Cytomegalovirus ulcerative oesophagitis in a young healthy immunocompetent patient

Cytomegalovirus (CMV) gastrointestinal disease usually arises in patients with immunodeficiency or immunosuppression, being rare in immunocompetent hosts. Although increasing in incidence, few cases of CMV gastrointestinal disease have been described among young healthy patients. Currently, there is uncertainty in approaching these patients, including the need for antiviral therapy that remains to be established. This case report describes a CMV ulcerative oesophagitis in a young healthy immunocompetent patient with good evolution with no need for antiviral therapy, the youngest case being reported in the literature until now.

Complementary and Integrative Gastroenterology

Complementary and integrative medicine is developing within gastroenterology, expanding options particularly for inflammatory bowel disease, irritable bowel syndrome, and reflux esophagitis. This article encompasses new developments in complementary integrative medicine with an emphasis on herbal therapies. Studies of potential therapies have been advancing with increasing sophistication. The best studied with the most promising results in ulcerative colitis is the use of curcumin both for the induction and maintenance of remission. Other polyphenols, such as resveratrol and epigallocatechin-3-gallate, also have supportive data for ulcerative colitis. Mind-body approaches have been applied in these diseases with positive data, particularly for irritable bowel syndrome.

Esophagitis in Adolescents

Esophagitis is the end result of a variety of insults to epithelial homeostasis. Eosinophilic esophagitis is a manifestation of non-IgE-mediated food allergy that most commonly affects the esophagus of males who have other atopic phenomena. Reflux esophagitis reflects repeated exposure to acidic gastric contents because of failure of the normal protections afforded by the LES. Because certain histologic features can be present in either condition, endoscopic biopsy alone does not distinguish them. Their symptoms overlap, but the treatment options are very different, such that making a formal diagnosis by following consensus guidelines is essential. A treatment protocol designed to manage the inflammation by controlling the provocative factors (acid for GERD and food antigens for EoE) or suppressing the inflammation (ie, topical steroids for EoE) should result in normalization of the mucosa and resolution of symptoms. Eosinophilic esophagitis is a chronic condition that rarely remits spontaneously, so any therapeutic modality will need to be continued indefinitely.

[Clinical, endoscopic and morphological manifestations of oesophageal lesion in systemic scleroderma]

Oesophageal lesion is the commonest visceral manifestation of systemic scleroderma (SSD) affecting the quality of life and fraught with serious complications. The aim of this study was to evaluate clinical, endoscopic andmorphological manifestations of oesophageal lesion in systemic scleroderma and its relationships with other clinical symptoms and pharmacotherapy of the disease.

MATERIALS AND METHODS

479 patients with SSD (93.7% women, 6.3% men, mean age 48.7 +/- 19.2 yr). All of them underwent EGDS in 2005-2010. 123 patients were examined for the detection of Barrett's oesophagus (BO), total screening regardless of complaints was conducted in 2010. Control group included 1018 age and sex-matched patients with RA who underwent EGDS in 2008-2009.

RESULTS

Oesophageal lesions occurred much more frequently in SSD than in RA. Oesophageal symptoms were documented in 70.0 and 29.9% cases, non-erosive oesopahgitis in 28.8 and 1.5%, erosive esophagitis in 22.5 and 2.2% ulcers in 0.8 and 0% (p < 0.001). BO manifested as intestinal metaplasia (histological study of mucosal biopsy) was found in 30 SSD patients (4.2%). Screening revealed BO in 8.9% of the patients. The development of erosive oesophagitis was unrelated to the age of the patients, duration of the disease and its form (localized or diffusive), lung pathology or Sjogren's syndrome. Cytotoxic medicines significantly increased the frequency of erosive oesophagitis, it tended to increase under effect of NSAID and low doses of aspirin. Long-term intake of PPI did not reduce the risk of oesophagitis and BO.

CONCLUSION

Half of the patients with SSD have oesophagitis. Over 20% of them suffer its complications (erosion and ulcers) and 9% have BO. All such patients need endoscopic study ofoesophagus regardless of clinical symptoms.

[Reflux esophagitis (esophageal hiatus hernia)]

Recently, the guidelines for the treatment of gastroesophageal reflux disease (GERD) by the Japanese Society of Gastroenterology. There are many statements including recommended grade (from A to D) and evidence level (from I to VI) for the epidemiology, pathogenesis, diagnosis, medical treatments, surgical treatment of GERD, reflux esophagitis after gastrectomy, and non-typical symptoms of GERD. In this manuscript, we showed the latest date and current status of GERD in Japan used this guidelines. In summary, the prevalence of GERD has been increasing since the end of 1990s, the 1st choice of medical treatment is proton pump inhibitors, endoscopic treatments for GERD are not available in Japan, laparoscopic Toupet fundoplication is superior to laparoscopic Nissen fundoplication as postoperative dysphagia with similar reflux control, and complications of surgical treatment are pneumothorax, splenic injury, aortic injury, gastric ulcer, sever dysphagia, gastric perforation etc., but complication rate is low.

[Diagnostic and treatment of gastroesophageal reflux disease]

We propose a diagnostic algorithm based on the evaluation of GERD symptoms, the test results with a single dose of alginate with heartburn and EGD--esophagogastroduodenoscopy data. The diagnosis of GERD with reflux esophagitis based on the endoscopic detection of characteristic changes of esophagus. Diagnostic criteria endoscopically negative forms of GERD are the presence of symptoms of concern to the patient, the absence of damage to the esophagus during EGD and rapid relief of heartburn, a single dose of alginate (alginate positive test). Drug of choice for reflux esophagitis is an PPI. Specify the role of Helicobacter pylori diagnosis, indications for eradication in patients with GERD.

Time trends of endoscopic and pathological diagnoses related to gastroesophageal reflux disease in a Chinese population: eight years single institution experience

The discrepancy between Eastern and Western countries exists regarding the time trends of Barrett's esophagus (BE)/adenocarcinoma. We aimed to elucidate this issue through a retrospective review of the endoscopic and pathological diagnoses of gastroesophageal reflux disease (GERD) over time in a Chinese population. All records were analyzed from 2000 to 2007. Records included demographic data, clinical indication for endoscopy, and endoscopic findings. The total number of endoscopic procedures increased over time. The indications for referral endoscopy secondary to GERD increased from 366 cases (4.9%) in the beginning of the study to 1439 cases (14.1%) at the end. Concomitant GERD symptoms did not significantly change (range, 13-15.1%) in screening endoscopic studies. Endoscopic detection of erosive esophagitis increased in referral populations from 1546 (20.7%) to 5207 cases (51%) and by screening endoscopy from 791 (14.5%) to 1983 cases (23.5%). The prevalence of nonerosive reflux disease and BE did not change over time. BE-associated dysplasia and adenocarcinoma were rare. The detection of Los Angeles class A disease increased with time in referral endoscopy cases with a focus on erosive esophagitis composition. The endoscopic demand for GERD investigation and the GERD endoscopic diagnosis increased in our population. The results were related to a higher prevalence of low-grade erosive disease diagnosed. The incidence of BE-associated dysplasia and adenocarcinoma has been the same and the increased screening did not detect more cancers.

[Clinical observation on acupuncture for treatment of reflux esophagitis of heat stagnation of liver and stomach type]

OBJECTIVE

To observe the clinical therapeutic effect of acupuncture for treatment of reflux esophagitis of heat stagnation of liver and stomach type.

METHODS

Sixty-one cases were randomly divided into an acupuncture group (31 cases) and a medication group (30 cases). The acupuncture group was treated with needles at Zusanli (ST 36), Zhongwan (CV 12), Weishu (BL 21) and Neiguan (PC 6) mainly, once a day; and the medication group was treated with oral administration of 20 mg Omeprazole, once a day. The scores of clincial symptoms, comprehensive therapeutic effect, results of gastroscopy and pathology as well as recurrence rate etc. were observed before and after treatment.

RESULTS

After treatment, the scores of symptoms significantly decreased in the two groups (both P < 0.01). The total effective rate of the acupuncture group was 90.3% (28/31), and 90.0% (27/30 )in the medication group, there was no statistical difference between two groups (P > 0.05); results of gastroscopy and esophageal mucosa pathology showed no statistical difference between two groups (both P > 0.05), the recurrence rate 12 weeks after treatment of 9.1% in the acupuncture group was lower than that of 42.9% in the medication grou p (P < 0.05).

CONCLUSION

Acupuncture has preferable short and long-term therapeutic effects for treatment of reflux esophagitis of heat stagnation of liver and stomach type.

[The outcomes of treatment of gastroesophageal reflux disease with laparoscopic "floppy" fundoplication]

Gastroesophageal reflux disease (GERD) has been a serious health and social problem. Population based survey revealed that around 40 per cent of the whole population reported monthly GERD related symptoms. When not treated properly GERD can lead to severe complications such as Barrett's oesophagus (BE) and adenocarcinoma as a consequence. Various methods can be useful in diagnosis of GERD but only gastroscopy is a widespread investigation that enables to establish the diagnosis of reflux disease. The symptoms of reflux disease can be effectively treated by drugs, surgical procedures remain the way of curing the cause of gastroesophageal reflux. Nowadays the laparoscopic fundoplication is a standard in operative treatment of the ailment.

AIM OF STUDY

was to evaluate of GERD treatment with laparoscopic "floppy" Nissen fundoplication (LFN).

MATERIAL AND METHODS

A group of 41 patients who underwent LNF were recruited for the study. All qualified patients underwent pre and post-surgical upper GI endoscopy and were requested to answer the questions in a GERD-related quality of life questionnaire. The main group of patients was divided into two subgroups--those with concomitant hiatal hernia and those without hernia. The outcomes of treatment were then compared between the subgroups.

RESULTS

After the procedure the endoscopic improvement of reflux oesophagitis and better symptoms self-assessment were found.

CONCLUSIONS

Laparoscopic "floppy" Nissen fundoplication is an effective method of treatment of erosive oesophagitis and its symptoms.

[Peptic stenosing esophagitis]

The authors have performed examination and treatment of 55 patients with peptic stricture of the esophagus. The algorithm of examination (X-ray method, endoscopic method, express pH-metry of the upper part of the gastrointestinal tract, USI of the abdominal cavity organs) allowed characterization of the stricture, detection of the disease which resulted in its development. The treatment included endoscopic methods (bougienage, balloon dilatation) for restoration of patency of the esophagus, pharmacotherapy directed to suppression of gastric secretion and improving the motor function of the gastrointestinal tract. Frequent relapses of peptic strictures, suspected neoplasias in the patient's esophagus should be treated surgically.

[Acid related diseases progress in 2007]

The treatment of reflux disease did not changed. PPI treatment remains the first line treatment and surgery a second line treatment. The effect of surgery in reflux disease reduces and, after ten years, a part of the operated patients needs PPI again. The triple therapy is the treatment of choice of Helicobacter pylori infection. Patients with persistent Helicobacter pylori infection, after a first treatment, should be treated with a sequential treatment. PPI are effective in the prevention of gastroduodenal lesions and in the treatment of dyspeptic symptoms during NSAID treatment. IPP should be given to all patients presenting dyspeptic symptoms under NSAID or COX-2 administration.

[Endoscopic methods of treatment of variceal haemorrhages]

Haemorrhages from oesophagal varices are one of the most lifethreatening complications of the portal hypertension. Among various methods of treatment, endoscopic techniques are accepted and acknowledged as basic ones. The object of this paper is:--to present the variety of endoscopic procedures--to analyse the methodology and techniques of endoscopic procedures--to compare the effectiveness, safety and possible complications of different endoscopic techniques--to analyse the recommendations for treatment of acute variceal haemorrhages, primary and secondary prophylaxis. Endoscopic methods of haemostasis are essential in the treatment of acute variceal haemorrhages. Medical centres having at their disposal endoscopic methods of treating variceal haemorrhages can use the following techniques: EIS-endoscopic injection sklerotherapy--obliterating bleeding varices by injecting polidocanol or alcohol); rubber bands (EVL-Endoscopic Variceal Ligation); clipsing (closing varices with metal clipses). There are also different possibilities of combining methods mentionned above. In the primary prophylaxis of variceal haemorrhages, as the results of different studies are ambiguous, the endoscopic methods are used cautiously and for special indications only; pharmacological methods (non-selective b-blockers) have a leading role here. In the secondary prophylaxis of haemorrhages (in patients with history of previous variceal haemorrhages) endoscopic techniques have an acknowledged and leading role among other therapeutic methods. When comparing different endoscopic methods, crucial differences can be observed between their effectiveness, safety and technical possibilities of performing the procedures.

Erosive esophagitis and nonerosive reflux disease (NERD): comparison of epidemiologic, physiologic, and therapeutic characteristics

Nonerosive reflux disease (NERD) and erosive esophagitis are the main presentations of gastroesophageal reflux disease. However, NERD is the most common presentation of gastroesophageal reflux disease in community-based patients. Patients with NERD differ in demographic characteristics from patients with erosive esophagitis, primarily in sex distribution, weight/body mass index, and prevalence of hiatal hernia. Physiologically, patients with NERD tend to have normal lower esophageal sphincter resting pressure, minimal esophageal body motility abnormalities, low esophageal acid exposure profile and minimal nighttime esophageal acid exposure. Patients with NERD have a lower symptom response rate to proton pump inhibitor once daily than patients with erosive esophagitis. Additionally, NERD patients demonstrate a longer lag-time for symptom resolution and lack of difference in symptom response rate between half to full dose proton pump inhibitor as compared with patients with erosive esophagitis.

[Peptic diseases]

There are no real therapeutical acquisitions in the year 2006. The latest breakthroughs related to peptic disease treatment are the subject of this article. In particular various therapeutic procedures in reflux disease, including Barrett's oesophagus are developed here. Two important items were emphasized in the treatment of gastric and duodenal ulcers, in particular Helicobacter pylori eradication and the treatment of bleeding ulcer. Prophylaxis of gastrointestinal lesions due to AINS is also approached in detail.

[Diagnosis and treatment of primary peptic stricture of the esophagus]

Results of treatment of 271 patients, suffering primary peptic stricture of the esophagus (PPSE), were analyzed. Application of antireflux operation on esophagogastic junction with forceful esophageal bougienage had permitted to achieve recovery in majority of them. Esophageal resection is indicated in PPSE, which do not submit instrumental dilatation and in presence of high-grade dysplasia, situated within the organ segments, affected by metaplasia.

Effect of gastric bypass on Barrett's esophagus and intestinal metaplasia of the cardia in patients with morbid obesity

Gastric bypass in patients with morbid obesity should be an excellent antireflux procedure, because no acid is produced at the small gastric pouch and no duodenal reflux is present, due to the long Roux-en-Y limb. Five hundred fifty-seven patients with morbid obesity submitted to resectional gastric bypass, and routine preoperative upper endoscopy with biopsy samples demonstrated 12 patients with Barrett's esophagus (2.1%) and three patients with intestinal metaplasia of the cardia (CIM). An endoscopic procedure was repeated twice after surgery, producing seven patients with short-segment Barrett's esophagus (BE) and five patients with long-segment BE. Body mass index (BMI) decreased significantly, from 43.2 kg/m(2) to 29.4 kg/m(2) 2 years after surgery. Symptoms of reflux esophagitis, which were present in 14 of the 15 patients, disappeared in all patients 1 year after surgery. Preoperative erosive esophagitis and peptic ulcer of the esophagus healed in all patients. There was regression from intestinal metaplasia to cardiac mucosa in four patients (57%) with short-segment BE, and in one patient (20%) with long-segment BE. Two (67%) of three cases with CIM had regression to cardiac mucosa. There was no progression to low- or high-grade dysplasia. Gastric bypass in patients with Barrett's esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent.

Reflux Esophagitis in Three Cats Associated With Metaplastic Columnar Esophageal Epithelium

Gastroesophageal reflux is a relatively common condition in dogs and cats and may lead to secondary reflux esophagitis. A consequence of chronic gastroesophageal reflux that is well described in humans is Barrett’s esophagus, which is the replacement of the normal squamous epithelium of the distal esophagus with metaplastic columnar epithelium. Three cats with clinical and endoscopic signs of chronic esophagitis had metaplastic columnar epithelium on biopsy of the distal esophageal mucosa. Suspected underlying causes were cardial incompetence and sliding hiatal hernia. Two cats had complete resolution of the clinical signs after treatment. One cat was euthanized.

[The clinical strategy for the Barrett's esophagus]

The treatment of Barrett's esophagus is controversial. Current treatments include endoscopic therapy, surgical procedures, gastric acid-suppressive therapy with proton pump inhibitors (PPIs), and cancer chemoprevention such as nonsteroidal anti-inflammatory drugs. Endoscopic therapy combined with gastric acid suppressive therapy can result in squamous reepithelialization of the Barrett's mucosa. Antireflux surgery and PPIs therapy are potential options for the treatment of gastroesophageal reflux symptoms in patients with Barrett's esophagus. But there are no prospective studies that support any alternative approach to treatment. Although chemoprevention therapy may reduce cancer risk in Barrett's esophagus, no randomized controlled trials that prove its efficacy have been reported.

Recent developments in the pathophysiology and therapy of gastroesophageal reflux disease and nonerosive reflux disease

PURPOSE OF REVIEW

Gastroesophageal reflux disease is a very common disorder. Proton pump inhibitors are the highly successful mainstay of medical gastroesophageal reflux disease treatment. However, some limitations of proton pump inhibitor therapy continue to drive studies that aim at better understanding and managing manifestations of gastroesophageal reflux disease. This review summarizes recent progress in our understanding of the pathophysiology and treatment of gastroesophageal reflux disease.

RECENT FINDINGS

Recent studies have demonstrated a potential role of increased gastric acid secretion in gastroesophageal reflux disease, a factor largely neglected during the last decade. Failure to respond adequately to proton pump inhibitor therapy has been attributed to diagnostic inaccuracy, to nocturnal acid breakthrough, to ongoing non-acid reflux and to esophageal hypersensitivity. The relevance of nocturnal acid breakthrough has been recently challenged. Transient lower esophageal sphincter relaxations are a major mechanism of gastroesophageal reflux disease; inhibition of transient lower esophageal sphincter relaxations is a potentially important therapeutic target. Recent studies have focused on GABA receptor stimulation using baclofen or sodium valproate. The role of esophageal body peristalsis in the clearance of reflux events has been questioned. Endoscopic antireflux therapies aim at perendoscopic reinforcement of the antireflux barrier as a novel therapeutic approach to gastroesophageal reflux disease. At present, long-term and controlled data are scarce. Recent observations have challenged the long-term efficacy of surgical antireflux therapy.

SUMMARY

Increased understanding of the pathophysiology of gastroesophageal reflux disease may lead to new or improved treatments. Major advances have been made in the role of gastric acid secretion, the control of transient lower esophageal sphincter relaxations and mechanisms underlying esophageal hypersensitivity. Recent studies have highlighted some shortcomings of proton pump inhibitor therapy and of antireflux surgery. Novel approaches are treatments aimed at decreasing transient lower esophageal sphincter relaxations and endoscopic antireflux procedures. Large-scale controlled studies are lacking for both treatments.

[Barrett's esophagus: diagnosis and therapy]

Barrett's esophagus is usually diagnosed by the endoscopic and histological finding of columnar epithelium with intestinal metaplasia in the distal esophagus. The prevalence of Barrett's esophagus (long segment) is <2% in the general population and 3-5% in patients with chronic reflux symptoms. Barrett mucosa predisposes patients to adenocarcinoma that develops in approximately 0.5% of these patients per year (Barrett mucosa --> dysplasia --> cancer sequence). The incidence of esophageal adenocarcinoma over the past few decades; the present incidence, however, is still rather low and is reported to be approximately 4 and approximately 0.5 per 100,000 in males and females, respectively. The malignant potential of the Barrett mucosa increases with dysplastic changes. Guidelines for surveillance and therapy are based on the presence and the degree of dysplastic lesions. Long-term studies on cost-effectiveness of these guidelines are, however, still missing.

[Reflux esophagitis]

Gastroesophageal reflux disease (GERD) is one of the most prevalent diseases in the industrialized countries. Approximately 15-25% of adults suffer from reflux symptoms, characterized mainly by heartburn and/or regurgitation. Currently, antisecretory medication with proton pump inhibitors (PPI) or antireflux surgery are the established options for GERD-treatment. PPI are the therapeutic gold standard in acute, long-term or on-demand therapy of GERD. Since PPI do not restore the antireflux barrier but merely suppress acid secretion a life-long tablet adherence is required in most cases. In view of limitations of PPI and the potential risks of laparoscopic surgery, several endoscopic antireflux techniques were developed and may evolve as a valuable third option. However, so far objective long-term data are lacking for choosing the appropriate patient who will benefit most from endoluminal antireflux therapy.

[Immunotropic treatment of patients with surgical treatment of the gastrointestinal tract]

Results of examination of systemic immunity state, microbiocenosis and immunohistological changes of tissues of the esophagus and stomach in 37 adult patients and 69 children with erosive-ulcerous diseases of the gastrointestinal tract were analyzed. Based on these examinations, up-to-date immunomodulator tamerit inhibiting pathologic activity of monocytes/macrophage system with simultaneous activation of neutrophil granulocytes was used in 154 adult patients and 69 children. Positive result was achieved in all the cases when tamerit was used.

[Reflux disease therapy]

The frequency of gastroesophageal reflux disease is on a constant rise in western countries. Reflux therapy can be subdivided into the treatment of acute erosive reflux esophagitis and the subsequent recurrence prophylaxis, and into the treatment of non-erosive reflux disease as well as the atypical reflux symptoms. Based on conventional large-scale studies, a highly effective therapy is available which offers virtually complete acid blockade using proton pump inhibitors (PPI) of the prazole type. Used for acute treatment, they offer a cure for reflux esophagitis and freedom from symptoms in approx. 90% of the cases, while also showing high efficacy in recurrence prophylaxis. Conversely, the rate of side effects, particularly serious ones, is very low and the long-term safety of this therapy has been good. Since the risk of erosive reflux esophagitis recurring is > 80% without PPI therapy, the majority of the patients will require a long-term, potentially even life-long therapy with PPI. Other therapeutic options are being discussed as alternatives to such long-term prophylaxis. In selected cases, surgical therapy by laparoscopic fundoplication is one option. Alternatively, endoscopical anti-reflux procedures are increasingly coming into use; their merit in long-term prophylaxis however, cannot yet be evaluated. Whenever PPI therapy does not lead to complete freedom from symptoms, an alternative therapeutic approach should be given consideration even in patients with atypical reflux symptoms. The therapy of the Barrett's esophagus, a potentially long-term sequelae of reflux disease, will not be dealt with in this overview, as it is the subject of a separate presentation.

Optimizing symptom relief and preventing complications in adults with gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) is a chronic illness causing recurrent typical and atypical symptoms. Possible complications include oesophagitis, ulcer, stricture and Barrett's oesophagus. Evidence suggests that the intraoesophageal pH correlates directly with the degree of mucosal injury. Proton pump inhibitors (PPIs) are the first choice of therapy because they are significantly more effective than histamine-2-receptor antagonists (H(2)RAs) in achieving and sustaining an intragastric pH above 4.0. Numerous trials have shown that PPIs provide superior and faster relief of heartburn compared with H(2)RAs. PPIs have also been shown to be superior to H(2)RAs in healing oesophageal ulcers and improving the clinical outcome of patients with stricture formation. Unfortunately, even higher-than-standard doses of PPIs do not provide a complete regression in the length of Barrett's oesophagus, which is the most serious complication of GORD. Although the majority of patients with oesophagitis relapse within 6 months of stopping PPI therapy, maintenance PPI therapy prevents this in more than 80% of cases. Surgical and endoscopic procedures are alternative approaches to managing GORD. Surgery is successful but is not without risk. Endoscopic procedures are promising, but comparative and longer-term efficacy and safety data are needed.

Gastroesophageal reflux disease: a typical spectrum disease (a new conceptual framework is not needed)

Gastroesophageal reflux disease (GERD) is a common GI disorder, particularly frequent in the primary care setting, with a high direct and indirect economic burden on society. Despite the high prevalence and costs of the disease, the epidemiology and natural history of GERD have not been fully elucidated. It has recently been suggested to abandon the current model of GERD as a "spectrum" disease and to adopt a new conceptual framework, e.g., categorizing GERD into three unique groups of patients: nonerosive reflux disease, erosive esophagitis, and Barrett's esophagus. In the present review we present arguments against this proposal, and argue that the concept of a single disease, potentially progressing from mild nonerosive forms toward metaplasia and neoplasia (adenocarcinoma), still holds true and may in fact help us in planning the diagnostic and therapeutic approach as well as in allocating financial resources much better than the proposed model of a "tripartited" disease. Independently from the conceptual model adopted, however, more data on the natural history of patients with GERD are eagerly needed.

GERD 2003: issues from the past and a consensus for the future

Gastroesophageal reflux disease (GERD) has evolved from a scarcely reported, little understood disease process just a century ago to a now highly prevalent disease with up to 25% of the population complaining of symptoms of reflux. Throughout history attempts have been made to delineate the esophagus and related pathologies, but it has not been until relatively recently that enough has been understood about its screening, diagnosis and treatment to make a substantial impact on sufferers. Although the use of antacids and thereafter histamine 2 receptor antagonists dramatically improved the management of GERD, it was the advent of the proton pump inhibitor (PPI) class of drugs that revolutionized medical care. Although the relationship of hiatus hernia to reflux was well accepted, the modest results of open fundoplication fell into further disregard given the efficacy of PPIs. The PPIs are currently the most effective form of therapy and are equivalent on a milligram for milligram basis. While currently no novel drugs or devices are of proven efficacy for GERD, the development of an acid-suppressive agent of equal efficiency to a PPI but with a more rapid onset of action and a greater duration of effectiveness would be of particular clinical utility for the future.

Diagnosis and management of reflux esophagitis

Esophagitis has generally been considered rare in dogs and cats. However, it may not be as uncommon as previously thought due to the increased awareness of the disease and the increasing availability of endoscopy. Esophagitis can be caused by gastroesophageal reflux, trauma, foreign bodies, ingestion of caustic substances, structural abnormalities (ie, hiatal hernia, neoplasms), and chronic vomiting. This article will focus on the diagnosis and treatment of esophagitis secondary to gastroesophageal reflux. This is a diagnosis based on clinical signs, exclusion of other causes of esophagitis, and typical radiographic, endoscopic, and histopathologic findings.

[Peptic stricture of the esophagus: long term outcome of conservative treatment]

BACKGROUND

Endoscopic dilatation of esophageal strictures is a simple and safe procedure.

AIM

To analyze the long term outcome of conservative treatment for esophageal peptic stricture in patients with high surgical risk.

PATIENTS AND METHODS

Twenty consecutive patients, 13 male, whose mean age was 75.2 years, with a peptic stricture of the esophagus and high surgical risk were prospectively studied. All were subjected to endoscopic esophageal dilatation and treated with continuous medical antireflux therapy thereafter.

RESULTS

Only five patients complied with antireflux treatment on a regular basis. The remaining 15 were non compliant or abandoned it. A total of 56 dilatations were done (mean 2.8 per patient, range 1-6). No complications were observed after the procedure. With a mean follow up period of 49 months, the outcome of the conservative treatment was classified as excellent or good in all the cases. Eight patients (40%) died of causes unrelated to the treatment. Two patients had an organic foreing body impactation. This situation was solved endoscopically in both.

CONCLUSION

In high risk patients, endoscopic dilatation, with or without regular antireflux medical treatment is a simple, safe and effective therapy in the management of peptic oesophagel stenosis.

Quality of life and cost-effectiveness of combined therapy for reflux esophagitis

OBJECTIVE

To evaluate clinical, Quality of Life (QoL) and medical cost outcomes in patients with symptomatic reflux esophagitis (RE) receiving different "triple combination therapy".

METHODS

A multicenter medical effectiveness trial conducted in 10 hospitals of 5 regions in Zhejiang Province. 248 patient-volunteers were assigned to 8 weeks of "triple combination therapy" with Lansoprazole plus Cisapride and Sucralfate or Ranitidine plus Cisapride and Sucralfate. Main outcomes assessment included symptoms scale scores, RE severity, QoL at baseline and 8 weeks. Medical cost data were collected with cost analysis questionnaire.

RESULTS

(1) More Lansoprazole group patients noted RE symptoms resolution than Ranitidine group (92.3% vs 78.4%, P<0.01). There was no striking difference between two groups in RE healing rate (90.8% vs 82.9%, P>0.05). (2) RE significantly impaired QoL of patients (P<0.001). Compared with Ranitidine group, QoL in Lansoprazole group had significant improvement (rate of "good" QoL 64.5% vs 45.6%, P<0.01). (3) There was close correlation between symptomic effectiveness and QoL rating scale in both the Lansoprazole and Ranitidine group (P<0.01, r=0.235 and 0.353 respectively). There were no statistical difference of medical cost between the two groups (P>0.05).

CONCLUSION

RE significantly impaired QoL of patients. "Triple combination therapies" can significantly improve RE symptoms and QoL. Lansoprazole combination therapy was more cost-effective than Ranitidine combination group.

Asthmatics with gastroesophageal reflux: long term results of a randomized trial of medical and surgical antireflux therapies

OBJECTIVE

In short term studies, asthma symptoms and pulmonary function have been reported to improve during and after medical treatment or surgical correction of gastroesophageal reflux (GER). In this study, we aimed to determine whether prolonged treatment of GER altered the long term natural history of asthma in asthmatics with GER.

METHODS

A total of 62 patients with both GER and asthma entered a randomized study of antireflux treatments for at least 2 yr: 24 controls (antacids as needed); 22 medical (ranitidine 150 mg t.i.d.); and 16 surgical (Nissen fundoplication). Asthma was defined as a previous diagnosis of asthma with discrete attacks of wheezing and 20% reversibility in airway disease. GER was defined as an abnormal ambulatory 24-h esophageal pH test and macroscopic or microscopic evidence of GER disease. Overall clinical status, asthma symptom scores, and pulmonary medication requirements were recorded monthly. Peak expiratory flow rates were recorded up to seven times per day for 1 wk of each month throughout the years. Pulmonary function, esophageal manometry, and endoscopy with biopsy were repeated yearly.

RESULTS

The 62 patients were followed for up to 19.1 yr. In the surgical group, but not in the medical or control groups, there was an immediate and sustained reduction in acute nocturnal exacerbations of wheezing, coughing, and dyspnea. By the end of 2 yr, improvement, marked improvement, or cure in the overall asthma status occurred in 74.9% of the surgical group, 9.1% of the medical group and 4.2% of the control group, whereas the overall status worsened in 47.8% of the control group, 36.4% of the medical group, and 12.5% of the surgical group (p < 0.001, surgical vs medical and control). The mean asthma symptom score of the surgical group improved 43%, compared with less than 10% in the medical and control groups (p = 0.0009). As determined by changes in peak expiratory flow rates, there was no statistically significant difference in pulmonary function during the 2-yr period or during regularly scheduled follow-up. There was no difference in medication requirements among the groups. There was no difference between the groups in overall survival.

CONCLUSION

In patients with both GER and asthma, antireflux surgery (but not medical therapy with ranitidine 150 mg t.i.d.) has minimal effect on pulmonary function, pulmonary medication requirements, or survival, but significantly improves asthma symptoms and overall clinical status.

Schatzki's rings do not protect against acid reflux and may decrease esophageal acid clearance

Schatzki's rings (SR) are a common cause of intermittent solid food dysphagia, but their etiology is unclear. Many believe they are related to acid reflux, hypothesizing that the rings act as a protective barrier against further reflux. The purpose of this study was to determine whether dilation of SR affected the degree of acid reflux. Twenty patients participated in the study. All patients underwent esophageal manometry and 24-hr pH monitoring off all acid inhibitory medications before and two weeks after esophageal dilation. No significant differences were noted in any of the reflux parameters measured before and after dilation. However, there was a trend toward reduction in symptom score in all patients, a decrease in Johnson-DeMeester score, and a decrease in supine reflux time in patients with thick SR after dilation. There was no correlation between ring diameter and the presence or absence of reflux. In conclusion, Schatzki's rings do not prevent esophageal reflux, and they may act to decrease esophageal acid clearance, especially in the supine position, thereby increasing esophageal acid exposure.

[Reflux esophagitis]

There are some factors which influence reflux esophagitis, in our country atrophic gastritis is important for the degree of it especially. Helicobacter pylori(H.P.) infection is popular in aged patients, so atrophic gastritis is also popular in such patients, then the frequency of reflux esophagitis is low comparing with other countries. But because of the late of H.P. infection comes to be higher and the eradication therapy for the peptic ulcer diseases has been done in these days, the late of atrophic gastritis comes to be lower and reflux esophagitis comes to be higher. In aged patients medication and physical factors influence reflux esophagitis and these factors are different in each patient. So it is very important to treat the patient of reflux esophagitis considering of each factor.

[Psycho-physiological aspects of gastroesophageal reflux disease]

It is well known that there is an interaction between physiological and psychological aspects of gastrointestinal diseases, also in esophageal symptoms. Based on this bio-psycho-social interaction, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) is really unknown. The present article reviews the basic pathophysiological factors of GERD including psycho-physiological aspects and presents potential concepts of multidisciplinary GERD treatment.