[Clinical practice patterns of gastroenterologists for initial and maintenance therapy in gastroesophageal reflux disease: a nationwide online survey in Korea]

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis.

Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Refractory gastroesophageal reflux disease: Current status and perspectives

Patients with gastroesophageal reflux disease (GERD) who do not respond to an 8-12 wk course of acid-suppressive therapy with a proton pump inhibitor twice daily, with symptoms such as heartburn and acid reflux symptoms persisting after therapy, can be diagnosed with refractory GERD (RGERD). It is estimated that RGERD accounts for approximately 10%-40% of all GERD cases. Due to complicated causes, the clinical recognition of RGERD is insufficient. Thanks to the advances in the basic and clinical research of RGERD in recent years, there have been updated consensus guidelines on the diagnosis and treatment of RGERD in America and Asia (including China). This paper reviews the definition, epidemiology, pathophysiology, diagnostic evaluation, and treatment of RGERD.

[Updated guidelines 2012 for gastroesophageal reflux disease]

In 2010, a Korean guideline for the management of gastroesophageal reflux disease (GERD) was made by the Korean Society of Neurogastroenterology and Motility, in which the definition and diagnosis of GERD were not included. The aim of this guideline was to update the clinical approach to the diagnosis and management of GERD in adult patients. This guideline was developed by the adaptation process of the ADAPTE framework. Twelve guidelines were retrieved from initial queries through the Appraisal of Guidelines for Research & Evaluation II process. Twenty-seven statements were made as a draft and revised by modified Delphi method. Finally, 24 consensus statements for the definition (n=4), diagnosis (n=7) and management (n=13) of GERD were developed. Multidisciplinary experts participated in the development of the guideline, and the external review of the guideline was conducted at the finalization phase.

Is use of PPIs related to increased intraepithelial lymphocytes in the colon?

BACKGROUND

The use of proton pump inhibitors (PPIs) is thought to increase the incidence of microscopic colitis (MC), although the exact mechanisms are not fully understood. Increased infiltration of intraepithelial lymphocytes (IELs) is a pathologic finding of MC (including collagenous or lymphocytic colitis).

AIMS

We investigated whether PPI use is associated with increased IEL infiltration and inflammation in the lamina propria.

METHODS

We retrospectively reviewed the medical records and histological reports of 78 patients receiving PPIs who had no symptoms of diarrhea, and their age- and gender- matched controls. The levels of IELs and inflammation in the lamina propria were assessed independently by two pathologists using H&E and immunohistochemical staining for CD3 and CD8.

RESULTS

The IEL count was significantly higher in the PPI group than in controls (12.92 ± 6.27 vs. 8.10 ± 4.21 per 100 epithelial cells, p < 0.001), as was the extent of inflammation (1.74 ± 0.90 vs. 0.86 ± 0.78, p < 0.001). PPI use was associated with increased IEL infiltration in a multivariate analysis (OR, 3.232; 95 % CI, 1.631-6.404, p < 0.001). Within the PPI group, however, the IEL count was not significantly associated with gender, age, type of PPI, or duration of PPI use.

CONCLUSIONS

The use of PPIs has a significant association with increased IEL infiltration for subjects without symptoms of diarrhea. This finding suggests that changes such histological alterations seen in the early phage seen in MC possibly represent the stage of the disease even before the onset of symptoms.

Advances in research of esophageal visceral hypersensitivity

Gastroesophageal reflux disease (GERD) is a common disorder that is often associated with unpleasant symptoms requiring utilization of health care resource. Both animal and clinical studies suggest that a variety of receptors on afferent nerves sensitized upon exposure to acid increase afferent input to the spinal cord dorsal horn neurons and lead to a reduction in threshold of these neurons together with an increase in their receptive field. This increased sensitivity of primary afferent nerves is described as peripheral sensitization, whereas the consequent increase in sensitivity of the spinal dorsal horn neurons is described as central sensitization. Once these mechanisms have been established, they can cause a long-term increase in sensitivity of tissues to previously innocuous stimuli. Furthermore, psychological stress and mechanical stimulation both have been shown to increase DIS and may therefore facilitate peripheral sensitization. Currently peripheral and central sensitizations are considered to be important mechanisms of esophageal pain hypersensitivity and occurrence of symptoms to even physiological amounts of acid. In these patients treatments aimed at reducing neuronal sensitivity may be effective. This article mainly focuses on the recent advances in research of esophageal visceral hypersensitivity.

[Guidelines for the treatment of gastroesophageal reflux disease]

Gastroesophageal reflux disease (GERD) is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. In the last decade, GERD has been increasing in Korea. Seventeen consensus statements for the treatment of GERD were developed using the modified Delphi approach. Acid suppression treatments, such as proton pump inhibitors (PPIs), histmine-2 receptor antagonists and antacids are effective in the control of GERD-related symptoms. Among them, PPIs are the most effective medication. Standard dose PPI is recommended as the initial treatment of erosive esophagitis (for 8 weeks) and non-erosive reflux disease (at least for 4 weeks). Long-term continuous PPI or on-demand therapy is required for the majority of GERD patients after the initial treatment. Anti-reflux surgery can be considered in well selected patients. Prokinetic agents and mucosal protective drugs have limited roles. Twice daily PPI therapy can be tried to control extra-esophageal symptoms of GERD. For symptomatic patients with Barrett's esophagus, long-term treatment with PPI is required. Further studies are strongly needed to develop better treatment strategies for Korean patients with GERD.