Atypical symptoms in patients with gastroesophageal reflux disease

Pepsin and pH of Gastric Juice in Patients With Gastrointestinal Reflux Disease and Subgroups

GOAL

The aim of this study was to investigate the pepsin values and pH results of gastric juice among the subtypes of gastroesophageal reflux disease (GERD) and functional heartburn.

BACKGROUND

The major destructive agents of GERD on the esophageal epithelium are gastric acid and pepsin. No precise information about pepsin concentration in gastric juice exists.

STUDY

Ninety patients with GERD, 39 erosive reflux disease (ERD) Los Angeles (LA) grade A/B, 13 ERD LA grade C/D, 19 nonerosive reflux disease (NERD), 8 esophageal hypersensitivity, 11 functional heartburn, and 24 healthy controls were included in the study. During endoscopy gastric juices from the patients were aspirated and their pH readings immediately recorded. Gastric juice samples were analyzed using Peptest, a lateral flow device containing 2 unique human monoclonal antibodies to detect any pepsin present in the gastric juice sample.

RESULTS

The highest mean gastric pepsin concentration (0.865 mg/mL) and the lowest median gastric pH (1.4) was observed in the LA grade C/D group compared with the lowest mean gastric pepsin concentration (0.576 mg/mL) and the highest median gastric pH (2.5) seen in the NERD group. Comparing pH, the NERD patient group was significantly higher (P=0.0018 to P=0.0233) when compared with all other GERD patient groups.

CONCLUSIONS

The basal gastric pepsin level in the healthy control group was comparable to literature values. There was good correlation and a significant linear relationship between the gastric pepsin level and gastric pH within the patient groups. The severity of the GERD disease is related to the lowest pH and the highest pepsin concentration in gastric juice.

Current advances in the diagnosis and management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is very common and defined as troublesome symptoms owing to excessive acid reflux. The spectrum of GERD is broad, including not only erosive esophagitis and Barrett's esophagus but also nonerosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn. Patients with reflux symptoms despite normal endoscopy remain common clinical presentation, can be heterogeneous overlapping with functional gastrointestinal disorders. Ambulatory esophageal pH monitoring with and without impedance helps the diagnosis of NERD. Metrics such as baseline impedance and postreflux swallow induced peristaltic wave enhance diagnostic accuracy in patients with inconclusive diagnoses. The major treatment of all manifestations of GERD is acid suppression with proton pump inhibitors, while other therapies, such as reflux-reducing agents and adjunctive medications, can be individualized where the response to traditional management is incomplete. GERD patients often need long-term treatment due to frequent relapses. Anti-reflux surgery can be effective too. Endoscopic therapies have some promising results, but long-term outcomes remain to be determined.

Chronic non-allergic rhinitis with neutrophils is associated with higher acid exposure time: A pH-impedance monitoring study

BACKGROUND & AIM

Chronic rhinitis, a diffuse disease with a prevalence of 40%, can be classified in allergic (AR) and non-allergic rhinitis (NAR). Nasal cytology allows for the identification of different NAR sub-types according to the inflammatory cell infiltrate. NAR etiopathogenesis is not well clarified and, for NARNE (non-allergic rhinitis with neutrophils) subtype, gastroesophageal reflux disease (GERD) has been suggested as one of the etiopathogenetic factors. Aim of this study is to evaluate the role of GERD in patients with NARNE.

METHODS

Fifty-one consecutive patients referred to our Ear, Nose and Throat (ENT) unit with nasal symptoms and cytology suggestive for NAR, were enrolled in the study. All the patients performed a gastroenterological evaluation, high resolution esophageal manometry and a 24-h pH-Impedance monitoring.

RESULTS

Twenty-five (49%) patients tested positive at nasal cytology for NARNE. A pathologic pH-impedance was identified in seven patients (28%) with NARNE, as opposed to only one (4%) with different NAR subtypes. Statistical analysis showed that higher acid exposure time (AET) and weaker post nasal drainage were more common in NARNE vs. other NAR patients.

CONCLUSIONS

NARNE strongly correlates with higher AET and refluxes number; thus, NARNE patients should be tested with pH-impedance monitoring in addition to nasal cytology.

Altered oesophageal mechanosensitivity of secondary peristalsis as a pathophysiological marker in patients with globus sensation

OBJECTIVE

Secondary peristalsis is important for clearance of retained food bolus and refluxate from the oesophagus. We aimed to investigate whether patients with globus sensation have altered physiological characteristics of secondary peristalsis.

DESIGN

Prospective case-controlled study SETTING: Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.

PARTICIPANTS

Seventeen globus patients and 18 healthy controls.

MAIN OUTCOME MEASURES

After a baseline recording of primary peristalsis, secondary peristalsis was stimulated with slow and rapid mid-oesophageal injections of air. Distension thresholds and peristaltic activities of secondary peristalsis were analysed and compared between the patients and healthy controls.

RESULTS

The threshold volume for generating secondary peristalsis during slow air distension did not differ between the patient and control groups (P = .55). The threshold volume for generating secondary peristalsis during rapid air distension was significantly greater in patients with globus than healthy controls (7.0 ± 0.9 vs 5.0 ± 0.3 mL, P = .04). Secondary peristalsis was triggered less frequently in globus patients as compared with healthy control after rapid air distension (40% [30%-65%] vs 60% [60%-83%], P = .001). There was no difference in any of peristaltic parameters for primary and secondary peristalsis between the groups.

CONCLUSIONS

Our work identifies functional defects of oesophageal secondary peristalsis in patients with globus sensation and such defects are characterised with defective triggering of secondary peristalsis during rapid air distension. Whether current findings have therapeutic implication in the management of patients with globus sensation warrants further investigation.

[The frequency and clinical aspects of extraesophageal syndromes in elderly patients with gastroesophageal reflux disease]

AIM

To investigate the frequency of extraesophageal syndromes in elderly patients with gastroesophageal reflux disease (GERD).

MATERIALS AND METHODS

This cross-sectional study was conducted to compare the clinical manifestations of GERD in 1100 patients aged 60 to 75 years and in 453 patients aged 36 to 60 years. A control group consisted of 154 elderly patients without GERD and 178 mature-aged patients without this condition. GERD was diagnosed via analysis of its symptoms, esophagogastroduodenoscopy, and 24-hour pH monitoring on the basis of the Montreal consensus guidelines. Extraesophageal syndromes were detected actively using the current methods accepted to treat lung, heart, and ENT diseases and a simultaneous gastroesophageal examination.

RESULTS

Chronic cough, asthma, chronic laryngitis, cardialgias and cardiac arrhythmias were much more common in elderly patients with GERD than in those without this condition and prevalent in patients with erosive esophagitis and Barrett's esophagus as compared with those with non-erosive reflux disease. The mature-aged patients were recorded to have similar but less pronounced trends. The authors proposed an algorithm for the management of patients with extraesophageal manifestations of GERD, the important aspect of which was two-month acid-suppressive therapy used as both diagnostic testing and empirical treatment for this pathology.

CONCLUSION

The extraesophageal manifestations of GERD in elderly patients are a serious clinical problem calling for considerable attention.

Patients with refractory reflux symptoms often do not have GERD

BACKGROUND

In patients with typical reflux symptoms that persist despite proton pump inhibitors (PPIs) it is sometimes overlooked that treatment fails due to the presence of other disorders than gastroesophageal reflux disease (GERD). The aim of this study was to determine the underlying cause of reflux symptoms not responding to PPI therapy in tertiary referral patients.

METHODS

Patients with reflux symptoms refractory to PPI therapy who underwent 24-h pH-impedance monitoring were analyzed. Patients in whom a diagnosis was already established before referral, who had previous esophageal or gastric surgery, or who had abnormalities on gastroscopy other than hiatus hernia, were excluded.

KEY RESULTS

In total, 106 patients were included. Esophageal manometry showed achalasia in two patients and distal esophageal spasm in another two. Twenty-four-hour pH-impedance monitoring revealed a total acid exposure time <6% in 60 patients (56.6%) of which 25 had a positive symptom association probability (SAP) while 35 showed a negative SAP. Sixty-nine patients ended up with a final diagnosis of GERD while 32 patients (30.2%) were diagnosed with functional heartburn (FH), two with functional chest pain, two with achalasia, and one with rumination. A trend toward an association with a final diagnosis of FH was found with the atypical symptom epigastric pain (p = 0.059) and with a secondary diagnosis of functional dyspepsia (p = 0.083).

CONCLUSIONS & INFERENCES

Approximately one-third of the patients referred with refractory reflux symptoms suffer from disorders other than GERD, predominantly FH. This explains, at least partly, why many patients will not benefit from acid inhibitory treatment.

Clinical characteristics and effectiveness of lansoprazole in Japanese patients with gastroesophageal reflux disease and dyspepsia

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) frequently have symptoms of dyspepsia in addition to reflux symptoms. Treatment options for dyspepsia are not standardized. The aim of this study was to clarify the therapeutic effect of lansoprazole on dyspepsia in Japanese patients with GERD.

METHODS

GERD patients with dyspepsia were enrolled and treated with lansoprazole 15 or 30 mg once daily for 4 weeks. Reflux and dyspeptic symptoms were assessed by questionnaires before treatment, and 2 and 4 weeks after the start of lansoprazole treatment.

RESULTS

In the effectiveness analysis set (n = 12,653), heartburn was reported by 91.6 % of patients at study enrollment. Postprandial fullness was the most frequently reported dyspepsia symptom at the start of the study, reported by 79.0 % of enrolled patients. After 4 weeks of lansoprazole treatment, heartburn symptoms were improved in 75.7 % of patients and symptoms of postprandial fullness were improved in 68.7 % of patients. The therapeutic effect of low and high doses of lansoprazole on dyspepsia, as well as on reflux symptoms, was approximately 10 % higher in patients with endoscopy-confirmed erosive esophagitis (60.1-82.2 %), than in patients with non-erosive reflux diseases (53.0-73.3 %). Lansoprazole was well tolerated.

CONCLUSION

In this large-scale clinical study, lansoprazole effectively relieved dyspepsia in addition to reflux symptoms in patients with GERD.

Prevalence of Extraesophageal Symptoms in Patients With Gastroesophageal Reflux Disease: A Multicenter Questionnaire-based Study in Korea

Background/Aims

Many patients with gastroesophageal reflux disease (GERD) also present with extraesophageal symptoms (EESs). This study sought to determine the prevalence of concomitant EESs and to evaluate quality of life (QOL) impairment in a Korean population with GERD.

Methods

This questionnaire-based study was carried out from 64 hospitals in Korea between October 2008 and March 2009. Patients with typical GERD symptoms of heartburn or acid regurgitation were recruited for study. Participants filled out questionnaire consisting of GerdQ questions and EES questions. All participants underwent endoscopy and were divided into patients with erosive reflux disease (ERD) and with non-erosive reflux disease (NERD).

Results

A total of 1,712 patients were included in this study. Of these, 697 (40.7%) patients had ERD and 1,015 (59.3%) NERD. The prevalence of EES was 90.3%. The most prevalent EES was epigastric burning (73.2%), followed by globus (51.8%), chest pain (48.4%), cough (32.0%), hoarseness (24.2%) and wheezing (17.3%). Individual EES was more prevalent in patients with ERD than in those with NERD. Regarding QOL, 701 patients (41.0%) had sleep disturbance and 676 (37.7%) had taken additional over-the-counter medication for heartburn and/or regurgitation, which were more prevalent in patients with ERD than in those with NERD (49.5% vs. 35.1% and 45.8% vs. 32.2%, respectively; all P < 0.001).

Conclusions

The prevalence of EES is high in Korean patients with symptomatic GERD. Individual EES is more prevalent in patients with ERD than in those with NERD. QOL impairment is observed less frequently than previous studies.