Beneficial Effect of Heat-Killed Lactic Acid Bacterium Lactobacillus johnsonii No. 1088 on Temporal Gastroesophageal Reflux-Related Symptoms in Healthy Volunteers: A Randomized, Placebo-Controlled, Double-Blind, Parallel-Group Study

A randomized, placebo-controlled, double-blind, parallel-group clinical study was conducted to examine the effects of ingesting a heat-killed lactic acid bacterium, Lactobacillus johnsonii No. 1088 (LJ88) on temporal gastroesophageal reflux-related symptoms in healthy volunteers. A total of 120 healthy Japanese volunteers of both sexes, aged between 21 and 63 years, whose Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) total score was 8 or greater, but who were not diagnosed with functional dyspepsia according to the Rome IV classification, were enrolled. They were randomly assigned to either the LJ88 or placebo group and instructed to ingest the test food (1 billion heat-killed LJ88 or placebo) once a day for six weeks. Gastroesophageal reflux-related symptoms were evaluated using FSSG scores as a primary endpoint. The Gastrointestinal Symptoms Rating Scale (GSRS), stomach state questionnaire, and serum gastrin concentration were used as secondary endpoints. In the FSSG evaluation, the heartburn score was significantly improved at 6 weeks in the LJ88 group compared to the placebo group. No severe adverse events related to the test food were observed. In conclusion, daily ingestion of heat-killed LJ88 improved temporal heartburn symptoms in non-diseased individuals.

Managing heartburn and reflux in primary care

ABSTRACT

This article describes an algorithmic approach to caring for patients presenting with heartburn and reflux, including empiric treatment with acid-suppression therapy and a data-driven approach to diagnostic testing. This article also reviews the efficacy and safety profile of the widely available and commonly used proton pump inhibitors. Refining our approach to diagnostic testing can reduce time to diagnosis, better control patients' symptoms, and limit complications of longstanding disease.

Untangling Nonerosive Reflux Disease From Functional Heartburn

Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have nonerosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common phenotype of gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. A diagnosis of NERD requires endoscopy and reflux testing, whereas a diagnosis of functional heartburn also requires esophageal manometry. NERD is treated most commonly with medical, endoscopic, and surgical antireflux approaches, whereas functional heartburn as well as NERD can be treated with neuromodulators, psychological intervention, and complementary medicine options.

Effectiveness of Manual Treatment on Pregnancy Symptoms: Usefulness of Manual Treatment in Treating Pregnancy Symptoms

Objectives

To determine the usefulness of manual treatment in reducing or eliminating pregnancy symptoms during first and second trimester.

Methods

Manual treatment of the cervical and thoracic spine was performed in a group of 115 pregnant women who developed pregnancy symptoms during normal pregnancy. A rotational traction of the cervical spine was applied. Patients in whom the treatment was unsuccessful underwent second round of treatment after a pause of a minimum 3 days. Patients for whom the treatment was initially successful but later relapsed also repeated whole procedure. Pregnancy symptoms analyzed in this study were heartburn, nausea, vomiting, dizziness, headache, insomnia, neck pain, hyperosmia and hypersalivating.

Results

Manual treatment successfully treated pregnancy symptoms in 91 (79.1%) patients, it was partially successful for 22 (19.1%), and unsuccessful for 2 patients (1.7%) after the first treatment. After the second treatment, out of a total 56 patients, the treatment was completely successful in 40 (71.4%), partially successful in 14 (25%), and unsuccessful in 2 (3.6%) patients. The highest success rate was in eliminating headache (97.3%), vomiting (95.9%), dizziness (94.5%), nausea (92.9%), neck pain (92.9%), insomnia (91.9%), heartburn (88.8%), hyperosmia (78.5%) and hyper salivating (78%).

Conclusion

Manual therapy in pregnancy is a drugless, etiological, usually highly effective therapy. It is a low cost, rapid, safe, and well tolerated treatment for pregnancy symptoms which frequently has an immediate effect, thus making it an optimal treatment for pregnancy symptoms.

Feasibility and acceptability of esophageal-directed hypnotherapy for functional heartburn

Functional heartburn (FH) is a benign but burdensome condition characterized by painful, burning epigastric sensations in the absence of acid reflux or symptom-reflux correlation. Esophageal hypersensitivity and its psychological counterpart, esophageal hypervigilance (EHv) drive symptom experience. Hypnotherapy (HYP) is an established and preferred intervention for refractory symptoms in functional gastrointestinal disorders (FGIDs) and could be applied to FH. The objective of this study was to determine the feasibility, acceptability, and clinical utility of 7 weekly sessions of esophageal-directed HYP (EHYP) on heartburn symptoms, quality of life, and EHv. Similar to other work in FGIDs and regardless of hypnotizability, there were consistent and significant changes in heartburn symptoms, visceral anxiety, and quality of life and a trend for improvement in catastrophizing. We would recommend EHYP in FH patients who are either non-responsive to medications or who would prefer a lifestyle intervention.

Interventions for heartburn in pregnancy

BACKGROUND

Heartburn is one of the most common gastrointestinal symptoms in pregnant women. It can occur in all trimesters of pregnancy. The symptoms of heartburn in pregnancy may be frequent, severe and distressing, but serious complications are rare. Many interventions have been used for the treatment of heartburn in pregnancy. These interventions include advice on diet, lifestyle modification and medications. However, there has been no evidence-based recommendation for the treatment of heartburn in pregnancy.

OBJECTIVES

To assess the effects of interventions for relieving heartburn in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2015), ClinicalTrials.gov (2 March 2015), Asian & Oceanic Congress of Obstetrics & Gynaecology (AOCOG) conference proceedings (20-23 October 2013, Centara Grand & Bangkok Convention Centre, Bangkok, Thailand), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTS of interventions for heartburn in pregnancy compared with another intervention, or placebo, or no intervention. Cluster-RCTs would have been eligible for inclusion but none were identified. We excluded studies available as abstracts only and those using a cross-over design.Interventions could include advice on diet, lifestyle modification and medications (such as antacids, sucralfate, histamine 2-receptor antagonists, promotility drugs and proton pump inhibitors (PPIs)).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included nine RCTs involving 725 women. However, five trials did not contribute data. Four trials involving 358 women contributed data. Trials were generally at mixed risk of bias.We only identified data for three comparisons: pharmaceutical treatment versus placebo or no treatment; acupuncture versus no treatment and pharmacological intervention versus advice on dietary and lifestyle changes. Pharmaceutical treatment compared with placebo or no treatmentTwo trials evaluated any pharmaceutical treatment compared with placebo or no treatment. One trial examined a treatment rarely used nowadays (intramuscular prostigmine 0.5 mg versus placebo). One trial evaluated the effect of magnesium and aluminium hydroxide plus simethicone liquid and tablet compared with placebo. For the primary outcome of this review (relief of heartburn), women who received pharmaceutical treatment reported complete heartburn relief more often than women receiving no treatment or placebo (risk ratio (RR) 1.85, 95% confidence interval (CI) 1.36 to 2.50 in two RCTs of 256 women, I(2) = 0%, moderate-quality evidence). Data on partial relief of heartburn were heterogenous and showed no clear difference (average RR 1.35, 95% CI 0.38 to 4.76 in two RCTs of 256 women, very low-quality evidence). In terms of secondary outcomes, there was no clear difference in the rate of side effects between the pharmaceutical treatment group and the placebo/no treatment group (RR 0.63, 95% CI 0.21 to 1.89 in two RCTs of 256 women, very low-quality evidence). Pharmacological intervention versus advice on dietary and lifestyle choicesOne study compared 1 g of sucralfate with advice on dietary and lifestyle choices in treating heartburn. More women in the sucralfate group experienced complete relief of heartburn compared to women who received advice on diet and lifestyle choices (RR 2.41, 95% CI 1.42 to 4.07; participants = 65; studies = one). The only secondary outcome of interest addressed by this trial was side effects. The evidence was not clear on intervention side effects rate between the two groups (RR 1.74, 95% CI 0.07 to 41.21; participants = 66; studies = one). There was only one instance of side effects in the pharmacological group. Acupuncture compared with no treatmentOne trial evaluated acupuncture compared with no treatment but did not report data relating to this review's primary outcome (relief of heartburn). In terms of secondary outcomes, there was no difference in the rate of side effects between women who had acupuncture and women who had no treatment (RR 2.43, 95% CI 0.11 to 55.89 in one RCT of 36 women). With regard to quality of life, women who had acupuncture reported improved ability to sleep (RR 2.80, 95% CI 1.14 to 6.86) and eat (RR 2.40, 95% CI 1.11 to 5.18 in one RCT of 36 women).The following secondary outcomes were not reported upon in any of the trials included in the review: miscarriage, preterm labour, maternal satisfaction, fetal anomalies, intrauterine growth restriction, low birthweight.

AUTHORS' CONCLUSIONS

There are no large-scale RCTs to assess heartburn relief in pregnancy. This review of nine small studies (which involved data from only four small studies) indicates that there are limited data suggesting that heartburn in pregnancy could be completely relieved by pharmaceutical treatment. Three outcomes were assessed and assigned a quality rating using the GRADE methods. Evidence from two trials for the outcome of complete relief of heartburn was assessed as of moderate quality. Evidence for the outcomes of partial heartburn relief and side effects was graded to be of very low quality. Downgrading decisions were based in part on the small size of the trials and on heterogenous and imprecise results.There are insufficient data to assess acupuncture versus no treatment and no data to assess other comparisons (miscarriage, preterm labour, maternal satisfaction, fetal anomalies, intrauterine growth restriction, low birthweight).Further RCTs are needed to fully evaluate the effectiveness of interventions for heartburn in pregnancy. Future research should also address other medications such as histamine 2-receptor antagonists, promotility drugs, proton pump inhibitors, and a raft-forming alginate reflux suppressant in treatment of heartburn in pregnancy. More research is needed on acupuncture and other complimentary therapies as treatments for heartburn in pregnancy. Future research should also evaluate any adverse outcomes, maternal satisfaction with treatment and measure pregnant women's quality of life in relation to the intervention.

Heartburn in pregnancy

INTRODUCTION

Heartburn is a common complaint during pregnancy; the incidence is reported to be between 17% and 45%.

METHODS AND OUTCOMES

We conducted a systematic overview and aimed to answer the following clinical question: What are the effects of interventions to prevent or treat heartburn in pregnancy? We searched Medline, Embase, The Cochrane Library, and other important databases up to December 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review).

RESULTS

At this update, searching of electronic databases retrieved 80 studies. After deduplication and removal of conference abstracts, 59 records were screened for inclusion in the review. Appraisal of titles and abstracts led to the exclusion of 58 studies and the further review of one full publication. The full article evaluated did not meet our reporting criteria, and thus no new evidence was added at this update. We performed a GRADE evaluation for two PICO combinations.

CONCLUSIONS

In this systematic overview, we categorised the efficacy for six interventions, based on information about the effectiveness and safety of acid-suppressing drugs, antacids with or without alginates, raising the head of the bed, reducing caffeine intake, reducing intake of fatty foods, and reducing the size and frequency of meals.

Overlap of functional heartburn and gastroesophageal reflux disease with irritable bowel syndrome

Several studies indicate a significant degree of overlap between irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). Likewise, both functional heartburn (FH) and IBS are functional digestive disorders that may occur in the same patients. However, data establishing a solid link between FH and IBS are lacking, mainly because the clinical definition of FH has undergone substantial changes over the years. The available literature on the overlap between GERD or FH and IBS highlights considerable heterogeneity in terms of the criteria and diagnostic procedures used to assess heartburn and IBS. In particular, several epidemiological studies included patients with concomitant IBS and GERD without any attempt to distinguish FH (as defined by the Rome III criteria) from GERD via pathophysiological investigations. Independent of these critical issues, there is preliminary evidence supporting a significant degree of FH-IBS overlap. This underscores the need for studies based on updated diagnostic criteria and accurate pathophysiological classifications, particularly to distinguish FH from GERD. This distinction would represent an essential starting point to achieving a better understanding of pathophysiology in the subclasses of patients with GERD and FH and properly assessing the different degrees of overlap between IBS and the subcategories of heartburn.The present review article intends to appraise and critically discuss current evidence supporting a possible concomitance of GERD or FH with IBS in the same patients and to highlight the pathophysiological relationships between these disorders.

Role of the primary care provider in the diagnosis and management of heartburn

BACKGROUND

Heartburn affects an estimated 42% of the US population. Often, patients are able to recognize symptoms and self-treat heartburn; however, patients with more persistent and/or troublesome symptoms should be evaluated by a physician or other healthcare provider.

SCOPE

This review focuses on the role of the primary care provider in the diagnosis and treatment of heartburn.

METHODS

A search was conducted on PubMed (to November 2009) and articles relevant to the management of heartburn by a primary care provider topic were selected.

FINDINGS

Diagnostic tools, such as endoscopy, and ambulatory pH monitoring, are recommended for advanced assessment of patients with frequent heartburn to avert misdiagnosis and to identify complications of reflux disease. Over-the-counter and prescription treatments for frequent heartburn symptoms include antacids, histamine(2)-receptor antagonists (H(2)RAs), antacid/H(2)RA combinations, and proton pump inhibitors (PPIs). Among these, PPIs represent the mainstay of acute and maintenance treatment regimens in reflux disorders and are more effective than H(2)RAs for long-term use due to the development of tolerance to the latter therapy. While once-daily PPI therapy may be sufficient in most patients, a few may require twice-daily PPI therapy to alleviate their symptoms. This review is limited by its relatively narrow focus on articles cited in PubMed.

CONCLUSION

The primary care provider is ideally situated to advise patients on the best treatment option for their condition and to provide follow-up care if required.

[Dysphagia, heartburn and esophageal bolus impaction in a 43-year old male patient: not always reflux disease]

We report a case of a 43 year old male patient, who was admitted with recurring esophageal bolus impactions. Since his childhood he has been complaining about dysphagia and was unable to swallow medication. He also complained about heartburn. The last esophageal bolus impaction was some weeks ago. After elimination of the bolus impaction with a rigid endoscope we found a high grade stenosis in the proximal esophagus that could not even be passed with a children's endoscope. An initial treatment of eosinophil esophagitis would be the therapy with a local corticoid for 6-9 month. In patients with typical rings or stenosis a dilation therapy might be necessary.

Interventions for heartburn in pregnancy

BACKGROUND

Heartburn is a common symptom in pregnancy affecting up to 80% of women in the third trimester. The reasons for the increase in symptoms in pregnancy are not well understood, but the effects of pregnancy hormones on the lower oesophageal sphincter and gastric clearance are thought to play a part. A range of interventions have been used to relieve symptoms including advice on diet and lifestyle, antacids, antihistamines, and proton pump inhibitors. The safety and effectiveness of these interventions to relieve heartburn in pregnancy have not been established.

OBJECTIVES

To assess the effect of interventions to relieve heartburn in pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2008).

SELECTION CRITERIA

We included randomised controlled trials evaluating interventions to relieve heartburn.

DATA COLLECTION AND ANALYSIS

We assessed eligibility for inclusion and extracted data independently.

MAIN RESULTS

Three studies were eligible for inclusion, together they included a total of 286 women. All three were placebo controlled trials, each examining a different medication to relieve heartburn (intramuscular prostigmine, an antacid preparation and an antacid plus ranitidine). All three produced positive findings in favour of the intervention groups. It was not possible to pool findings from studies to produce an overall treatment effect.

AUTHORS' CONCLUSIONS

There was little information to draw conclusions on the overall effectiveness of interventions to relieve heartburn in pregnancy.

Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn

BACKGROUND

The current standard of care in proton pump inhibitor failure is to double the proton pump inhibitor dose, despite limited therapeutic gain. Aims To determine the efficacy of adding acupuncture vs. doubling the proton pump inhibitor dose in gastro-oesophageal reflux disease patients who failed symptomatically on proton pump inhibitors once daily.

METHODS

Thirty patients with classic heartburn symptoms who continued to be symptomatic on standard-dose proton pump inhibitors were enrolled into the study. All participants underwent upper endoscopy while on proton pump inhibitors once daily. Subsequently, patients were randomized to either adding acupuncture to their proton pump inhibitor or doubling the proton pump inhibitor dose over a period of 4 weeks. Acupuncture was delivered twice a week by an expert.

RESULTS

The two groups did not differ in demographic parameters. The acupuncture + proton pump inhibitor group demonstrated a significant decrease in the mean daytime heartburn, night-time heartburn and acid regurgitation scores at the end of treatment when compared with baseline, while the double-dose proton pump inhibitor group did not demonstrate a significant change in their clinical endpoints. Mean general health score was only significantly improved in the acupuncture + proton pump inhibitor group.

CONCLUSION

Adding acupuncture is more effective than doubling the proton pump inhibitor dose in controlling gastro-oesophageal reflux disease-related symptoms in patients who failed standard-dose proton pump inhibitors.

Refractory heartburn to proton pump inhibitors: epidemiology, etiology and management

Patients with refractory heartburn to proton pump inhibitors (PPIs) represent a distinctive group which is difficult to manage. In a systematic review of the relative literature we found that approximately 20% of patients with erosive esophagitis and 15-25% of patients with normal endoscopy and abnormal 24-hour esophageal pH monitoring continue to report heartburn despite treatment with standard dose PPIs. Furthermore, approximately 30-40% of patients with normal endoscopy and 24-hour pH studies and 15-20% of patients with Barrett's esophagus have refractory heartburn to double dose PPIs. In such cases, compliance to therapy, duodeno-gastroesophageal reflux, gastro-esophageal motility disorders and eradication of Helicobacter pylori infection may contribute to symptoms. Based on the available evidence, we suggested an algorithm for the evaluation and management of these patients.

Endoscopic removal of the wireless pH monitoring capsule in patients with severe discomfort

BACKGROUND

Few patients have significant symptoms during wireless esophageal pH monitoring, and the capsule typically sloughs spontaneously. Severe discomfort during monitoring can occur that requires endoscopic dislodgement of the capsule.

OBJECTIVE

To determine the frequency with which endoscopic capsule dislodgement is required and the outcomes of the intervention.

DESIGN

Chart review.

SETTING

University-based outpatient endoscopy facility.

PATIENTS

A total of 452 consecutive patients undergoing wireless pH monitoring over a 3.5-year period.

INTERVENTIONS

Endoscopic dislodgement of the capsule by using nudging with the endoscope tip and cold snare techniques.

RESULTS

Eight subjects (1.8%) required endoscopic capsule dislodgement because of severe chest pain or odynophagia (n = 7) or severe foreign-body sensation (n = 1). Chest pain was the initial indication for pH monitoring in 5 (62.5%) of the subjects. Initial nudging with the endoscope tip successfully dislodged 2 capsules; continued nudging produced mucosal stripping in 3 subjects, which required hemostasis in 1. A cold snare was used successfully, without complication, to separate the capsule from stripped mucosa and as a primary removal method in the remainder of subjects. Capsule removal uniformly resulted in marked improvement of discomfort.

CONCLUSIONS

Endoscopic removal of the capsule was required in <2% of subjects who underwent wireless pH monitoring. Separation of the capsule from the mucosa with a cold snare may be the preferred method of accomplishing uncomplicated removal.

Functional esophageal disorders

Functional esophageal disorders represent processes accompanied by typical esophageal symptoms (heartburn, chest pain, dysphagia, globus) that are not explained by structural disorders, histopathology-based motor disturbances, or gastroesophageal reflux disease. Gastroesophageal reflux disease is the preferred diagnosis when reflux esophagitis or excessive esophageal acid exposure is present or when symptoms are closely related to acid reflux events or respond to antireflux therapy. A singular, well-defined pathogenetic mechanism is unavailable for any of these disorders; combinations of sensory and motor abnormalities involving both central and peripheral neural dysfunction have been invoked for some. Treatments remain empirical, although the efficacy of several interventions has been established in the case of functional chest pain. Management approaches that modulate central symptom perception or amplification often are required once local provoking factors (eg, noxious esophageal stimuli) have been eliminated. Future research directions include further determination of fundamental mechanisms responsible for symptoms, development of novel management strategies, and definition of the most cost-effective diagnostic and treatment approaches.

Review article: the management of heartburn in pregnancy

Heartburn is a normal consequence of pregnancy. The predominant aetiology is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. Serious reflux complications during pregnancy are rare; hence upper endoscopy and other diagnostic tests are infrequently needed. Gastro-oesophageal reflux disease during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line drug therapy. If symptoms persist, any of the histamine2-receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. All but omeprazole are FDA category B drugs during pregnancy. Most drugs are excreted in breast milk. Of systemic agents, only the histamine2-receptor antagonists, with the exception of nizatidine, are safe to use during lactation.

Medical consultation for gastro-oesophageal reflux symptoms: reasons and associated factors

OBJECTIVES

To evaluate the frequency of medical consultation for gastro-oesophageal reflux symptoms (GORS) and to ascertain reasons for consultation and associated factors.

METHODS

Telephone survey of 2,500 persons using a validated questionnaire. Data were analyzed using multiple logistic regression, in which the dependent variable was consultation for GORS and the independent variables were sociodemographic factors and the clinical characteristics of GORS.

RESULTS

Of those reporting GORS, 28% had consulted their physician about them in the last year. Main reasons for seeking medical advice were GORS-induced concern in 48%, and intensity of GORS in 42.6%. Factors independently associated with medical consultation were: housewife (odds ratio (OR) 1.9; 95% CI 1.1-3.4) or retired status (OR 2.3; 95% CI 1.3-4.1), frequent GORS (OR 2.4; 95% CI 1.6-3.5), severe GORS (OR 2.4; 95% CI 1.4-4.2), nocturnal GORS (OR 1.6; 95% CI 1.1-2.3), and association of epigastric pain (OR 1.7; 95% CI 1.0-2.7) or nausea (OR 1.7; 95% CI 1.1-2.8).

CONCLUSION

The high frequency of medical consultation for GORS in Spain makes it an important healthcare problem. The fact that half the patients seek medical advice due to concern about the nature of GORS illustrates the benefits of explaining the nature, treatment and prognosis of GORS. The clinical relevance of GORS does not reside in its frequency alone, since severe or nocturnal symptoms, albeit occasional, are also associated with medical consultation.

Primary-care physicians' perceptions and practices on the management of GERD: results of a national survey

BACKGROUND

Gastroesophageal reflux disease (GERD) is frequently managed by primary-care physicians (PCPs) although little is known about their current practices and management patterns.

METHODS

We administered a questionnaire-based survey to PCPs attending sponsored educational conferences on GERD. Questionnaires were completed anonymously before the conferences and asked about prescribing patterns, indications for surgical referral, and issues concerning Barrett's esophagus and H. pylori infection.

RESULTS

A total of 1046 completed questionnaires (97% acceptance rate) were received. Most PCPs prescribed a proton pump inhibitor (PPI) for GERD without prior authorization and without first using an H2-receptor antagonist (H2RA). Many gave an H2RA with once-daily PPI treatment for patients with nocturnal heartburn. Most referrals for anti-reflux surgery were for inadequate response to medical treatment, although PCPs usually first sought gastroenterological consultation. There was a widespread acceptance of screening GERD patients for Barrett's esophagus. There was general confusion about any relationship between H. pylori infection and GERD; 80% of PCPs tested for the infection in at least some patients who only had symptoms of GERD.

CONCLUSIONS

Our survey has identified a number of areas of controversy and confusion related to the management of GERD. We hope that our findings can assist in the development of educational materials on GERD for PCPs.

Delivery of radiofrequency energy to the lower esophageal sphincter improves symptoms of gastroesophageal reflux

BACKGROUND

The Stretta procedure has been proposed as a novel therapeutic alternative to antireflux surgery for gastroesophageal reflux disease (GERD). Early reports indicated improvement in GERD symptoms overall, but improvement in patients who have poor outcome after surgery remains unclear.

METHODS

Patients with reflux who did not have a hiatal hernia were offered the procedure. All were administered a GERD Health Related Quality of Life survey at preprocedure and at greater than 3 months postprocedure. Differences in pre- and postprocedure responses were deemed significant with the use of the Wilcoxon rank sum test with P <.05.

RESULTS

Fifty patients underwent the Stretta procedure. There were no complications. All were evaluated postprocedure, with 74% completing a postprocedure survey. Overall heartburn score improved from 3.19 (scale, 0-5) preprocedure to 1.74 postprocedure (P=.0012). Overall symptoms satisfaction score improved from 3.92 to 1.63 (P=.0001). Symptoms satisfaction score of patients who failed antireflux surgery improved from 3.5 to 1.75 (P=.0166), and, in those with a body mass index >30, it improved from 4.11 to 1.56 (P=.0024). Four patients went on to have antireflux surgery after having the Stretta procedure.

CONCLUSIONS

Stretta improves heartburn symptoms both overall and in patients with poor outcome after antireflux surgery, with a low procedural risk. It may have a role in the treatment of patients with primary reflux and in those who have failed antireflux surgery or who are a high risk for surgery.

Assessment of reflux symptom severity: methodological options and their attributes

Despite major advances in our understanding of reflux disease, the management of this disorder still presents many challenges. Reduction of heartburn is the most readily apparent objective for the patient with reflux disease. Thus the ability to measure heartburn accurately is of fundamental importance to clinical research in reflux disease. Here, the available data on the assessment of reflux symptoms--predominantly heartburn--in clinical trials of symptomatic reflux disease are examined.

Treatment of gastroesophageal reflux disease: defining endpoints that are important to patients

Patients with gastroesophageal reflux disease (GERD) seek treatment to obtain relief of their symptoms. Symptoms are important to patients because they interfere with activities of daily living and impair quality of life. Clinical trials in GERD have traditionally focused on the healing of erosive esophagitis, and symptom endpoints have been relegated to a secondary role. In primary care, however, patients typically are treated empirically without definition of the presence or absence of esophagitis. Patient-centered endpoints such as complete symptom resolution, patient satisfaction, and improvement in quality of life therefore provide more meaningful results in the broad population of patients with GERD, provided they are coupled with objective data on mucosal healing. This article reviews the importance of patient-centered endpoints in the assessment of the treatment of GERD and concludes that complete resolution of symptoms is the most rigorous endpoint in clinical trials and provides a meaningful endpoint for therapy in clinical practice.

Clinical Manifestations and Esophageal Complications of GERD

This report focuses on the manifestations of gastroesophageal reflux disease (GERD) that are caused directly by contact between refluxed gastric juice and the esophageal mucosa. These manifestations include heartburn, peptic esophageal erosion and ulceration, peptic esophageal stricture, and Barrett esophagus. Peptic esophageal erosions and ulcerations are excavated defects in the esophageal mucosa that result when epithelial cells succumb to the caustic effects of refluxed acid and pepsin. Uncommonly, esophageal ulcers are complicated by hemorrhage, perforation, and penetration into the airway. Esophageal ulcers can stimulate fibrous tissue production and collagen deposition that result in stricture formation, and the ulcers can heal through a metaplastic process in which an intestinal-type epithelium replaces the damaged squamous cells (Barrett esophagus). The management of these conditions is discussed below.

Cost-effectiveness and cost-utility of long-term management strategies for heartburn

OBJECTIVES

To compare the expected costs and outcomes of seven alternative long-term primary care strategies for the management of patients with moderate-to-severe heartburn over a 1-year period.

METHODS

A decision-analytic model was developed to estimate costs and effects (weeks with heartburn symptoms and quality adjusted life years [QALYs]) for each strategy. Meta-analyses were used to synthesize acute treatment and maintenance studies and physician surveys to collect information on patient management. The impact of uncertainty on the base case results was assessed using probabilistic sensitivity analysis. Probability distributions were defined for key model parameters and techniques of Monte Carlo simulation were used to draw values from these distributions. Cost-effectiveness acceptability curves (CEACs) conditional on the monetary value decision makers are willing to pay for a symptom-free day or QALY were created for each strategy.

RESULTS

In the base case, no strategy was strictly dominated by any other strategy. However, two strategies (maintenance H2-receptor antagonists H2RA] and step-down proton pump inhibitor PPI]) were dominated through principles of extended dominance. The least costly and least effective strategy was intermittent H2RA, while maintenance PPI was the most costly and most effective.

CONCLUSIONS

This analysis showed that the best way of managing patients with heartburn depends on how much society is willing to pay to achieve health improvements. Based on the commonly quoted threshold of US 50,000 dollars per QALY, the optimal primary care strategy for managing patients with moderate-to-severe heartburn symptoms is to treat the symptoms with a PPI followed by maintenance therapy with an H2RA to prevent symptomatic recurrence.

Medical therapy of supraesophageal gastroesophageal reflux disease

Medical therapy of supraesophageal gastroesophageal reflux disease (GERD) is based on the principals for treating patients with heartburn and erosive esophagitis, observations from the few available clinical trials, and clinical experience. In general, patients with supraesophageal GERD require higher doses of antireflux therapy, principally with proton pump inhibitors, for longer periods of time to effectively relieve symptoms compared with patients with heartburn and/or erosive esophagitis. This article reviews the current literature and discusses a suggested approach to medical management of these often complex patients.

Treatment of gastroesophageal reflux disease: use of algorithms to aid in management

Effective treatment of gastroesophageal reflux disease demands an awareness of several factors: the disease spectrum, its varied symptom presentation, and potential complications; when to refer to a gastroenterologist or surgeon; and the various treatment options available. By taking these factors into consideration, algorithms can provide a useful framework within which clinicians can approach decision making regarding management of gastroesophageal reflux disease. As such, algorithms can be a good clinical tool for meeting the goals of effective disease management. Presented below are treatment algorithms for the primary care physician, gastroenterologist, and surgeon. Improved understanding of these algorithms can assist clinicians in the care of patients with this common disease.