acid-suppressive treatment.
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Affiliation(s)
- M Cicala
- Department of Digestive Disease, University Campus Bio Medico, Rome, Italy.
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Abstract
The term "symptomatic gastroesophageal reflux disease" (GERD) refers to those patients who present with the typical GERD symptoms of heartburn and regurgitation, yet do not have endoscopic evidence of esophagitis. The primary goals of managing symptomatic GERD are to control symptoms and improve quality of life. A clinical assessment of the GERD patient can identify important clinical features, such as atypical and extraesophageal symptoms for which acid-suppressive agents tend to be less effective. Performing an endoscopy can further identify the patient as having nonerosive reflux disease, erosive esophagitis, or Barrett's esophagus-diagnoses which can help determine treatment but may not prove predictive of therapeutic response. Determining acid exposure through pH testing can predict therapeutic response, with those revealing an abnormal acid exposure time being more responsive to acid-suppressive therapy. However, the performance of an endoscopy and pH testing on each patient is clearly not practical. Whereas the natural history of symptomatic GERD is still largely undefined, acid-suppressive therapy appears to be the best approach available for both the short-term and long-term management of this disease.
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Affiliation(s)
- Eamonn M M Quigley
- Department of Medicine, Clinical Sciences Building, Cork University Hospital, National University of Ireland, Wilton Road, Cork, Ireland
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Tack J, Janssens J. Functional Heartburn. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:251-258. [PMID: 12095472 DOI: 10.1007/s11938-002-0047-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Functional heartburn is defined as the presence of a retrosternal burning sensation in the absence of pathologic gastroesophageal reflux. The underlying pathophysiology seems to be heterogeneous. In a subset of patients, esophageal hypersensitivity to physiologic esophageal acid exposure is involved, and this is likely to respond to intensive antireflux treatment. Antireflux surgery was not studied systematically in these patients and should be considered only in exceptional cases. In the remaining patients, non-acid reflux, esophageal mechanosensitivity, and psychological factors may be involved. Treatment options in these patients are limited owing to a lack of studies. Emerging therapies include selective serotonin reuptake inhibitors and relaxation therapy.
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Affiliation(s)
- Jan Tack
- Department of Internal Medicine, Division of Gastroenterology, University Hospital, Gasthuisberg, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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Affiliation(s)
- E M Quigley
- Department of Medicine, National University of Ireland, Cork
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Abstract
Nonerosive reflux disease is defined as the presence of typical symptoms of gastroesophageal reflux disease caused by intraesophageal acid in the absence of visible esophageal mucosal injury at endoscopy. Recent studies demonstrate that it is a chronic disease with a significant impact on quality of life, and it is very common in primary care settings. Treatment with acid inhibitory agents is effective, and proton pump inhibitors are the most effective form of therapy.
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Affiliation(s)
- R Fass
- Section of Gastroenterology, Southern Arizona VA Health Care System and University of Arizona Health Sciences Center, Tucson, USA
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Slim K, Bousquet J, Kwiatkowski F, Lescure G, Pezet D, Chipponi J. Quality of life before and after laparoscopic fundoplication. Am J Surg 2000; 180:41-5. [PMID: 11036138 DOI: 10.1016/s0002-9610(00)00415-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laparoscopic fundoplication is a well-established surgical option for the treatment of gastroesophageal reflux disease. The aim of this study was to assess the surgical outcomes from the patient's point of view by using a validated quality of life instrument. METHODS Fifty patients have been prospectively included. All patients underwent a standardized 270-degree posterior fundoplication. Quality of life was measured by the Gastrointestinal Quality of Life Index (GIQLI), a 36-item-questionnaire. The patients received the questionnaire before surgery, and 3 months and 1 year after surgery. RESULTS Preoperative score was 95.6+/-21 points. The score increased significantly (P <0.0005) at 3 months (103.6+/-16) and 1 year (111.4+/-22) after surgery. This improvement concerned the four domains of the questionnaire (symptoms, social functioning, physical status, and emotions). The score in patients at 1 year remained, however, significantly lower than that in healthy persons (126+/-18). CONCLUSIONS GIQLI is a sensitive tool to assess surgical outcomes after fundoplication. The quality of life after surgery did not reach the level of healthy population, not because of failure of surgery to treat GERD but probably because of functional dyspepsia that was present prior to surgery and did not change after fundoplication.
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Affiliation(s)
- K Slim
- Department of General and Digestive Surgery, Jean Perrin Center, Clermont-Ferrand, France
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Havelund T, Lind T, Wiklund I, Glise H, Hernqvist H, Lauritsen K, Lundell L, Pedersen SA, Carlsson R, Junghard O, Stubberöd A, Anker-Hansen O. Quality of life in patients with heartburn but without esophagitis: effects of treatment with omeprazole. Am J Gastroenterol 1999; 94:1782-9. [PMID: 10406235 DOI: 10.1111/j.1572-0241.1999.01206.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Because improvement in quality of life (QoL) is an important therapeutic goal in patients with heartburn but without esophagitis, the aim of the present study was to compare the impact of omeprazole 20 mg or 10 mg daily with that of placebo on QoL in patients with heartburn as the predominant symptom. METHODS QoL was measured at baseline and after 4 wk using two validated questionnaires, the Psychological General Well-Being (PGWB) index and the Gastrointestinal Symptom Rating Scale. RESULTS The two questionnaires were completed by 163 patients in the omeprazole 20 mg group, 163 in the omeprazole 10 mg group, and 82 in the placebo group. The reflux dimension of the Gastrointestinal Symptom Rating Scale showed a significant improvement in terms of reflux symptoms on omeprazole 20 mg versus omeprazole 10 mg and placebo, and on omeprazole 10 mg compared with placebo. The total score of the PGWB index improved significantly more on both doses of omeprazole than on placebo. The mean scores rose from 96.8 to 103.9 on omeprazole 20 mg, from 98.4 to 106.0 on omeprazole 10 mg, and from 98.0 to 100.6 on placebo. All dimensions of the PGWB index improved on treatment with omeprazole, but the improvements were most pronounced in the dimensions depicting anxiety, depressed mood, and self-control. CONCLUSIONS It is concluded that treatment with omeprazole 20 mg and omeprazole 10 mg restores QoL to a level comparable with that observed in a healthy population.
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Affiliation(s)
- T Havelund
- Department of Medicine, Odense University Hospital, Denmark
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Ringel Y, Drossman DA. Treatment of patients with functional esophageal symptoms: is there a role for a psychotherapeutic approach? J Clin Gastroenterol 1999; 28:189-93. [PMID: 10192601 DOI: 10.1097/00004836-199904000-00001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Wiklund I, Glise H, Jerndal P, Carlsson J, Talley NJ. Does endoscopy have a positive impact on quality of life in dyspepsia? Gastrointest Endosc 1998; 47:449-54. [PMID: 9647367 DOI: 10.1016/s0016-5107(98)70243-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND It is unclear whether normal endoscopy results in patients investigated for dyspepsia has therapeutic value. Therefore the aim of this study was to evaluate the effect of the endoscopy on quality of life and dyspeptic symptoms. METHODS One hundred ninety-six symptomatic patients (85 men and 111 women, mean age 42.9 years), who were receiving no treatment, were investigated before and 1 week after endoscopy with the use of a battery of validated questionnaires. RESULTS Before endoscopy the health-related quality of life was compromised in comparison with a normal population, but 1 week after a negative endoscopy it is increased to a level which was close to the normal range despite no major change in symptoms. Physical activity and sleep scores improved significantly after endoscopy. CONCLUSION The present results suggest that a negative endoscopy improves quality of life in the short-term in patients with dyspepsia, even though symptoms may persist.
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Shibata Y, Nimura Y, Toyoda S, Yasui A, Kawamura T. Acid reflux test for gastroesophageal reflux after distal gastrectomy: diagnosis and clinical effect of cisapride. J Am Coll Surg 1998; 186:596-600. [PMID: 9583703 DOI: 10.1016/s1072-7515(98)00086-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Y Shibata
- First Department of Surgery, Nagoya University School of Medicine, Japan
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Lind T, Havelund T, Carlsson R, Anker-Hansen O, Glise H, Hernqvist H, Junghard O, Lauritsen K, Lundell L, Pedersen SA, Stubberöd A. Heartburn without oesophagitis: efficacy of omeprazole therapy and features determining therapeutic response. Scand J Gastroenterol 1997; 32:974-9. [PMID: 9361168 DOI: 10.3109/00365529709011212] [Citation(s) in RCA: 288] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Data are limited on the value of effective antisecretory therapy in the relief of heartburn in patients without oesophagitis. METHODS Patients with heartburn, without endoscopic signs of oesophagitis, were randomized to double-blind treatment with omeprazole, 20 or 10 mg once daily, or placebo, for 4 weeks (n = 509). Pre-treatment oesophageal acid exposure was assessed using 24-h intra-oesophageal pH monitoring. Heartburn was assessed at 2 and 4 weeks. RESULTS At 4 weeks the proportion of patients with complete absence of heartburn was 46% (95% confidence interval, 39-53%) with 20 mg omeprazole, 31% (25-38%) with 10 mg omeprazole, and 13% (7-20%) with placebo. Satisfaction with therapy was reported by 66%, 57%, and 31% of the patients, respectively. CONCLUSION Omeprazole, 20 and 10 mg once daily, provides rapid relief of heartburn in patients without endoscopic oesophagitis.
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Affiliation(s)
- T Lind
- Dept. of Surgery, Kärnsjukhuset, Skövde, Sweden
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Glise H, Hallerbäck B, Wiklund I. Quality of life: a reflection of symptoms and concerns. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1996; 221:14-7. [PMID: 9110390 DOI: 10.3109/00365529609095545] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Upper gastrointestinal complaints are common in the general population. Most patients consulting have no or only minimal markers of disease. It is important to evaluate new methods for the assessment and follow-up of treatment of these new patient groups. METHODS AND RESULTS Recent publications on Quality of Life (QOL) and upper gastrointestinal disease are reviewed with the specific aim of relating the effect of disease symptoms and patient concerns to the outcome of investigations. We found that QOL is adversely affected in upper gastrointestinal disorders and that effective treatment medically or surgically normalizes the scores. There is a good correlation between degree of symptoms and QOL outcome. Patients' concern affects the outcome. CONCLUSION QOL assessments are helpful in evaluating the impact of upper gastrointestinal disease.
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Affiliation(s)
- H Glise
- Dept. of Surgery, NAL, Trollhättan, Sweden
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Wiklund I, Butler-Wheelhouse P. Psychosocial factors and their role in symptomatic gastroesophageal reflux disease and functional dyspepsia. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1996; 220:94-100. [PMID: 8898445 DOI: 10.3109/00365529609094759] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients with symptoms of GERD and dyspepsia are among the most common consulters in general practice and are different from their counterparts in the community who choose not to consult although they suffer from similar symptoms. They represent a heterogeneous group with considerable symptom overlap. They have a relatively poor quality of life and endoscopic findings can only explain symptoms in about half of these patients. Thus psychosocial factors which could contribute to their morbidity should be explored. While some studies have methodological shortcomings, main findings are that key psychological factors are anxiety, tension, neuroticism, somatization, fears of malignancy, negative assessment of health, depression, a poor social network and less effective coping strategies. Physical illness is likely to bring on psychological distress due to discomfort or threat of ill health. Cognizance of psychosocial factors will facilitate an understanding of the underlying problems and will improve diagnosis and selection of optimal treatment.
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Affiliation(s)
- I Wiklund
- Astra Hässle Research Laboratories, Mölndal, Sweden
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Affiliation(s)
- B T Johnston
- Department of Medicine, Queen's University of Belfast, Royal Victoria Hospital
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