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Sawada A, Sifrim D, Fujiwara Y. Esophageal Reflux Hypersensitivity: A Comprehensive Review. Gut Liver 2023; 17:831-842. [PMID: 36588526 PMCID: PMC10651372 DOI: 10.5009/gnl220373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/01/2022] [Accepted: 10/18/2022] [Indexed: 01/03/2023] Open
Abstract
Reflux hypersensitivity (RH) is one of the phenotypes of gastroesophageal reflux disease. The latest Rome IV defines RH as a condition with typical reflux symptoms and positive reflux-symptom association despite normal acid exposure. Subsequently, the Lyon consensus proposed detailed cutoff values for the criteria on the basis of experts' consensus. Rome IV brought a clear-cut perspective into the pathophysiology of gastroesophageal reflux disease and the importance of esophageal hypersensitivity. This perspective can be supported by the fact that other functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia often overlap with RH. Although several possible pathophysiological mechanisms of esophageal hypersensitivity have been identified, there is still unmet medical needs in terms of treatment for this condition. This review summarizes the current knowledge regarding RH.
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Affiliation(s)
- Akinari Sawada
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Abstract
INTRODUCTION Increased nonacid reflux is diagnosed in a subgroup of patients with gastroesophageal reflux disease who often present with reflux symptoms refractory to proton-pump inhibitor therapy. Despite the prevalence of this condition, the management approach for patients with increased nonacid reflux can often be varied and unclear. AIMS Our primary aim was to investigate physician management patterns for patients who had received a diagnosis of increased nonacid reflux on impedance-pH studies. METHODS Reflux studies in patients with increased nonacid reflux per Lyon Consensus criteria and management approaches were retrospectively reviewed. Reflux symptom survey, manometry findings, reflux symptom association (RSA) on reflux testing, immediate posttesting management information, and managing provider information were assessed. RESULTS A total of 43 subjects in total were analyzed. Management plan after a diagnosis of increased nonacid reflux was decided by a gastroenterologist in over 95% of cases and varied greatly with no changes being the most common. Even among subjects with + RSA on reflux monitoring, no change in management was the most common action, although this occurred much less frequently compared to subjects with - RSA (28.6% vs. 78.6%, p < 0.01). When change in therapy occurred, medical treatment with baclofen was the most common choice (21.4%). Other management changes included medications for visceral hypersensitivity and antireflux surgery, although these changes occurred rarely. CONCLUSIONS Abnormally increased nonacid reflux is frequently encountered on impedance-pH studies; however, management decisions vary significantly among gastroenterologists. When treatment change is implemented, they are variable and can include lifestyle modifications, medication trials, or antireflux surgery. Future development of standardized management algorithms for increased nonacid reflux is needed.
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Affiliation(s)
- Chanakyaram A Reddy
- Division of Gastroenterology, University of Michigan Hospitals-Michigan Medicine, 3912 Taubman Center, 1500 E Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA.
| | - Lydia Watts
- Division of Gastroenterology, University of Michigan Hospitals-Michigan Medicine, 3912 Taubman Center, 1500 E Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA
| | - Jason R Baker
- Division of Gastroenterology, University of Michigan Hospitals-Michigan Medicine, 3912 Taubman Center, 1500 E Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA
| | - Joan W Chen
- Division of Gastroenterology, University of Michigan Hospitals-Michigan Medicine, 3912 Taubman Center, 1500 E Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA
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Akiyama J, Hosaka H, Kuribayashi S, Moriyasu S, Hisada Y, Okubo H, Watanabe K, Imbe K, Nagata N, Kojima Y, Yokoi C, Uemura N, Shimoyama Y, Kawamura O, Yamada M, Kusano M. Efficacy of Vonoprazan, a Novel Potassium-Competitive Acid Blocker, in Patients with Proton Pump Inhibitor-Refractory Acid Reflux. Digestion 2020; 101:174-183. [PMID: 30897577 DOI: 10.1159/000497775] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/07/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIM We evaluated the efficacy of vonoprazan (VPZ), a novel potassium-competitive acid blocker, in patients with proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD), exhibiting continued pathological esophageal acid exposure (EAE). METHODS Despite ≥8 weeks of appropriate PPI therapy, patients with -persistent reflux symptoms and pathological EAE times (EAETs ≥4%) were invited to switch to VPZ treatment. After an 8-week-course of once-daily VPZ (20 mg), multichannel intraluminal impedance-pH (MII-pH) monitoring was repeated to compare gastric acid exposure times (GAETs), EAETs, and other reflux parameters relative to the baseline values. Before each MII-pH study, reflux symptom severities were scored using the Gastrointestinal Symptom Rating Scale; erosive esophagitis and fasting plasma gastrin levels were also assessed. RESULTS From among the 124 patients undergoing MII-pH monitoring, 13 patients (median age, 69 years; females, 64%) were monitored at baseline (while on PPI therapy) and after VPZ therapy. The median GAET associated with VPZ treatment (23.8%) was less than that for PPI treatment (41.1%; p = 0.01), including both daytime and nighttime measurements. VPZ therapy resulted in better median EAET values (4.5%) than did PPI therapy (10.6%) during the 24-h monitoring period (p = 0.055). EAE normalization was achieved in 46% of VPZ-treated patients and was associated with complete gastric acid suppression (p = 0.005). After switching to VPZ, reflux symptoms (p < 0.01) and erosive esophagitis (p = 0.01) improved. CONCLUSION In patients with PPI-refractory GERD, VPZ provides more potent gastric acid suppression, more effective EAE control, enhanced symptom improvement, and better esophagitis healing than PPIs.
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Affiliation(s)
- Junichi Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan, .,Department of Medicine and Molecular Science, Gunma University, Maebashi, Japan,
| | - Hiroko Hosaka
- Department of Medicine and Molecular Science, Gunma University, Maebashi, Japan.,Division of Gastroenterology and Hepatology, Integrative Center of Internal Medicine, Gunma University Hospital, Maebashi, Japan
| | - Shiko Kuribayashi
- Department of Medicine and Molecular Science, Gunma University, Maebashi, Japan.,Division of Gastroenterology and Hepatology, Integrative Center of Internal Medicine, Gunma University Hospital, Maebashi, Japan
| | - Shiori Moriyasu
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yuya Hisada
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetaka Okubo
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhiro Watanabe
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Koh Imbe
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naoyoshi Nagata
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasushi Kojima
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Chizu Yokoi
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuyuki Shimoyama
- Department of Medicine and Molecular Science, Gunma University, Maebashi, Japan.,Division of Gastroenterology and Hepatology, Integrative Center of Internal Medicine, Gunma University Hospital, Maebashi, Japan
| | - Osamu Kawamura
- Department of Medicine and Molecular Science, Gunma University, Maebashi, Japan.,Division of Gastroenterology and Hepatology, Integrative Center of Internal Medicine, Gunma University Hospital, Maebashi, Japan
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University, Maebashi, Japan
| | - Motoyasu Kusano
- Department of Medicine and Molecular Science, Gunma University, Maebashi, Japan.,Division of Gastroenterology and Hepatology, Integrative Center of Internal Medicine, Gunma University Hospital, Maebashi, Japan
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Sawada A, Itami H, Nakagawa K, Hirano S, Kitamura H, Nakata R, Takashima S, Abe Y, Saito M, Yazaki E, Kawamura O, Tanaka F, Takeuchi T, Koike T, Masamune A, Fujiwara Y, Higuchi K, Sifrim D. Supragastric belching in Japan: lower prevalence and relevance for management of gastroesophageal reflux disease compared to United Kingdom. J Gastroenterol 2020; 55:1046-1053. [PMID: 32839926 PMCID: PMC7567718 DOI: 10.1007/s00535-020-01720-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Supragastric belching (SGB) may play a role in the pathophysiology of proton pump inhibitors (PPIs)-refractoriness in gastroesophageal reflux disease (GERD). SGB may be present in up to 40% of reflux symptoms in PPI-refractory GERD. Most reports on SGB have come from Western countries, and little is known about the prevalence and relevance of SGB in Asian refractory GERD patients. This study aimed at comparing the role of SGB in GERD patients in Japan and the UK. METHODS We re-analyzed impedance-pH monitoring tracings from patients who were referred to tertiary centers in Japan and the UK due to PPI-refractory reflux symptoms. The prevalence of excessive SGB and the impact of SGB on reflux symptoms were compared between the two countries. RESULTS Impedance-pH tracings from124 Japanese and 83 British patients were re-analyzed. Japanese patients were significantly younger and had smaller body mass index than the British (P < 0.001). Japanese patients had significantly lower prevalence of excessive SGB (18.5%) than the UK (36.1%) irrespective of reflux phenotype (P = 0.006). Logistic regression analysis showed that the geographical/cultural difference was the only factor associated with the different prevalence of SGB (odds ratio; 2.91, 95% CI 1.09-7.73, P = 0.032). SGB were related to typical reflux symptoms very rarely in Japan [0% (0-4.9)] compared to the UK [35% (0-54.1)] (P = 0.071). CONCLUSIONS The prevalence of SGB and their impact on reflux symptoms is significantly lower in Japan compared to the UK. The difference is not related to reflux parameters but might come from ethnic/cultural factors to be further characterized.
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Affiliation(s)
- Akinari Sawada
- Barts and The London School of Medicine and Dentistry, Wingate Institute of Neurogastroenterology, Blizard Institute, Upper GI Physiology Unit Royal London Hospital, Queen Mary University of London, 26 Ashfield Street, London, E12AJ, UK
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hideaki Itami
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenichiro Nakagawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shinji Hirano
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Kitamura
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Rieko Nakata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shingo Takashima
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Abe
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Etsuro Yazaki
- Barts and The London School of Medicine and Dentistry, Wingate Institute of Neurogastroenterology, Blizard Institute, Upper GI Physiology Unit Royal London Hospital, Queen Mary University of London, 26 Ashfield Street, London, E12AJ, UK
| | - Osamu Kawamura
- Department of Gastroenterology, Kamimoku SPA Hospital, Minakami, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshihisa Takeuchi
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kazuhide Higuchi
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Wingate Institute of Neurogastroenterology, Blizard Institute, Upper GI Physiology Unit Royal London Hospital, Queen Mary University of London, 26 Ashfield Street, London, E12AJ, UK.
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Kawami N, Hoshino S, Hoshikawa Y, Takenouchi N, Umezawa M, Hanada Y, Kaise M, Iwakiri K. Pathogenesis of Potassium-Competitive Acid Blocker-Resistant Non-Erosive Reflux Disease. Digestion 2019; 98:194-200. [PMID: 29870976 DOI: 10.1159/000488530] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The present study examined the pathogenesis of potassium-competitive acid blocker (P-CAB)-resistant non-erosive reflux disease (NERD). METHODS Forty-three patients with NERD, who had persistent reflux symptoms despite the administration of P-CAB, were included in this study. After excluding eosinophilic esophagitis and primary esophageal motility disorders, esophageal impedance-pH monitoring was performed. In symptom index (SI)-positive patients, the mechanism of SI-positivity and percent time with intragastric pH > 4 and with esophageal pH < 4 were investigated according to the presence or absence of Helicobacter pylori infection. RESULTS One (2.3%) of 43 patients had a primary esophageal motility disorder (Jackhammer esophagus). Eighteen (41.9%) and 3 (7%) patients were SI-positive for liquid and gas-only reflux, respectively, and the remaining 21 patients who were SI-negative (48.8%) had functional heartburn. All patients SI-positive for liquid reflux were SI-positive for weakly acidic reflux. Gastric acid was sufficiently suppressed by P-CAB, regardless of the presence or absence of H. pylori infection. CONCLUSIONS The pathogenesis of -P-CAB-resistant NERD was elucidated in 51% of patients. Symptoms in all patients SI-positive for liquid reflux were related to weakly acidic reflux, and symptoms related to acid reflux may be ruled out by the administration of P-CAB.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Chen X, Li P, Wang F, Ji G, Miao L, You S. Psychological Results of 438 Patients with persisting Gastroesophageal Reflux Disease Symptoms by Symptom Checklist 90-Revised Questionnaire. Euroasian J Hepatogastroenterol 2017; 7:117-121. [PMID: 29201791 PMCID: PMC5670252 DOI: 10.5005/jp-journals-10018-1230] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023] Open
Abstract
Aims and objectives: Gastroesophageal reflux disease (GERD) affects mental state and social activities. On the contrary, mental disorders may also play a crucial role in GERD symptoms. The purpose of the study was to analyze the data of Symptom Checklist 90-Revised (SCL-90-R) questionnaire from patients with persisting GERD and to explore the impact of psychological factors on them. Materials and methods: The patients accepted SCL-90-R questionnaire survey, following endoscopy, high-resolution manometry (HRM), and ambulatory impedance-pH monitoring. Based on these results, we divided patients into different groups. The result of SCL-90-R was also compared with degree of acid reflux, symptoms, symptom duration, and gender. Results: The data from 438 patients were analyzed. All patients were divided into reflux esophagitis (RE; 63, 14.38%); nonerosive gastroesophageal reflux disease (NERD; 106, 24.20%); functional heartburn (FH; 123, 28.08%), hypersensitive esophagus (HE; 67, 15.29%), diffuse esophageal spasm (DES; 5: 1.14%), hypertensive (10, 3.42%); weak peristalsis (14, 3.20%); achalasia (50, 11.42%). There were significant differences between different groups regarding depression (DEP), anxiety (ANX), paranoid ideation (PAR), and psychoticism (PSY). The patients with ≥2 years with GERD presented with increased scores in DEP, ANX, and PSY. Women had dramatically higher scores than men in each domain (p < 0.05). Conclusion: Data have shown that GERD patients exhibit differential levels of psychological symptoms. Long duration of GERD was related to typical plus atypical symptoms and females seem to be more prone to develop psychological disorders. How to cite this article: Chen X, Li P, Wang F, Ji G, Miao L, You S. Psychological Results of 438 Patients with persisting Gastroesophageal Reflux Disease Symptoms by Symptom Checklist 90-Revised Questionnaire. Euroasian J Hepato-Gastroenterol 2017;7(2):117-121.
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Affiliation(s)
- Xia Chen
- Department of Gastroenterology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ping Li
- Department of Gastroenterology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Fei Wang
- Department of Gastroenterology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Guozhong Ji
- Department of Gastroenterology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lin Miao
- Department of Gastroenterology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Sihong You
- Department of Gastroenterology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Frazzoni M, de Bortoli N, Frazzoni L, Tolone S, Savarino V, Savarino E. Impedance-pH Monitoring for Diagnosis of Reflux Disease: New Perspectives. Dig Dis Sci 2017; 62:1881-1889. [PMID: 28550489 DOI: 10.1007/s10620-017-4625-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 05/19/2017] [Indexed: 12/17/2022]
Abstract
Heartburn is the most specific symptom of gastroesophageal reflux disease (GERD). In clinical practice, heartburn relief by a proton pump inhibitor (PPI) trial does suffice to confirm GERD. However, an objective diagnosis of GERD is required before anti-reflux endoscopic or surgical interventions, independently from PPI response. Thus, since normal findings at upper endoscopy are detected in the majority of patients with heartburn, reflux monitoring is often required. When traditional catheter-based or wireless pH tests are used, reflux episodes are conventionally identified by pH drops below 4.0 units. Combined impedance-pH monitoring has the advantage to provide a comprehensive assessment of both physical and chemical properties of refluxate and the distinction between acid and weakly acidic refluxes, both proven to cause heartburn. Unfortunately, the conventional impedance-pH parameters, namely acid exposure time and number of reflux events, are characterized by suboptimal diagnostic sensitivity, and the reliability of symptom-reflux association indexes remains questionable. Therefore, novel impedance parameters, namely the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI), have recently been proposed in order to achieve a better diagnostic yield. In fact, they proved to be highly accurate in distinguishing reflux-related from reflux-unrelated heartburn, off- as well as on-PPI therapy. Currently, manual review of impedance-pH tracings is needed because of the modest accuracy of available software tools for automated analysis. PSPW index and MNBI are highly applicable and reproducible, and their calculation requires a few additional minutes during the manual review of impedance-pH tracings. So far, we believe that PSPW index and MNBI are ready for prime time and should become part of the standard analysis of impedance-pH tracings for GERD diagnosis in patients with endoscopy-negative heartburn.
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Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Viale Giardini 1355, 41100, Modena, Italy.
| | - Nicola de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Leonardo Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Viale Giardini 1355, 41100, Modena, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, 2nd University of Napoli, Naples, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
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Tolone S, Gualtieri G, Savarino E, Frazzoni M, de Bortoli N, Furnari M, Casalino G, Parisi S, Savarino V, Docimo L. Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors. World J Gastrointest Surg 2016; 8:719-728. [PMID: 27933133 PMCID: PMC5124700 DOI: 10.4240/wjgs.v8.i11.719] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/17/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.
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Pugliese D, Mauro A, Consonni D, Bravi I, Tenca A, Elvevi A, Conte D, Penagini R. pH Impedance vs. traditional pH monitoring in clinical practice: an outcome study. J Gastroenterol 2016; 51:130-7. [PMID: 26033511 DOI: 10.1007/s00535-015-1090-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/16/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The addition of impedance to 24-h pH monitoring has allowed detection of weakly acidic reflux, but the extent to which pH-impedance (pH-MII) monitoring improves outcomes is unknown. METHODS This was a prospective observational study. Patients referred for pH or pH-MII monitoring completed a standardized questionnaire on improvement in the dominant symptom, their satisfaction, and treatment at 3 and 12 months after the test during a telephone interview. RESULTS A total of 184 patients (mean age, 52 years, range, 19-82 years; 35 % with typical symptoms; and 89 % tested off therapy) completed pH (n = 92) or pH-MII monitoring (n = 92) over a period of 15 months. The two arms were similar in terms of demographic, clinical, and endoscopic variables. Ten patients in the pH-MII arm showed evidence of weakly acidic reflux disease. There was no difference in the percentage of patients in the pH and pH-MII monitoring arms who experienced improvement in their dominant symptom after 3 (58 vs. 63 %; p = 0.621) or 12 months (66 vs. 70 %; p = 0.234), and the same was true for patient satisfaction. There were also no between-group difference in the use of proton pump inhibitors (PPIs) after 3 (63 vs. 68.5 %; p = 0.437) or 12 months (47 vs. 60.5 %; p = 0.051). PPIs were prescribed more frequently after a positive test (p < 0.001) although they were used by 45.6 % of the negative patients. Only one patient underwent fundoplication. CONCLUSIONS Two-thirds of patients undergoing pH-MII monitoring experience a positive outcome, similarly to what occurs after traditional pH monitoring. Physicians often pay little attention to the test results, especially if they are negative.
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Nakagawa K, Koike T, Iijima K, Saito M, Kikuchi H, Hatta W, Ara N, Uno K, Asano N, Shimosegawa T. Characteristics of symptomatic reflux episodes in Japanese proton pump inhibitor-refractory non-erosive reflux disease patients. World J Gastroenterol 2015; 21:13352-13359. [PMID: 26715820 PMCID: PMC4679769 DOI: 10.3748/wjg.v21.i47.13352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/13/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023] Open
Abstract
AIM: To clarify the pathogenesis of gastroesophageal reflux disease symptoms in non-erosive reflux disease (NERD) patients.
METHODS: Thirty-five NERD patients with persistent symptoms, despite taking rabeprazole 10 mg twice daily for at least 8 wk, were included in this study. All patients underwent 24 h combined impedance - pH on rabeprazole. The symptom index (SI) was considered to be positive if ≥ 50%, and proximal reflux episodes were determined when reflux reached 15 cm above the proximal margin of the lower esophageal sphincter.
RESULTS: In 14 (40%) SI-positive patients, with liquid weakly acid reflux, the occurrence rate of reflux symptoms was significantly more frequent in proximal reflux episodes (46.7%) than in distal ones (5.7%) (P < 0.001). With liquid acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (38.5%) and distal ones (20.5%) (NS). With mixed liquid-gas weakly acid reflux, the occurrence rate of reflux symptoms in proximal reflux episodes was significantly more frequent (31.0%) than in distal reflux ones (3.3%) (P < 0.001). With mixed liquid-gas acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (29.4%) and distal ones (14.3%) (NS).
CONCLUSION: The proximal extent of weakly acidic liquid and mixed liquid-gas reflux is a major factor associated with reflux perception in SI-positive patients on proton pump inhibitor therapy.
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Frazzoni M, Piccoli M, Conigliaro R, Frazzoni L, Melotti G. Laparoscopic fundoplication for gastroesophageal reflux disease. World J Gastroenterol 2014; 20:14272-14279. [PMID: 25339814 PMCID: PMC4202356 DOI: 10.3748/wjg.v20.i39.14272] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/30/2014] [Accepted: 05/14/2014] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor (PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total (360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior (Toupet) fundoplication, and the anterior (Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Gastroesophageal reflux disease (GERD) is frequently diagnosed by symptoms and good response to acid suppression with proton pump inhibitors. Further work up is required when the diagnosis of GERD is uncertain, for alarm symptoms, PPI-refractoriness, and often for extraesophageal presentations. Useful tools include endoscopy for mucosal assessment and reflux monitoring (pH or impedance-pH) to quantify reflux burden. Objective documentation of pathological reflux is mandatory prior to anti-reflux surgery. In some patients, symptoms that can be attributed to GERD may have other causes; in these patients, testing that excludes GERD helps direct the diagnostic and treatment efforts to other causes.
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Frazzoni M, Bertani H, Manta R, Mirante VG, Frazzoni L, Conigliaro R, Melotti G. Impairment of chemical clearance is relevant to the pathogenesis of refractory reflux oesophagitis. Dig Liver Dis 2014; 46:596-602. [PMID: 24709005 DOI: 10.1016/j.dld.2014.03.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 02/11/2014] [Accepted: 03/11/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND The pathophysiological mechanisms underlying proton pump inhibitor-refractory reflux oesophagitis has been scarcely studied. AIMS To assess impedance-pH parameters relevant to the pathogenesis of refractory reflux oesophagitis. METHODS Cases referred for heartburn/regurgitation refractory to high-dosage proton pump inhibitors between January 2008 and December 2012 were reviewed and subdivided into refractory oesophagitis (29 patients, 72% males, median age 50 years), healed oesophagitis (18 patients, 67% males, median age 54 years), and non-erosive reflux disease (49 patients, 53% males, median age 42 years). On-therapy impedance-pH tracings were blindly re-analysed by one observer to assess gastric and oesophageal acid exposure time and chemical clearance as expressed by the post-reflux swallow-induced peristaltic wave index. RESULTS The median gastric and oesophageal acid exposure time did not differ among the three groups (35%, 34%, 41% and 1.2%, 0.7%, 0.8%, respectively; P>0.05 for all comparisons). A normal oesophageal acid exposure time was found in two thirds of patients with refractory oesophagitis. The post-reflux swallow-induced peristaltic wave index was significantly lower in refractory oesophagitis (16%) than in healed oesophagitis (30%) and non-erosive reflux disease (29%) (P=0.003). CONCLUSIONS Refractory reflux oesophagitis is characterized by impairment of chemical clearance. Adequate acid suppression is found in the majority of patients who would likely not benefit from further proton pump inhibitor dose escalation.
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Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy.
| | - Helga Bertani
- Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
| | - Raffaele Manta
- Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
| | | | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Rita Conigliaro
- Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy
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Abstract
Esophageal pH monitoring is considered the gold standard for the diagnosis of gastroesophageal reflux disease because of the normal ranges across the pediatric age range. However, this method can only detect acid reflux. Multichannel intraluminal impedance-pH (MII-pH) monitoring has recently been used for the detection of bolus reflux in infants and children. This method allows for the detection of liquid, gas or mixed reflux in addition to acid, weakly acidic or weakly alkaline reflux. MII-pH monitoring can record the direction of flow and the height of reflux, which are useful parameters to identify an association between symptoms and reflux. However, the technique is limited by its high cost and the lack of normative data of MII-pH in the pediatric population. Despite certain limitations, MII-pH monitoring will become more common and gradually replace pH monitoring in the future, because pH monitoring is part of MII-pH.
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Affiliation(s)
- Myung Seok Shin
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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