Gastroesophageal Reflux and Sleep Disturbances: A Bidirectional Association in a Population-Based Cohort Study, The HUNT Study

Wake up to gastro-oesophageal reflux disease: The interplay between arousal and night-time reflux

This review examines the temporal association between nocturnal gastro-oesophageal reflux and sleep-arousal cycles. Most nocturnal gastro-oesophageal reflux events occur during the awake cycle, and arousals precede most nocturnal gastro-oesophageal reflux events, indicating that arousal from sleep predisposes to nocturnal gastro-oesophageal reflux. This sheds light on the complex relationship between nocturnal gastro-oesophageal reflux and sleep, and has implications for managing nocturnal gastro-oesophageal reflux symptoms. The appearance of symptoms and the pathophysiology of nocturnal gastro-oesophageal reflux are influenced by sleep hygiene, sleep disturbances and the misalignment of circadian rhythms. Nocturnal gastro-oesophageal reflux and its related sleep disorders are prevalent and negatively impact the quality of life. There is conflicting evidence on whether nocturnal gastro-oesophageal reflux and sleep disturbances are causally linked, and whether sleep disturbances drive nocturnal gastro-oesophageal reflux. Poor sleep quality increases oesophageal hypersensitivity and overall acid exposure. The nocturnal gastro-oesophageal reflux is linked to the more severe forms of gastro-oesophageal reflux disease, especially with atypical/extra-oesophageal manifestations and complications of mucosal damage such as oesophagitis and stricture, Barret's oesophagus, and oesophageal adenocarcinoma. This review highlights the role of sleep problems in presenting nocturnal gastro-oesophageal reflux, and the potential benefits of treating sleep disturbances in enhancing patient care and quality of life.

Prevalence and risk factors of gastroesophageal reflux disease in Iran: A cross-sectional analysis from the PERSIAN cohort

BACKGROUND

This study assessed the prevalence of gastroesophageal reflux disease (GERD) in a general adult population in Iran. The association between GERD and various factors was also evaluated.

METHODS

We performed a cross-sectional study on 163,018 individuals aged over 35 who were enrolled in the PERSIAN cohort. GERD was defined as the occurrence of heartburn and/or regurgitation symptoms at least several days a month. Survey design analysis for pooled data was performed and multiple regression analysis was conducted to determine the independent risk factors for GERD.

RESULTS

The prevalence of GERD in our study was estimated at 21.86% (95% confidence interval:17.4%-36.4%). The mean age of the participants was 49.84 years±9.25 (35-70) and 44.75% of the participants were male. Symptoms of heartburn and regurgitation were reported in 18.65% (n: 29,170) and 6.06% (n: 9,717) of participants, respectively. In the multivariate analysis, several factors were found to be associated with a higher prevalence of GERD: female sex, age >50, current smoking, opium use, weekly consumption of fried foods, frequent consumption of hot tea, less than 6 hours of sleep per night, psychiatric disorders, usage of NSAIDs, and poor oral hygiene, were associated with a higher prevalence of GERD. Conversely, higher education levels and average physical activity were found to be less commonly associated with GERD.

CONCLUSION

We found a relatively high prevalence of GERD (21.86%) in this population-based study in Iran. By identifying modifiable risk factors, this research offers opportunities for targeted interventions and lifestyle modifications to reduce the burden of GERD.

The status quo of short video as sources of health information on gastroesophageal reflux disease in China: a cross-sectional study

Background

Positive lifestyle adjustments have become effective methods in treating gastroesophageal reflux disease (GERD). Utilizing short video platforms to encourage GERD patients for effective self-disease management is a convenient and cost-effective approach. However, the quality of GERD-related videos on short video platforms is yet to be determined, and these videos may contain misinformation that patients cannot recognize. This study aims to assess the information quality of GERD-related short videos on TikTok and Bilibili in China.

Methods

Search and filter the top 100 GERD-related videos on TikTok and Bilibili based on comprehensive rankings. Two independent gastroenterologists conducted a comprehensive evaluation of the video quality using the Global Quality Score and the modified DISCERN tool. Simultaneously, the content of the videos was analyzed across six aspects: definition, symptoms, risk factors, diagnosis, treatment, and outcomes.

Results

A total of 164 GERD-related videos were collected in this study, and videos from non-gastrointestinal health professionals constitute the majority (56.71%), with only 28.66% originating from gastroenterology health professionals. The overall quality and reliability of the videos were relatively low, with DISCERN and GQS scores of 2 (IQR: 2-3) and 3 (IQR: 2-3), respectively. Relatively speaking, videos from gastrointestinal health professionals exhibit the highest reliability and quality, with DISCERN scores of 3 (IQR: 3-4) and GQS scores of 3 (IQR: 3-4), respectively.

Conclusion

Overall, the information content and quality of GERD-related videos still need improvement. In the future, health professionals are required to provide high-quality videos to facilitate effective self-disease management for GERD patients.

Bidirectional correlation between gastroesophageal reflux disease and sleep problems: a systematic review and meta-analysis

Objectives

Gastroesophageal reflux disease (GERD) and sleep problems are highly prevalent among the general population. Both them are associated with a variety of psychiatric disorders such as depression and anxiety, which is highlighting an underexplored connection between them. This meta-analysis aims to explore the association between sleep problems and GERD.

Methods

We conducted a comprehensive search on PubMed, Cochrane Library, Embase, and Web of Science, using Medical Subject Headings (MeSH) and keywords, covering articles from the inception of the databases until August 2023. Stata statistical software, version 14.0, was utilized for all statistical analyses. A fixed-effects model was applied when p > 0.1 and I2 ≤ 50%, while a random-effects model was employed for high heterogeneity (p < 0.1 and I2 > 50%). Funnel plots and Egger's test were used to assess publication bias.

Results

Involving 22 studies, our meta-analysis revealed that insomnia, sleep disturbance, or short sleep duration significantly increased the risk of GERD (OR = 2.02, 95% CI [1.64-2.49], p < 0.001; I2 = 66.4%; OR = 1.98, 95% CI [1.58-2.50], p < 0.001, I2 = 50.1%; OR = 2.66, 95% CI [2.02-3.15], p < 0.001; I2 = 62.5%, respectively). GERD was associated with an elevated risk of poor sleep quality (OR = 1.47, 95% CI [1.47-1.79], p < 0.001, I2 = 72.4%), sleep disturbance (OR = 1.47, 95% CI [1.24-1.74], p < 0.001, I2 = 71.6%), or short sleep duration (OR = 1.17, 95% CI [1.12-1.21], p < 0.001, I2 = 0).

Conclusion

This meta-analysis establishes a bidirectional relationship between four distinct types of sleep problems and GERD. The findings offer insights for the development of innovative approaches in the treatment of both GERD and sleep problems.

TRPV1 is a risk factor for sleep disturbance in patients with gastro-oesophageal reflux disease: a case control study

BACKGROUND/AIMS

Gastro-oesophageal reflux disease (GORD) is a chronic high-morbidity disease with a bidirectional relationship with sleep disturbance (SD) that may occur via the transient receptor potential vanilloid type 1 receptor (TRPV1) in the oesophageal mucosa. Yet the related mechanism was still unclear, the aim of this study is to investigate whether TRPV1 is associated with the presence of SD in GORD patients.

METHODS

A case-control study was performed. After the screening, A total of 88 subjects were assigned to GORD without sleep disturbance (GORD + NOSD, n = 28), GORD comorbid sleep disturbance (GORD + SD, n = 30) and matched healthy controls (n = 30). Mucosal tissue was obtained from the participants by digestive endoscopy, the levels of TRPV1 expressed in the oesophageal mucosa were detected via RT-qPCR and western blot in different groups, and the correlation between GORD and SD were also analysed.

RESULTS

In this study, we found that the Gastroesophageal Reflux Disease Diagnostic Questionnaire (GerdQ) scores was positively correlated with Pittsburgh Sleep Quality Index (PSQI) scores but negatively correlated with total sleep time (TST). We also found that the level of TRPV1 expressed in the oesophageal mucosa of GORD + SD was significantly higher than GORD + NOSD patients, and they were all higher than healthy controls.

CONCLUSION

The current study suggested a closer link exists between GORD and sleep disturbance, and TRPV1 in oesophageal mucosa may be a crucial factor affecting sleep in GORD patients.

Dietary factors involved in GERD management

Gastroesophageal reflux disease (GERD) is extremely common, and even modest weight gain has been associated with higher symptom burden as well as objective evidence of reflux on endoscopy and physiological measurement. Certain trigger foods, especially citrus, coffee, chocolate, fried food, spicy food and red sauces are frequently reported to worsen reflux symptoms, although hard evidence linking these items to objective GERD is lacking. There is better evidence that large meal volume and high calorie content can increase esophageal reflux burden. Conversely, sleeping with the head end of the bed raised, avoiding lying down close to meals, sleeping on the left side and weight loss can improve reflux symptoms and objective reflux evidence, especially when the esophagogastric junction 'reflux barrier' is compromised (e.g., in the presence of a hiatus hernia). Consequently, attention to diet and weight loss are both important elements of management of GERD, and need to be incorporated into management plans.

Short sleep duration is associated with a wide variety of medical conditions among United States military service members

OBJECTIVES

This cross-sectional study investigated self-reported sleep duration and its association with a comprehensive range of clinically-diagnosed medical condition categories (CDMCs), as well as the relationship between short sleep duration (≤6 h) and demographic/lifestyle factors, among United States military service members (SMs).

METHODS

A stratified random sample of SMs (n = 20,819) completed an online questionnaire on usual daily hours of sleep and demographic/lifestyle characteristics. CDMCs for a six-month period prior to questionnaire completion were obtained from a comprehensive military electronic medical surveillance system and grouped into 33 CDMCs covering both broad and specific medical conditions. Prevalence of CDMCs was compared among three sleep duration categories (≤4, 5-6 and ≥7 h).

RESULTS

SMs reported a mean ± standard deviation of 6.3 ± 1.4 h of sleep per day. After adjustment for demographic/lifestyle characteristics, shorter sleep duration was associated with higher odds of a medical condition in 25 of 33 CDMCs, with most (n = 20) demonstrating a dose-response relationship. The five CDMCs with the largest differences between ≤4 vs ≥ 7 h sleep were: diseases of the nervous system (odds ratio [OR] = 2.9, 95% confidence interval [95%CI] = 2.4-3.4), mental/behavioral diseases (OR = 2.7, 95%CI = 2.3-3.2), diseases of the musculoskeletal system (OR = 1.9, 95%CI = 1.6-2.1), diseases of the circulatory system (OR = 1.7, 95%CI = 1.3-2.2), and diseases of the digestive system (OR = 1.6, 95%CI = 1.2-2.0). Six hours of sleep or less was independently associated with older age, less formal education, race, Hispanic ethnicity, higher body mass index, smoking, and military service branch.

CONCLUSIONS

In this young, physically active population, reporting shorter sleep duration was associated with a higher risk of multiple CDMCs.

Dynorphin participates in interaction between depression and non-erosive reflux disease

BACKGROUND

To explore the relationships between anxiety/depression and NERD, we focused on dynorphin (Dyn), an important member of visceral hypersensitivity, and its related pathways.

METHODS

Pearson's correlation analysis on patients with NERD and in vivo experiment on NERD rat model. Part 1: Pearson's correlation analysis among serum levels of Dyn, clinical symptoms and HADS scores of NERD patients were carried on. Part 2: Wistar rats were randomly divided into 2 groups: control group and model group. The data of pH value, immobility time, serum Dyn concentration, NMDAR1 and SP expression were, respectively, derived from automatic pH recorder, tail suspension test, enzyme-linked immunosorbent assay, immunohistochemistry and immunofluorescence.

RESULTS

Part 1: Pearson's correlation analysis showed that there was a linear correlation between Clinical Symptom (CS) score and HADS score (HAD-A, HAD-D), and the correlation coefficients were 0.385 and 0.273 respectively; the correlation coefficient between lg (Dyn) and lg (CS score) was r = 0.441, P = 0.002; the correlation coefficient between lg(Dyn) and lg (HAD-D score) was r = 0.447, P = 0.002. Part 2: The pH value of the lower esophagus in the model group was lower than that in the control group (P < 0.01). The tail suspension immobility time of model group was significantly longer than that of control group (P < 0.01). The serum Dyn concentration and the expression level of NMDAR1 in spinal cord and SP in lower esophageal mucosa of model group were significantly higher than those of control group (P < 0.05).

CONCLUSION

Increased serum dynorphin level may be a sign of correlation between depression and NERD.

AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review

BACKGROUND & AIMS

As many as one-half of all patients with suspected gastroesophageal reflux disease (GERD) do not derive benefit from acid suppression. This review outlines a personalized diagnostic and therapeutic approach to GERD symptoms.

METHODS

The Best Practice Advice statements presented here were developed from expert review of existing literature combined with extensive discussion and expert opinion to provide practical advice. Formal rating of the quality of evidence or strength of recommendations was not the intent of this clinical practice update. BEST PRACTICE ADVICE 1: Clinicians should develop a care plan for investigation of symptoms suggestive of GERD, selection of therapy (with explanation of potential risks and benefits), and long-term management, including possible de-escalation, in a shared-decision making model with the patient. BEST PRACTICE ADVICE 2: Clinicians should provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors, relaxation strategies, and awareness about the brain-gut axis relationship to patients with reflux symptoms. BEST PRACTICE ADVICE 3: Clinicians should emphasize safety of proton pump inhibitors (PPIs) for the treatment of GERD. BEST PRACTICE ADVICE 4: Clinicians should provide patients presenting with troublesome heartburn, regurgitation, and/or non-cardiac chest pain without alarm symptoms a 4- to 8-week trial of single-dose PPI therapy. With inadequate response, dosing can be increased to twice a day or switched to a more effective acid suppressive agent once a day. When there is adequate response, PPI should be tapered to the lowest effective dose. BEST PRACTICE ADVICE 5: If PPI therapy is continued in a patient with unproven GERD, clinicians should evaluate the appropriateness and dosing within 12 months after initiation, and offer endoscopy with prolonged wireless reflux monitoring off PPI therapy to establish appropriateness of long-term PPI therapy. BEST PRACTICE ADVICE 6: If troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy and, in the absence of erosive reflux disease (Los Angeles B or greater) or long-segment (≥3 cm) Barrett's esophagus, perform prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or to rule out GERD. BEST PRACTICE ADVICE 7: Complete endoscopic evaluation of GERD symptoms includes inspection for erosive esophagitis (graded according to the Los Angeles classification when present), diaphragmatic hiatus (Hill grade of flap valve), axial hiatus hernia length, and inspection for Barrett's esophagus (graded according to the Prague classification and biopsied when present). BEST PRACTICE ADVICE 8: Clinicians should perform upfront objective reflux testing off medication (rather than an empiric PPI trial) in patients with isolated extra-esophageal symptoms and suspicion for reflux etiology. BEST PRACTICE ADVICE 9: In symptomatic patients with proven GERD, clinicians should consider ambulatory 24-hour pH-impedance monitoring on PPI as an option to determine the mechanism of persisting esophageal symptoms despite therapy (if adequate expertise exists for interpretation). BEST PRACTICE ADVICE 10: Clinicians should personalize adjunctive pharmacotherapy to the GERD phenotype, in contrast to empiric use of these agents. Adjunctive agents include alginate antacids for breakthrough symptoms, nighttime H2 receptor antagonists for nocturnal symptoms, baclofen for regurgitation or belch predominant symptoms, and prokinetics for coexistent gastroparesis. BEST PRACTICE ADVICE 11: Clinicians should provide pharmacologic neuromodulation, and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies in patients with functional heartburn or reflux disease associated with esophageal hypervigilance reflux hypersensitivity and/or behavioral disorders. BEST PRACTICE ADVICE 12: In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients. BEST PRACTICE ADVICE 13: In patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients, and a salvage option in non-obese patients, whereas sleeve gastrectomy has potential to worsen GERD. BEST PRACTICE ADVICE 14: Candidacy for invasive anti-reflux procedures includes confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function.

Identification of independent risk factors for intraoperative gastroesophageal reflux in adult patients undergoing general anesthesia

BACKGROUND

Gastroesophageal reflux (GER) affects up to 20% of the adult population and is defined as troublesome and frequent symptoms of heartburn or regurgitation. GER produces significantly harmful impacts on quality of life and precipitates poor mental well-being. However, the potential risk factors for the incidence and extent of GER in adults undergoing general anesthesia remain unclear.

AIM

To explore independent risk factors for the incidence and extent of GER during general anesthesia induction.

METHODS

A retrospective study was conducted, and 601 adult patients received general anesthesia intubation or laryngeal mask surgery between July 2016 and January 2019 in Shanghai General Hospital of Nanjing Medical University. This study recruited a total of 601 adult patients undergoing general anesthesia, and the characteristics of patients and the incidence or extent of GER were recorded. The potential risk factors for the incidence of GER were explored using multivariate logistic regression, and the risk factors for the extent of GER were evaluated using multivariate linear regression.

RESULTS

The current study included 601 adult patients, 82 patients with GER and 519 patients without GER. Overall, we noted significant differences between GER and non-GER for pharyngitis, history of GER, other digestive tract diseases, history of asthma, and the use of sufentanil (P < 0.05), while no significant differences between groups were observed for sex, age, type of surgery, operative time, body mass index, intraoperative blood loss, smoking status, alcohol intake, hypertension, diabetes mellitus, psychiatric history, history of respiratory infection, history of surgery, the use of lidocaine, palliative strategies, propofol, or rocuronium bromide, state anxiety inventory, trait anxiety inventory, and self-rating depression scale (P > 0.05). The results of multivariate logistic regression indicated that female sex [odds ratio (OR): 2.702; 95% confidence interval (CI): 1.144-6.378; P = 0.023], increased age (OR: 1.031; 95%CI: 1.008-1.056; P = 0.009), pharyngitis (OR: 31.388; 95%CI: 15.709-62.715; P < 0.001), and history of GER (OR: 11.925; 95%CI: 4.184-33.989; P < 0.001) were associated with an increased risk of GER, whereas the use of propofol could protect against the risk of GER (OR: 0.942; 95%CI: 0.892-0.994; P = 0.031). Finally, age (P = 0.004), operative time (P < 0.001), pharyngitis (P < 0.001), history of GER (P = 0.024), and hypertension (P = 0.017) were significantly associated with GER time.

CONCLUSION

This study identified the risk factors for GER in patients undergoing general anesthesia including female sex, increased age, pharyngitis, and history of GER.

Associations between Lifestyle Habits, Perceived Symptoms and Gastroesophageal Reflux Disease in Patients Seeking Health Check-Ups

Gastroesophageal reflux disease (GERD) is one of the most common diseases. It mainly causes the stomach contents to flow back to the esophagus, thereby stimulating the esophagus and causing discomfort. From the results of our research, we intend to provide the general public with information related to preventing gastroesophageal reflux disease and medical personnel with information on the treatment and care of patients with gastroesophageal reflux disease. This study aimed to investigate the association of lifestyle habits and perceived symptoms on GERD in patients who underwent routine health check-ups. This study was conducted as a retrospective cross-sectional design to collect GERD cases from the medical records containing the health questionnaires and the report of endoscopic findings on the day of the health check-up. A total of 5653 patients were enrolled between 1 January 2016, and 31 December 2018. About 60.2% (n = 3404) of patients with GERD were diagnosed based on endoscopic findings. Descriptive and multivariate logistic regression analyses were performed to identify the risk factors of the development of GERD. The results of the multivariate logistic regression analysis showed that age, sex, waist circumference, Areca catechu chewing habit, sleep disorders, otolaryngology symptoms, and hepatobiliary and gastrointestinal symptoms were significantly associated with GERD. In this study, our results can be used as a reference for public health care and clinicians. Because most GERD cases can be controlled and prevented by lifestyle modifications, health professionals should always obtain a detailed history regarding symptoms and lifestyle habits associated with GERD.

Heartburn in children and adolescents in the presence of functional dyspepsia and/or irritable bowel syndrome correlates with the presence of sleep disturbances, anxiety, and depression

ABSTRACT

The aim of this study was to assess the relationship of heartburn in pediatric patients with functional dyspepsia (FD) and irritable bowel syndrome (IBS) with gastrointestinal symptoms, sleep disturbances, and psychologic distress.The overlap in symptoms of FD, IBS, and gastroesophageal reflux disease (GERD) predicts greater symptom severity and decreased quality of life and presents opportunities for improved diagnostic classification and personalized therapeutics.A cross-sectional observational study of 260 pediatric patients with abdominal pain was conducted. Patients completed standardized questionnaires assessing clinical symptoms, sleep quality, and psychologic symptoms during routine clinical care. Questionnaire data were compared for patients reporting heartburn and not reporting heartburn using χ2 and t tests where appropriate.Gastrointestinal symptoms were significantly more prevalent among patients with a positive report of heartburn (vs a negative report of heartburn): pain with eating (83% vs 67%, P = .007), bloating (63% vs 44%, P = .005), acid regurgitation (47% vs 24%, P ≤ .001), and chest pain (45% vs 20%, P ≤ .001). Likewise, initiating and maintaining sleep (P = .007), arousal/nightmares (P = .046), sleep-wake transition (P = .001), hyperhidrosis during sleep (P = .016), and anxiety (P = .001) and depression (P = .0018) were also significantly increased in patients who reported heartburn versus patients who did not report heartburn.Patients with a positive report of heartburn, whether classified as having FD and/or IBS, had increased gastrointestinal symptoms, sleep disturbances, anxiety, and depression than patients with a negative report of heartburn. A better understanding of these associations may allow for personalized treatment for youth with abdominal pain and heartburn as a primary symptom.

Impact of Retirement on Sleep Problems Among Older Workers and Their Partners

BACKGROUND AND OBJECTIVES

Sleep problems are a public health burden and have adverse health consequences in older adults. Despite sleep being a shared biological process between couples, to date there have not been any studies that have assessed the association between retirement and sleep, in older couples. The objective of this study was to examine the impact of retirement on diagnosed sleep problems in older Dutch couples.

RESEARCH DESIGN AND METHODS

This study used data from two waves of the NIDI Pension Panel Study for older Dutch adults living with a partner (n= 3,726). Logistic regression models examined the strength of association between retirement and sleep problems, while accounting for the moderating role of relationship characteristics.

RESULTS

Retirement was associated with decreased odds of sleep problems at wave 2 (OR= 0.60, 95%CI=0.46-0.78). Lower relationship quality was associated with increased odds of sleep problems in the fully adjusted model (OR=1.81, 95%CI=1.32-2.49). Having a partner with sleep problems was associated with increased risk of sleep problems as well (OR=1.51, 95%CI=1.07-2.13). There was evidence of effect modification by relationship quality (OR= 1.87, 95%CI =1.05-3.31).

DISCISSION AND IMPLICATIONS

Retirement and sleep do not occur in a social vacuum and have implications beyond the individual level. More research is therefore needed to understand the impact of sleep and its health consequences on older coupled workers. Such research may provide valuable insights for management and treatment of sleep problems and may have implications for public health of aging communities.

Severe reflux, sleep disturbances, and health-related quality of life after esophageal cancer surgery

PURPOSE

Esophagectomy for cancer is an extensive procedure often followed by severe complications. This study investigated whether patients with severe symptoms of reflux are more likely to have sleep disturbances and reduced health-related quality of life (HRQL) after esophagectomy.

METHODS

This Swedish nationwide prospective cohort study encompassed all patients who had undergone esophagectomy for cancer between 2013 and 2018. One year after surgery, the patients responded to three questionnaires on reflux (EORTC QLQOG25), sleep disturbances (KSQ), and HRQL (EORTC QLQ-C30). Multivariable logistic regression provided odds ratios (OR) with 95% confidence intervals (CI) for sleep disturbance/reduced HRQL between patients with and without reflux, adjusted for potential confounders.

RESULTS

Among 241 esophagectomy patients, 66 (27%) reported severe reflux. Patients with reflux had an increased risk of sleep disturbances (OR 2.3, 95% CI: 1.3-4.3) compared to patients without reflux. More specifically, these patients were more likely to suffer from poor sleep quality (OR 4.9, 95% CI: 1.9-12.4). Patients with reflux and sleep disturbances reported reductions in global quality of life, role function, emotional function, social function, and more symptoms in all scales, except for dyspnea.

CONCLUSIONS

This study suggests that patients with severe symptoms of reflux after esophagectomy have an increased risk of sleep disturbances and poor sleep quality, which in turn are associated with reduced HRQL.

IMPLICATIONS FOR CANCER SURVIVORS

Alleviating reflux after oesophageal cancer surgery is important, since this common symptom might reduce HRQL and well-being.

Mortality in gastro-oesophageal reflux disease in a population-based nationwide cohort study of Swedish twins

OBJECTIVES

The public health disorder gastro-oesophageal reflux disease (GORD) is linked with several comorbidities, including oesophageal adenocarcinoma (OAC), but whether life expectancy is reduced by GORD is uncertain. This study assessed all-cause and cancer-specific mortality in GORD after controlling for confounding by heredity and other factors.

DESIGN

Population-based cohort study from 1998 to 2015.

SETTING

Swedish nationwide study.

PARTICIPANTS

Twins (n=40 961) born in 1958 or earlier in Sweden.

EXPOSURE

GORD symptoms reported in structured computer-assisted telephone interviews.

OUTCOMES

The primary outcome was all-cause mortality and the secondary outcome was cancer-specific mortality among twins with GORD and twins without GORD. HRs and 95% CIs were analysed using parametric survival models, both in individual twin analyses and co-twin pair analyses, with adjustment for body mass index, smoking, education and comorbidity.

RESULTS

Among 40 961 individual twins, 5812 (14.2%) had GORD at baseline and 8062 (19.7%) died during follow-up of up to 16 years. The risks of all-cause mortality (HR=1.00, 95% CI: 0.94-1.07) and cancer-specific mortality (HR=0.99, 95% CI: 0.89-1.10) were not increased in individual twins with GORD compared with individual twins without GORD. Similarly, there were no differences in mortality outcomes in within-pair analyses. The OAC-specific mortality rate was 0.45 (95% CI: 0.32-0.66) per 1000 person-years in individual twins with GORD and 0.22 (95% CI: 0.18-0.27) per 1000 person-years without GORD, rendering an adjusted HR of 2.01 (95% CI: 1.35-2.98).

CONCLUSIONS

GORD did not increase all-cause or cancer-specific mortality when taking heredity and other confounders into account. The increased relative risk of mortality in OAC was low in absolute numbers.

Patient-reported outcomes 1 year after oesophageal cancer surgery

Purpose: To improve survivorship in patients who have undergone curatively intended treatment for oesophageal cancer, we aimed to identify key targets for future patient-reported outcomes research.Methods: This nationwide Swedish prospective cohort study enrolled patients between 2014 and 2019 who had undergone surgical resection for oesophageal cancer 1 year earlier. Eight well-validated patient-reported outcome measures, including health-related quality of life, psychological status and sleep, were presented as proportions and mean scores (MS) with 95% confidence intervals (CIs).Results: Among 281 participants, approximately half of the patients reported problems associated with food intake such as eating restrictions (49%) and food aversion (47%). Other common problems were sleep (51%), fatigue (41%) and anxiety (36%). Fewer patients suffered from financial difficulties (9%), trouble swallowing saliva (4%) and hair loss (7%). However, these problems were perceived as highly burdensome on an individual level.Conclusions: This nationwide, population-based study indicates that symptom burden is high in oesophageal cancer survivors 1 year after surgery. The most common problems are associated with food intake, sleep, fatigue and anxiety. However, less frequent symptoms were sometimes more debilitating for the individual patient.

Temporal Relationship Between Night-Time Gastroesophageal Reflux Events and Arousals From Sleep

INTRODUCTION

Night-time gastroesophageal reflux (nGER) symptoms are commonly associated with interrupted sleep. Most studies attempting to understand the relationship between sleep, arousal, and nGER events have been performed so using accelerometry; however, this technology is limited in its ability to precisely determine the temporal association between sleep and reflux events. We aimed to examine the temporal relationships between nGER events and arousal/awakening from sleep using high resolution, in-laboratory polysomnography (PSG).

METHODS

Individuals between 18 and 70 years who had undergone a gastroscopy within 12 months underwent simultaneous 24-hour pH/impedance monitoring and in-laboratory PSG. The temporal relationship between each nGER event and sleep/arousals/awakenings was determined for each participant. Analyses were limited to the sleep period (between "lights out" and time of final waking).

RESULTS

Analyses were conducted on the data from 25 individuals, 64% of whom had nGER episodes (5 ± 5 events per person, range 1-18) and 64% of whom had obstructive sleep apnea (OSA, mean apnea-hypopnea index 20 ± 11 events/hr, range 6-44). There were no differences in PSG-determined sleep duration, sleep efficiency, sleep architecture, arousals/awakenings, or sleep apnea severity between those with nGER and those without. Most nGER events (82%) occurred during a PSG epoch that had been classified as wake. Arousals/awakenings preceded almost all events (73/76), whereas fewer had an arousal/awakening after the event (15/76).

DISCUSSION

As opposed to what is typically assumed, nGER does not seem to cause arousal from sleep, but rather arousal from sleep predisposes to nGER.

The effect of sleep deficiency on esophageal acid exposure of healthy controls and patients with gastroesophageal reflux disease

BACKGROUND

Studies have demonstrated a bi-directional relationship between sleep deficiency and gastroesophageal reflux disease (GERD). However, there is limited data on how sleep deficiency affects esophageal acid exposure. We aimed to compare the effect of sleep deficiency on esophageal acid exposure of healthy controls versus GERD patients.

METHODS

Eleven patients from each of 2 groups were randomized to undergo pH-testing after 2 consecutive days of 7-8 hours of sleep per night (normal sleep) or 2 consecutive days of 4 hours of sleep per night (deficient sleep). All subjects then crossed over to the other arm, after 1-week washout period. While subjects were instructed to follow the study sleep protocol, actigraphy ensured subjects followed required sleeping time during study period.

KEY RESULTS

After normal sleep, all healthy controls had normal esophageal acid exposure. After deficient sleep, 5 healthy controls demonstrated an abnormal pH test. Overall, there was a significant increase in reflux parameters after deficient sleep as compared with normal sleep (% total time-6.15 ± 5.89 vs 1.74 ± 1.54, % upright time-4.72 ± 5.36 vs 0.87 ± 1.28, P < .05, respectively). After normal sleep, 6 GERD patients (54.5%) demonstrated an abnormal pH-testing. After deficient sleep, 10 GERD patients (90.9%) demonstrated an abnormal pH-testing. GERD patients demonstrated significantly higher reflux parameters than healthy controls after normal sleep (% total time-5.02 ± 3.45 vs 1.74 ± 1.54, % upright time-4.11 ± 3.98 vs 0.87 ± 1.28, P < .05, respectively).

CONCLUSIONS & INFERENCES

Sleep deficiency increased esophageal acid exposure in both healthy controls and GERD patients. Sleep deficiency also resulted in abnormal pH tests in almost half of healthy controls.

Lifestyle intervention for gastroesophageal reflux disease: a national multicenter survey of lifestyle factor effects on gastroesophageal reflux disease in China

BACKGROUND

Poor habits can worsen gastroesophageal reflux disease (GERD) and reduce treatment efficacy. Few large-scale studies have examined lifestyle influences, particularly eating habits, on GERD in China, and research related to eating quickly, hyperphagia, and eating hot foods is quite limited. The aim of this study was to evaluate the relationship between GERD pathogenesis and lifestyle factors to produce useful information for the development of a clinical reference guide through a national multicenter survey in China.

METHODS

Symptom and lifestyle/habit questionnaires included 19 items were designed. The questionnaire results were subjected to correlation analysis relative to GERD symptom onset. A standard proton pump inhibitor (PPI) was advised to correct patients with unhealthful lifestyle habits.

RESULTS

A total of 1518 subjects (832 GERD, 686 non-GERD) enrolled from six Chinese hospitals completed symptom and lifestyle/habit questionnaires. The top lifestyle factors related to GERD were fast eating, eating beyond fullness, and preference for spicy food. Univariate analysis showed that 21 factors, including male gender, a supra-normal body mass index (BMI), smoking, drinking alcohol, fast eating, eating beyond fullness, eating very hot foods, and drinking soup, among others, were associated with GERD (p < 0.05). Logistic multivariate regression analysis revealed the following risk factors for GERD [with odds ratios (ORs)]: fast eating (4.058), eating beyond fullness (2.849), wearing girdles or corsets (2.187), eating very hot foods (1.811), high BMI (1.805), lying down soon after eating (1.544), and smoking (1.521). Adjuvant lifestyle interventions improved outcomes over medication alone (z = -8.578, p < 0.001 Mann-Whitney rank sum test).

CONCLUSIONS

Lifestyle interventions can improve medication efficacy in GERD patients. Numerous habits, including fast eating, eating beyond fullness, and eating very hot foods, were associated with GERD pathogenesis. The present results may be useful as a reference for preventive education and treatment.

Association between digestive symptoms and sleep disturbance: a cross-sectional community-based study

BACKGROUND

This study was conducted to analyze the association between digestive symptoms and sleep disturbance, and to determine if any digestive symptoms are related to sleep disturbance.

METHODS

This was a cross-sectional study of 5792 subjects surveyed in a community-based cohort. Subjects provided information regarding the quality of sleep as assessed by the Pittsburgh Sleep Quality Index (PSQI), as well as digestive symptoms as assessed by the Gastrointestinal Symptom Rating Scale (GSRS). Logistic regressions were used to examine factors associated with sleep quality.

RESULTS

The mean PSQI global score of the no sleep disturbances group (n = 4948) was 3.92 (SD = 2.14), while that of the sleep disturbance group (n = 844) was 11.18 (SD = 2.17). The association between digestive symptoms and sleep disturbance was evaluated by logistic regression after adjusting for cofounding factors. The results revealed that sleep disturbances were associated with digestive symptoms (aOR = 1.29, 95% CI = 1.22-1.36), especially abdominal pains (aOR = 1.63, 95% CI = 1.19-2.25), acid regurgitation (aOR = 1.48, 95% CI = 1.17-1.86), abdominal distension (aOR = 1.80, 95% CI = 1.42-2.28), and eructation (aOR = 1.59, 95% CI = 1.24-2.03).

CONCLUSIONS

Digestive symptoms and sleep disturbances seem to be associated. These results will help medical professionals to effectively diagnose and manage patients with sleep disturbance. Furthermore, subsequent studies using comprehensive longitudinal data should be conducted to confirm the results of the present study.

Association between bruxism and symptomatic gastroesophageal reflux disease: A case-control study

OBJECTIVES

To examine the relation between bruxism and gastroesophageal reflux disease (GERD) and the contribution of depression, anxiety and impaired sleep quality to that association.

METHODS

A three-centre case-control study was conducted consisting of 887 consecutive clinically-diagnosed bruxism patients aged 18-75 years and 887 matched controls. Diagnosis of GERD was based on the Montreal definition: moderate/severe symptoms ≥ one day/week or mild symptoms ≥ two days/week. Logistic regression was used to evaluate the association between bruxism and GERD. Mediation analyses were used to test whether the association between bruxism and GERD was mediated by depression, anxiety or impaired sleep quality.

RESULTS

Binary logistic regression identified that GERD was associated with bruxism (odds ratio, 6.87; 95% confidence interval (CI), 4.34-10.88). This association was stronger in females (odds ratio, 12.27; 95% CI, 5.81-25.91) than in males (odds ratio, 3.99; 95% CI, 2.17-7.32). Multinomial logistic regression identified that GERD was associated with all types of bruxism (sleep bruxism alone, odds ratio, 6.71, 95% CI, 4.22-10.68; awake bruxism alone, odds ratio, 13.06, 95% CI, 5.32-32.05; overlap of sleep bruxism and awake bruxism, odds ratio, 6.48, 95% CI, 3.05-13.77). Ordinal logistic regression identified that longer GERD duration (> 2 years vs ≤ 2 years) was associated with bruxism frequency (odds ratio, 1.50; 95% CI, 1.10-2.05). Mediation analyses found that the association between bruxism and GERD was partially-mediated through depression, anxiety and impaired sleep quality.

CONCLUSIONS

Clinically-diagnosed bruxism is associated with symptomatic GERD and is partially-mediated through depression, anxiety and impaired sleep quality.

CLINICAL SIGNIFICANCE

Because bruxism is strongly associated with symptomatic GERD and patients with frequent bruxism symptoms tend to suffer from GERD for extensive time-periods, dentists should consider evaluation of GERD status as an elemental part of the medical examination of bruxism, especially severe bruxism.

All-cause and cancer-specific mortality in GORD in a population-based cohort study (the HUNT study)

OBJECTIVE

Gastro-oesophageal reflux is a public health concern which could have associated oesophageal complications, including adenocarcinoma, and possibly also head-and-neck and lung cancers. The aim of this study was to test the hypothesis that reflux increases all-cause and cancer-specific mortalities in an unselected cohort.

DESIGN

The Nord-Trøndelag health study (HUNT), a Norwegian population-based cohort study, was used to identify individuals with and without reflux in 1995-1997 and 2006-2008, with follow-up until 2014. All-cause mortality and cancer-specific mortality were assessed from the Norwegian Cause of Death Registry and Cancer Registry. Multivariable Cox regression was used to calculate HRs with 95% CIs for mortality with adjustments for potential confounders.

RESULTS

We included 4758 participants with severe reflux symptoms and 51 381 participants without reflux symptoms, contributing 60 323 and 747 239 person-years at risk, respectively. Severe reflux was not associated with all-cause mortality, overall cancer-specific mortality or mortality in cancer of the head-and-neck or lung. However, for men with severe reflux a sixfold increase in oesophageal adenocarcinoma-specific mortality was found (HR 6.09, 95% CI 2.33 to 15.93) and the mortality rate was 0.27 per 1000 person-years. For women, the corresponding mortality was not significantly increased (HR 3.68, 95% CI 0.88 to 15.27) and the mortality rate was 0.05 per 1000 person-years.

CONCLUSIONS

Individuals with severe reflux symptoms do not seem to have increased all-cause mortality or overall cancer-specific mortality. Although the absolute risk is small, individuals with severe reflux symptoms have a clearly increased oesophageal adenocarcinoma-specific mortality.