Medicine › Gastroenterology

Gastroesophageal reflux and treatments

Works Count: 75386

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Description

This cluster of papers focuses on the diagnosis, management, epidemiology, and complications of gastroesophageal reflux disease (GERD), including topics such as esophageal motility disorders, proton pump inhibitors, achalasia, hiatal hernia, laryngopharyngeal reflux, pediatric guidelines, and ambulatory monitoring.

Keywords

Gastroesophageal Reflux Disease; Esophageal Motility Disorders; Proton Pump Inhibitors; Achalasia; Epidemiology; Hiatal Hernia; Laryngopharyngeal Reflux; Pediatric Guidelines; Ambulatory Monitoring; Complications

Laparoscopic Nissen fundoplication: preliminary report.

1991-09-01

Bernard Dallemagne , J Weerts , C Jehaes +2 more

Twelve patients presenting with symptomatic esophagitis associated with hiatal hernia and gastroesophageal reflux underwent operative management under laparoscopic guidance. The antireflux procedure employed was the Nissen fundoplication. The authors completed … Twelve patients presenting with symptomatic esophagitis associated with hiatal hernia and gastroesophageal reflux underwent operative management under laparoscopic guidance. The antireflux procedure employed was the Nissen fundoplication. The authors completed the operation laparoscopically in nine patients. Postoperatively, patients were evaluated with repeat fiberoptic endoscopy, esophageal manometry, and barium contrast studies. Postoperative results were considered excellent on the basis of these studies and complete control of symptoms. The mortality rate was 0%. The only major operative complication was a pneumonia that occurred in one patient. At 1 month follow-up, six patients were totally asymptomatic. The authors conclude that laparoscopic treatment of gastroesophageal reflux associated with a hiatal hernia is feasible by a procedure that has already proven its value during open surgery.

Esophageal peristaltic dysfunction in peptic esophagitis

1986-10-01

Peter J. Kahrilas , W. J. Dodds , Walter J. Hogan +3 more

Healing and relapse of severe peptic esophagitis after treatment with omeprazole

1988-10-01

David J. Hetzel , John Dent , W D Reed +7 more

Predictors of outcome in patients with achalasia treated by pneumatic dilation

1992-12-01

Volker F. Eckardt , Christopher Aignherr , Gudrun Bernhard

The Otolaryngologic Manifestations of Gastroesophageal Reflux Disease (GERD): A Clinical Investigation of 225 Patients Using Ambulatory 24‐Hour pH Monitoring and an Experimental Investigation of the Role of Acid and Pepsin in the Development of Laryngeal Injury

1991-04-01

James A. Koufman

Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In … Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order to test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double‐probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx. Two hundred twenty‐five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24‐hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double‐probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy. The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18). The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population. Twenty‐eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentag with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively). By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%). All of the study patients were treated with antireflux therapy. Follow‐up was available on 68% of the patients and the mean follow‐up period was 11.6 ± 12.7 months. After 6 months of treatment, symptoms had resolved in 85% and medical therapy had failed in 15%. Subsequently, an additional 20% experienced medical treatment failure. Fifteen percent of patients underwent Nissen fundoplication, and all subsequently had resolution of symptoms. To further investigate the role of gastroesophageal reflux in the development of laryngeal damage, experiments mimicking the effects of intermittent reflux (of acid and pepsin) on the canine larynx were performed. The results of these experiments revealed: 1 . Intermittent reflux (three episodes per week) can result in severe laryngeal damage if there is prior mucosal injury; 2 . pepsin, and not hydrochloric acid, is the principal injurious agent of the refluxate; and, 3 . severe laryngeal damage can occur even when the pH of the refluxate is 4.0. The manuscript describes the limitations and advantages of standard diagnostic procedures and of 24‐hour pH monitoring. The differences between gastroenterology and otolaryngology patients with GERD are emphasized and specific new diagnostic and therapeutic recommendations are made.

Endoscopic and Surgical Treatments for Achalasia

2008-12-23

Guilherme M. Campos , Eric Vittinghoff , Charlotte Rabl +4 more

Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or … Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies.To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia.A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively.A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003).EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.

The enteric nervous system and neurogastroenterology

2012-03-06

John B. Furness

Patterns of Gastroesophageal Reflux in Health and Disease

1976-10-01

Tom R. DeMeester , Lawrence F. Johnson , GUY J. JOSEPH +3 more

Twenty-four-hour pH monitoring of the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic … Twenty-four-hour pH monitoring of the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studied with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic patients with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagatis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.

Validity and Reliability of the Reflux Symptom Index (RSI)

2002-06-01

Peter C. Belafsky , Gregory N. Postma , James A. Koufman

Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring

2006-03-24

Inder Mainie , Radu Țuțuian , Steven S. Shay +4 more

Empiric proton pump inhibitor (PPI) trials have become increasingly popular leading to gastroenterologists frequently evaluating gastro-oesophageal reflux disease (GORD) patients only after they have "failed" PPI therapy. Combined multichannel intraluminal … Empiric proton pump inhibitor (PPI) trials have become increasingly popular leading to gastroenterologists frequently evaluating gastro-oesophageal reflux disease (GORD) patients only after they have "failed" PPI therapy. Combined multichannel intraluminal impedance and pH (MII-pH) monitoring has the ability to detect gastro-oesophageal reflux (GOR) episodes independent of their pH and evaluate the relationship between symptoms and all types of GOR. Using this technique, we aimed to characterise the frequency of acid and non-acid reflux (NAR) and their relationship to typical and atypical GOR symptoms in patients on PPI therapy.Patients with persistent GORD symptoms referred to three centres underwent 24 hour combined MII-pH monitoring while taking PPIs at least twice daily. Reflux episodes were detected by impedance channels located 3, 5, 7, 9, 15, and 17 cm above the lower oesophageal sphincter (LOS) and classified into acid or non-acid based on pH data from 5 cm above the LOS. A positive symptom index (SI) was declared if at least half of each specific symptom events were preceded by reflux episodes within five minutes.A total of 168 patients (103 (61%) females and 65 (39%) males; mean age 53 (range 18-85) years) underwent combined MII-pH monitoring while taking PPIs at least twice daily. One hundred and forty four (86%) patients recorded symptoms during the study day and 24 (15%) patients had no symptoms during testing. Sixty nine (48%) symptomatic patients had a positive SI for at least one symptom (16 (11%) with acid reflux and 53 (37%) with NAR) and 75 (52%) had a negative SI. A total of 171 (57%) typical GORD symptoms were recorded, 19 (11%) had a positive SI for acid reflux, 52 (31%) for NAR, and 100 (58%) had a negative SI. One hundred and thirty one (43%) atypical symptoms were recorded, four (3%) had a positive SI for acid reflux, 25 (19%) had a positive SI for NAR, and 102 (78%) had a negative SI.Combined MII-pH identifies the relation of reflux of all types to persistent symptoms and the importance of NAR in patients taking PPIs.

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Prevalence and clinical spectrum of gastroesophageal reflux: A population-based study in Olmsted County, Minnesota

1997-05-01

G. Richard Locke , N. J. Talley , Sara L. Fett +2 more

The Validity and Reliability of the Reflux Finding Score (RFS)

2001-08-01

Peter C. Belafsky , Gregory N. Postma , James A. Koufman

Abstract Background The evaluation of medical and surgical outcomes relies on methods of accurately quantifying treatment results. Currently, there is no validated instrument whose purpose is to document the physical … Abstract Background The evaluation of medical and surgical outcomes relies on methods of accurately quantifying treatment results. Currently, there is no validated instrument whose purpose is to document the physical findings and severity of laryngopharyngeal reflux (LPR). Objective To evaluate the validity and reliability of the reflux finding score (RFS). Methods Forty patients with LPR confirmed by double‐probe pH monitoring were evaluated pretreatment and 2, 4, and 6 months after treatment. The RFS was documented for each patient at each visit. For test–retest intraobserver reliability assessment, a blinded laryngologist determined the RFS on two separate occasions. To evaluate interobserver reliability, the RFS was determined by two different blinded laryngologists. Results The mean age of the cohort was 50 years (± 12 standard deviation [SD]). Seventy‐three percent were women. The RFS at entry was 11.5 (± 5.2 SD). This score improved to 9.3 (± 4.7 SD) at 2 months, 7.3 (± 5.5 SD) at 4 months, and 6.1 (± 5.2 SD) at 6 months of treatment ( P <.001 with trend). The mean RFS for laryngologist no. 1 was 10.8 (± 4.1 SD) at the initial screening and 10.8 (± 4.0 SD) at the repeat evaluation (r = 0.95, P <.001). The mean RFS for laryngologist no. 2 was 11.1 (± 3.8 SD) at the initial screening and 10.9 (± 3.7 SD) at the repeat evaluation (r = 0.95, P <.001). The correlation coefficient for interobserver variability was 0.90 ( P <.001). Conclusions The RFS accurately documents treatment efficacy in patients with LPR. It demonstrates excellent inter‐ and intraobserver reproducibility.

Symptoms in gastro-oesophageal reflux disease

1990-01-01

A G Klauser , Norbert E. Schindlbeck , S. Müller‐Lissner

Prevalence of Symptoms of Gastroesophageal Reflux During Infancy

1997-06-01

Suzanne Nelson

<h3>Objectives:</h3> To determine the prevalence of symptoms associated with overt gastroesophageal reflux (GER) during the first year of life, to describe when most infants outgrow these symptoms, and to assess … <h3>Objectives:</h3> To determine the prevalence of symptoms associated with overt gastroesophageal reflux (GER) during the first year of life, to describe when most infants outgrow these symptoms, and to assess the prevalence of parental reports of various symptoms associated with GER and the percentages of infants who have been treated for GER. <h3>Design:</h3> Cross-sectional survey. <h3>Setting:</h3> Nineteen Pediatric Practice Research Group practices in the Chicago, Ill, area (urban, suburban, and semirural). <h3>Participants:</h3> A total of 948 parents of healthy children 13 months old and younger. <h3>Intervention:</h3> None. <h3>Main Outcome Measure:</h3> Reported frequency of regurgitation. <h3>Results:</h3> Regurgitation of at least 1 episode a day was reported in half of 0- to 3-month-olds. This symptom decreased to 5% at 10 to 12 months of age (<i>P</i><.001). Peak reported regurgitation was 67% at 4 months; the prevalence of symptoms decreased dramatically from 61% to 21% between 6 and 7 months of age. Infants with at least 4 episodes daily of regurgitation showed a similar pattern (<i>P</i><.001). Peak regurgitation reported as a "problem" was most often seen at 6 months (23%); this prevalence decreased to 14% at 7 months of age. Parental perception that regurgitation was a problem was associated with the frequency and volume of regurgitation, increased crying or fussiness, reported discomfort with spitting up, and frequent back arching. Reported treatment for regurgitation included a change in formula in 8.1%, thickened feedings in 2.2%, termination of breast-feeding in 1.1%, and medication in 0.2%. <h3>Conclusions:</h3> Complaints of regurgitation are common during the first year of life, peaking at 4 months of age. Many infants "outgrow" overt GER by 7 months and most by 1 year. Parents view this symptom as a problem more often than medical intervention is given. Arch Pediatr Adolesc Med. 1997;151:569-572

The Chicago Classification of esophageal motility disorders, v3.0

2014-12-03

Peter J. Kahrilas , Albert J. Bredenoord , Mark Fox +4 more

Abstract Background The Chicago Classification ( CC ) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high‐resolution manometry ( HRM ) studies, has gained acceptance worldwide. Methods … Abstract Background The Chicago Classification ( CC ) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high‐resolution manometry ( HRM ) studies, has gained acceptance worldwide. Methods This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version. Key Results Chicago Classification v3.0 utilizes a hierarchical approach, sequentially prioritizing: (i) disorders of esophagogastric junction ( EGJ ) outflow (achalasia subtypes I‐III and EGJ outflow obstruction), (ii) major disorders of peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus), and (iii) minor disorders of peristalsis characterized by impaired bolus transit. EGJ morphology, characterized by the degree of overlap between the lower esophageal sphincter and the crural diaphragm and baseline EGJ contractility are also part of CC v3.0. Compared to the previous CC version, the key metrics of interpretation, the integrated relaxation pressure ( IRP ), the distal contractile integral ( DCI ), and the distal latency ( DL ) remain unchanged, albeit with much more emphasis on DCI for defining both hypo‐ and hypercontractility. New in CC v3.0 are: (i) the evaluation of the EGJ at rest defined in terms of morphology and contractility, (ii) ‘fragmented’ contractions (large breaks in the 20‐mmHg isobaric contour), (iii) ineffective esophageal motility ( IEM ), and (iv) several minor adjustments in nomenclature and defining criteria. Absent in CC v3.0 are contractile front velocity and small breaks in the 20‐mmHg isobaric contour as defining characteristics. Conclusions & Inferences Chicago Classification v3.0 is an updated analysis scheme for clinical esophageal HRM recordings developed by the International HRM Working Group.

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Speed of healing and symptom relief in grade II to IV gastroesophageal reflux disease: A meta-analysis

1997-06-01

Naoki Chiba , CJ De Gara , JM Wilkinson +1 more

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Symptomatic gastroesophageal reflux: Incidence and precipitating factors

1976-11-01

Otto T. Nebel , Michael F. Fornes , Donald O. Castell

Mechanisms of Gastroesophageal Reflux in Patients with Reflux Esophagitis

1982-12-16

Wylie J. Dodds , John Dent , Walter J. Hogan +4 more

We evaluated the mechanisms of gastroesophageal reflux in 10 patients with reflux esophagitis and compared the results with findings from 10 controls. The patients had more episodes of reflux (35±15 … We evaluated the mechanisms of gastroesophageal reflux in 10 patients with reflux esophagitis and compared the results with findings from 10 controls. The patients had more episodes of reflux (35±15 in 12 hours, as compared with 9±8 in the controls) and a lower pressure of the lower esophageal sphincter (13±8 mm Hg as compared with 29±9 in the controls) (P<0.001). Reflux occurred by three different mechanisms: transient complete relaxation of the lower esophageal sphincter, a transient increase in intra-abdominal pressure, or spontaneous free reflux associated with a low resting pressure of the lower esophageal sphincter. In controls 94 per cent of reflux episodes were caused by transient sphincter relaxation. In the patients 65 per cent of episodes of reflux accompanied transient sphincter relaxation, 17 per cent accompanied a transient increase in intra-abdominal pressure, and 18 per cent occurred as spontaneous free reflux. The predominant reflux mechanism in individual patients varied: some had normal resting sphincter pressure and reflux that occurred primarily during transient sphincter relaxation, whereas others with low resting sphincter pressures had spontaneous free reflux or reflux that occurred during an increase in intra-abdominal pressure. (N Engl J Med. 1982; 307:1547–52.)

American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease

2008-10-01

Peter J. Kahrilas , Nicholas J. Shaheen , Michael F. Vaezi

Nissen Fundoplication for Gastroesophageal Reflux Disease

1986-07-01

Tom R. DeMeester , Luigi Bonavina , Mario Albertucci

One hundred consecutive patients had a primary Nissen fundoplication for gastroesophageal reflux disease. None of the patients had previous gastric or esophageal surgery or evidence of esophageal stricture or motility … One hundred consecutive patients had a primary Nissen fundoplication for gastroesophageal reflux disease. None of the patients had previous gastric or esophageal surgery or evidence of esophageal stricture or motility disorder. The primary symptom was persistent heartburn in 89 patients and aspiration in 11. An abnormal pattern of esophageal acid exposure was documented in all patients with 24-hour esophageal pH monitoring. By actuarial analysis, the operation was 91% effective in the control of reflux symptoms over a 10-year period. The incidence of postoperative symptomatic gas bloat and increased flatus was lower in patients with preoperative abnormal manometric measurements of the distal esophageal sphincter (p less than 0.05). Three modifications in operative technique were made during the course of the study to minimize the side effects of the operation. First, enlarging the caliber of the bougie to size the fundoplication reduced the incidence of temporary swallowing discomfort from 83 to 39% (p less than 0.01). Second, shortening the length of the fundoplication decreased the incidence of persistent dysphagia from 21 to 3% (p less than 0.01). Third, mobilizing the gastric fundus for construction of the fundoplication increased the incidence of complete distal esophageal sphincter relaxation on swallowing from 31 to 71% (p less than 0.05). This was done to prevent the delayed esophageal acid clearance secondary to incomplete sphincter relaxation observed after operation in five of 36 studied patients. It is concluded that by proper patient selection and the incorporation of the above surgical techniques, the Nissen fundoplication can re-establish a competent cardia and provide relief of reflux symptoms with minimal side effects.

ACG Clinical Guideline: Diagnosis and Management of Achalasia

2013-07-23

Michael F. Vaezi , John E. Pandolfino , Marcelo F. Vela

Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids … Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. Endoscopic finding of retained saliva with puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. In this ACG guideline the authors present an evidence-based approach in patients with achalasia based on a comprehensive review of the pertinent evidence and examination of relevant published data.

An evidence-based appraisal of reflux disease management --- the Genval Workshop Report

1999-04-01

John Dent , Johan G. Brun , A. Mark Fendrick +7 more

This report summarises conclusions from an evidence-based workshop which evaluated major clinical strategies for the management of the full spectrum of gastro-oesophageal reflux disease, with an emphasis on medical management.The … This report summarises conclusions from an evidence-based workshop which evaluated major clinical strategies for the management of the full spectrum of gastro-oesophageal reflux disease, with an emphasis on medical management.The disease was defined by the presence of oesophageal mucosal breaks or by the occurrence of reflux induced symptoms severe enough to impair quality of life.Endoscopy negative patients were recognised as the most common subgroup; most of these patients can be diagnosed by a well structured symptom analysis.There is a consistent hierarchy of eVectiveness of available initial and long term therapies that applies for all patient subgroups.Lifestyle measures were judged to be of such low eYcacy that they were rejected as a primary therapy for all patient subgroups.Proton pump inhibitor therapy was considered the initial medical treatment of choice because of its clearly superior eYcacy which results in the most prompt achievement of desirable outcomes at the lowest overall medical cost.It was acknowledged that most of patients require long term management and that any maintenance therapy should be chosen by step down to the regimen that is still eVective, but least costly.Endoscopic monitoring of routine long term therapy was considered inappropriate, on the basis that control of symptoms is an acceptably reliable indicator of healing in patients with oesophagitis.Laparoscopic antireflux surgery was recognised as a significant therapeutic advance, the results of which, however, depend substantially on the experience of the surgeon.There are currently no published direct comparisons of cost and eYcacy outcomes of optimal medical and surgical therapies for reflux disease.To a significant degree, the choice between medical and surgical therapy should depend on informed patient preference.Substantial advances have occurred recently in the understanding and treatment of reflux disease.By contrast, there has been relatively little research into the best strategies for capitalisation on these advances.This is a fertile field for future research. Rationale, structure and processes for the Workshop

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Prediction of variceal hemorrhage by esophageal endoscopy

1981-11-01

Kazushige Beppu , Kiyoshi Inokuchi , Nobuhiro Koyanagi +4 more

Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease

2013-02-19

Philip O. Katz , Lauren B. Gerson , Marcelo F. Vela

Gastroesophageal reflux disease (GERD) is arguably the most common disease encountered by the gastroenterologist. It is equally likely that the primary care providers will find that complaints related to reflux … Gastroesophageal reflux disease (GERD) is arguably the most common disease encountered by the gastroenterologist. It is equally likely that the primary care providers will find that complaints related to reflux disease constitute a large proportion of their practice. The following guideline will provide an overview of GERD and its presentation, and recommendations for the approach to diagnosis and management of this common and important disease. The document will review the presentations of any risk factors for GERD, the diagnostic modalities and their recommendation for use and recommendations for medical, surgical and endoscopic management including comparative effectiveness of different treatments. Extraesophageal symptoms and complications will be addressed as will the evaluation and management of "refractory" GERD. The document will conclude with the potential risks and side effects of the main treatments for GERD and their implications for patient management. Each section of the document will present the key recommendations related to the section topic and a subsequent summary of the evidence supporting those recommendations. An overall summary of the key recommendations is presented in Table 1. A search of OVID Medline, Pubmed and ISI Web of Science was conducted for the years from 1960–2011 using the following major search terms and subheadings including "heartburn", "acid regurgitation", "GERD", "lifestyle interventions", "proton pump inhibitor (PPI)", "endoscopic surgery," "extraesophageal symptoms," "Nissen fundoplication," and "GERD complications." We used systematic reviews and meta-analyses for each topic when available followed by a review of clinical trials.Table 1: Summary and strength of recommendationsTable 1: (continued)The GRADE system was used to evaluate the strength of the recommendations and the overall level of evidence (1,2). The level of evidence could range from "high" (implying that further research was unlikely to change the authors' confidence in the estimate of the effect) to "moderate" (further research would be likely to have an impact on the confidence in the estimate of effect) or "low" (further research would be expected to have an important impact on the confidence in the estimate of the effect and would be likely to change the estimate). The strength of a recommendation was graded as "strong" when the desirable effects of an intervention clearly outweigh the undesirable effects and as "conditional" when there is uncertainty about the trade-offs. It is important to be aware that GERD is defined by consensus and as such is a disease comprising symptoms, end-organ effects and complications related to the reflux of gastric contents into the esophagus, oral cavity, and/or the lung. Taking into account the multiple consensus definitions previously published (3,4,5), the authors have used the following working definition to define the disease: GERD should be defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung. GERD can be further classified as the presence of symptoms without erosions on endoscopic examination (non-erosive disease or NERD) or GERD symptoms with erosions present (ERD). SYMPTOMS AND EPIDEMIOLOGY Epidemiologic estimates of the prevalence of GERD are based primarily on the typical symptoms of heartburn and regurgitation. A systematic review found the prevalence of GERD to be 10–20% of the Western world with a lower prevalence in Asia (6). Clinically troublesome heartburn is seen in about 6% of the population (7). Regurgitation was reported in 16% in the systematic review noted above. Chest pain may be a symptom of GERD, even the presenting symptom (2,3). Distinguishing cardiac from non-cardiac chest pain is required before considering GERD as a cause of chest pain. Although the symptom of dysphagia can be associated with uncomplicated GERD, its presence warrants investigation for a potential complication including an underlying motility disorder, stricture, ring, or malignancy (8). Chronic cough, asthma, chronic laryngitis, other airway symptoms and so-called extraesophageal symptoms are discussed in a subsequent section. Atypical symptoms including dyspepsia, epigastric pain, nausea, bloating, and belching may be indicative of GERD but overlap with other conditions. A systematic review found that ∼38% of the general population complained of dyspepsia. Dyspepsia was more frequent in GERD patients than those without. These patients were at risk for a new diagnosis of GERD. Epigastric pain, early satiety, belching and bloating were more likely to respond to a PPI therapy compared with nausea. Overall, these symptoms can be considered to be associated with GERD if they respond to a PPI trial (9). A recent systematic review on the burden of GERD on quality of life (QOL) included 19 studies. Patients with disruptive GERD (daily or >weekly symptoms) had an increase in time off work and decrease in work productivity. Low scores on sleep scales were seen compared with patients with less frequent symptoms. A decrease in physical functioning was also seen (10). Nocturnal GERD has a greater impact on QOL compared with daytime symptoms. Both nocturnal symptoms and sleep disturbances are critical to elucidate when evaluating the GERD patient (11). The balance of evidence suggests that symptom frequency does not change as we age, however, the intensity of symptoms may decrease after the age of 50 (12). Aging increases the prevalence of erosive esophagitis, Los Angeles (LA) grades C and D (13). Barrett's esophagus increases in prevalence after age 50, especially in Caucasian males (14). There are little data addressing the features of GERD in women distinct from men. Patients with erosive esophagitis are more likely to be men, and women are more likely to have NERD. Barrett's esophagus is more frequent in men compared with women (15). The gender ratio for esophageal adenocarcinoma is estimated to be 8:1 male to female (14). There is a definite relationship between GERD and obesity. Several meta-analysis suggest an association between body mass index (BMI), waist circumference, weight gain and the presence of symptoms and complications of GERD including ERD and Barrett's esophagus (16,17). The ProGERD study, likely the largest of its kind (>5,000 patients) used logistic regression analysis to identify several independent risk factors for ERD. The odds for higher degrees of ERD increased as BMI rose (18). It is of greatest concern that there has been a well-documented association between BMI and carcinoma of the esophagus and gastric cardia (19). Establishing the diagnosis of GERDFigure: No Caption available.The diagnosis of GERD is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy. (Table 2) The symptoms of heartburn and regurgitation are the most reliable for making a presumptive diagnosis based on history alone; however, these are not as sensitive as most believe. A systematic review of seven studies found the sensitivity of heartburn and regurgitation for the presence of erosive esophagitis to be 30–76% and the specificity from 62–96% (20). Empiric PPI therapy (a PPI trial) is a reasonable approach to confirm GERD when it is suspected in patients with typical symptoms. A response to therapy would ideally confirm the diagnosis; however, a well done meta-analysis suggested some limitations of this approach with a sensitivity of 78% and specificity of 54% (21). Therefore, empiric therapy (or a so called PPI trial) has some limitations.Table 2: Diagnostic testing for GERD and utility of testsNon-cardiac chest pain has often been associated with the presence of GERD, and can be the presenting symptom. A meta-analysis found a high probability that non-cardiac chest pain responds to aggressive acid suppression (22). This study supported earlier work suggesting the efficacy and cost effectiveness of a PPI trial (PPI twice daily in variable doses) in patients with chest pain in whom a cardiac cause had been excluded. However, a more recent systematic review suggested that the response of non-cardiac chest pain to a PPI trial was significantly higher than placebo in patients with objective evidence of GERD (ERD on endoscopy and/or abnormal pH monitoring) (23). The response to PPIs compared with placebo was almost non-existent in the absence of objective documentation of GERD. As such, a diagnostic evaluation with endoscopy and pH monitoring should be considered before a PPI trial (24). The presence of heartburn in conjunction with chest pain was not predictive of PPI response of the chest pain component. Dysphagia has historically been an alarm symptom or warning sign and an indication for early endoscopy to rule out a GERD complication. Respiratory symptoms have been associated with GERD, based on retrospective case–control studies. In addition, dental erosions, erosion of dental enamel, sinusitis, chronic laryngitis and voice disturbance have similarly been associated with GERD. These are discussed later in the article. Overall, heartburn and regurgitation remain reliable symptoms of GERD as does non-cardiac chest pain. Other symptoms, while associated with GERD, are not as reliable. The causal relationship between GERD and the so-called atypical and extraesophageal manifestations remains difficult with only a history. Barium radiographs have been historically considered part of the potential diagnostic armamentarium in the patient with esophageal symptoms, including GERD. Although well-performed barium esophagrams with double contrast can detect signs of esophagitis, the overall sensitivity of this test is extremely low (25). The finding of barium reflux above the thoracic inlet with or without provocative maneuvers including the water siphon test does increase the sensitivity of the barium test; however, not sufficiently to be recommended as a diagnostic test without dysphagia (26). The endoscope has long been the primary tool used to evaluate the esophageal mucosa in patients with symptoms suspected due to GERD. Findings of GERD include erosive esophagitis, strictures, and a columnar lined esophagus ultimately confirmed to be Barrett's esophagus. As such, endoscopy has excellent specificity for the diagnosis of GERD especially when erosive esophagitis is seen and the LA classification is used (27). However, the vast majority of patients with heartburn and regurgitation will not have erosions (or Barrett's) limiting upper endoscopy as an initial diagnostic test in patients with suspected GERD (28). Endoscopy allows for biopsy of rings and strictures and screening for Barrett's. Although epidemiologic risk factors for Barrett's esophagus have been well-defined (age over 50, symptoms for>5–10 years, obesity, male sex) the sensitivity and specificity of these symptoms for abnormal endoscopy makes the utility of screening for Barrett's a controversial topic. Recent data indicate that it may be reasonable to perform endoscopy for screening in certain high-risk groups in particular overweight white males over the age of 50 with chronic GERD symptoms (12). The finding of any Barrett's esophagus segment has been associated with pathologic GERD and generally obviates the need for pH testing (29). In a 2009 study, 90% of short-segment BE patients were found to have abnormal pH-impedance testing (30). The addition of esophageal biopsies as an adjunct to an endoscopic examination has been re-emphasized because of the increased prevalence of eosinophilic esophagitis (EoE). Many clinicians routinely biopsy the esophagus in patients with reflux-type symptoms to look for EoE in the setting of an endoscopy that does not reveal erosive changes. Unfortunately, differentiating GERD from EoE using only biopsy is difficult and risks making a diagnosis and instituting treatment without supportive data. Low eosinophil counts in the distal esophagus while suggestive of GERD are not specific. In addition, a high eosinophil count may be seen with GERD and respond to PPIs (PPI responsive eosinophilia) (31). The sensitivity of the other histologic findings; basal cell hyperplasia, elongation of the rete pegs, papillary elongation, and even neutrophils, are of limited clinical usefulness (32,33). There are no studies examining the efficacy of PPIs based on microscopic findings alone. The use of routine biopsy of the esophagus to diagnose GERD cannot be recommended in a patient with heartburn and a normal endoscopy based on current literature. In addition, the practice of obtaining mucosal biopsies from a normal appearing esophagogastric junction has not been demonstrated to be useful in GERD patients (34). Esophageal manometry is of limited value in the primary diagnosis of GERD. Neither a decreased lower esophageal sphincter pressure, nor the presence of a motility abnormality is specific enough to make a diagnosis of GERD. Manometry should be used to aid in placement of transnasal pH-impedance probes and is recommended before consideration of antireflux surgery primarily to rule out achalasia or severe hypomotility (scleroderma-like esophagus), conditions that would be contraindications to Nissen fundoplication, but not to tailor the operation. Ambulatory reflux monitoring (pH or impedance-pH) is the only test that allows for determining the presence of abnormal esophageal acid exposure, reflux frequency, and symptom association with reflux episodes. Performed with either a telemetry capsule (usually 48 h) or transnasal catheter (24 h), pH monitoring has excellent sensitivity (77–100%) and specificity (85–100%) in patients with erosive esophagitis; however, the sensitivity is lower in those with endoscopy-negative reflux symptoms (<71%) when a diagnostic test is more likely to be needed (24). A consensus statement (35) suggested that impedance added to pH monitoring increased the sensitivity of reflux monitoring to close to 90%. Telemetry capsule pH monitoring offers increased patient tolerability and the option to extend the monitoring period to 48 or perhaps to 96 h. The additional monitoring period allows for combining and on and off therapy study in selected situations and offers additional opportunity to correlate symptoms with acid reflux. Catheter-based monitoring allows for the addition of impedance and detection of weakly acidic or non-acid reflux. Optimal use of these two options is certainly debated as is whether to test on or off therapy. As a true diagnostic test (is abnormal acid exposure present) and for evaluation before considering surgery in a patient with NERD an off therapy test is recommended. The use of on and off therapy monitoring in refractory GERD is discussed subsequently. When symptom correlation is required, the decision is more difficult. The two symptom association measures most often used are symptom index (SI) and symptom association probability (SAP). Both have methodological shortcomings that have been reviewed elsewhere (36) and prospective data to validate the ability of these symptom association measures to predict response to treatment is scarce. Both the SI and SAP have been validated when pH monitoring is performed off therapy in a patient with heartburn. A positive test on therapy, coupled with a symptom relationship, theoretically suggests GERD as a cause for symptoms but outcome studies are lacking for any symptom other than heartburn. For patient management, a strongly positive SI or SAP may suggest the need for a therapeutic intervention and a negative result supports the notion that the patient's symptoms are unlikely to be due to reflux. However, these indices should not be used in isolation and other reflux monitoring parameters as well the patient's presentation have to be taken into account. The relationship between H. pylori infection and GERD is controversial. As such, a full discussion is beyond the scope of this article. One issue most often discussed is whether treatment of H. pylori should be altered because of an exacerbation of GERD and if patients on long-term PPIs require screening and subsequent eradication of the bug to prevent the possibility of increasing risk of gastric cancer. A meta-analysis of 12 studies found no increase in GERD (erosive esophagitis) in patients with dyspeptic symptoms who were eradicated compared with those not. This same study found, in subgroup analysis, patients with peptic ulcer disease might experience the new onset of GERD symptoms after H. pylori eradication (37). Concern for the use of long-term PPI therapy in patients with H. pylori infection has been raised because of the potential for development of atrophic gastritis in infected patients on long-term PPI (38). This study prompted a Food and Drug Administration (FDA) review panel that concluded that the evidence was not sufficient to recommend testing of all patients on long-term PPI. The flaws in this study and lack of observational data on negative outcomes lead us to recommend against screening of GERD patients for H. pylori despite the European recommendation in favor of screening (39). GERD is frequent during pregnancy, manifests as heartburn, and may begin in any trimester. One study found onset of 52% in the first trimester, 40% in the second trimester, and 8% in the third trimester (40). Among 607 pregnant women attending an antenatal clinic, 22% experienced heartburn in the first trimester, 39% in the second, and 72% in the third, whereas only 14% of these women reported mild heartburn before their pregnancy (41). Severity also increased throughout pregnancy. Significant predictors of heartburn are increasing gestational age, heartburn before pregnancy, and parity. Maternal age is inversely correlated with heartburn. Race, pre-pregnancy BMI, and weight gain in pregnancy do not correlate with the onset of heartburn. Despite its frequent occurrence during pregnancy, heartburn usually resolves after delivery (42). Pregnancy and amount of weight gain during pregnancy were risk factors for frequent GERD symptoms 1 year post delivery (43). No other GERD symptom has been studied in pregnancy. The diagnosis of GERD during pregnancy should be based on symptoms and treatment symptom-based. Additional diagnostic testing is generally not required for the majority of patients with suspected GERD. In the occasional pregnant patient who does require testing, upper endoscopy is the test of choice, but should be reserved for patients whose symptoms are refractory to medical therapy or who have suspected complications. If possible however, endoscopy should be delayed until after the first trimester. It is uncommon to require ambulatory pH monitoring during pregnancy. Management of GERDFigure: No Caption available.SUMMARY OF THE EVIDENCE Lifestyle interventions are part of therapy for GERD. (Table 3) Counseling is often provided regarding weight loss, head of bed elevation, tobacco and alcohol cessation, avoidance of late-night meals, and cessation of foods that can potentially aggravate reflux symptoms including caffeine, coffee, chocolate, spicy foods, highly acidic foods such as oranges and tomatoes, and foods with high fat content.Table 3: Efficacy of lifestyle interventions for GERDA systematic review (44) evaluated the effect of dietary and other lifestyle modifications on lower esophageal sphincter pressure, esophageal pH, and GERD symptoms. Consumption of tobacco (12 trials), chocolate (2 trials), and carbonated beverages (2 trials) and right lateral decubitus position (3 trials) were shown to lower pressure of the lower esophageal sphincter (LES), whereas consumption of alcohol (16 trials), coffee and caffeine (14 trials), spicy foods (2 trials), citrus (3 trials), and fatty foods (9 trials) had no effect. There was an increase in esophageal acid exposure times with tobacco and alcohol consumption in addition to ingestion of chocolate and fatty foods. However, tobacco and alcohol cessation (4 trials) were not shown to raise LESP, improve esophageal pH, or improve GERD symptoms. In addition, there have been no studies conducted to date that have shown clinical improvement in GERD symptoms or complications associated with cessation of coffee, caffeine, chocolate, spicy foods, citrus, carbonated beverages, fatty foods, or mint. A recent systematic review concluded that there was lack of evidence that consumption of carbonated beverages causes or provokes GERD (45). Weight gain even in subjects with a normal BMI has been associated with new onset of GERD symptoms (46). Multiple cohort studies have demonstrated reduction in GERD symptoms with weight loss (47,48). Roux-en-Y gastric bypass, but not vertical banded gastroplasty, has been demonstrated to be effective in reduction of GERD symptoms (49). A large case–control study based on the Nurses Health Cohort demonstrated a 40% reduction in frequent GERD symptoms for women who reduced their BMI by 3.5 or more compared with controls (46). Assumption of the recumbent position has been associated with worsening of esophageal pH values and GERD symptoms. Three randomized controlled trials have demonstrated improvement in GERD symptoms and esophageal pH values with head of bed elevation using blocks or foam wedges (50,51,52). Medical options for patients failing lifestyle interventions include antacids, histamine-receptor antagonists (H2RA), or PPI therapy. A meta-analysis published in 2010 demonstrated that the placebo response in GERD clinical trials approximated 20% and was lower in patients with erosive esophagitis (11%) and PPI trials (14%) compared with trials with H2RAs (25%) (53). PPI therapy has been associated with superior healing rates and decreased relapse rates compared with H2RAs and placebo for patients with erosive esophagitis (54). A 1997 meta-analysis demonstrated superior healing rates for all grades of erosive esophagitis using PPI therapy compared with H2RAs, sucralfate, or placebo (55). The mean (±s.d.) overall healing proportion irrespective of drug dose or treatment duration was highest with PPIs (84%±11%) vs H2RAs (52%±17%), sucralfate (39%±22%), or placebo (28%±16%). PPIs showed a significantly faster healing rate (12%/week) vs. H2RAs (6%/week) and placebo (3%/week). PPIs provided faster, more complete heartburn relief (11.5%/week) vs. H2RAs (6.4%/week) (35). PPIs are associated with a greater rate of symptom relief in patients with ERD (∼70–80%) compared to patients with NERD (where the symptom relief approximates 50–60%) (56,57). For patients with non-erosive reflux disease, a Cochrane systematic review demonstrated superiority for PPI therapy compared with H2RAs and prokinetics for heartburn relief (58). On the basis of 32 trials with over 9,700 participants, the relative risk (RR) for heartburn remission (the primary efficacy variable) in placebo-controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32–0.44), for H2RAs 0.77 (two trials, 95% CI 0.60–0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73–1.01). In a direct comparison, PPIs were more effective than H2RAs (seven trials, RR 0.66, 95% CI 0.60–0.73) and prokinetics (two trials, RR 0.53, 95% CI 0.32–0.87). There are currently seven available PPIs including three that can be obtained over-the-counter (omeprazole, lansoprazole, and omeprazole-sodium bicarbonate). Four are available only by prescription (rabeprazole, pantoprazole, esomeprazole, and dexlansoprazole). Meta-analyses fail to show significant difference in efficacy for symptom relief between PPIs (59). A meta-analysis published in 2006 examining efficacy of PPI therapy for healing of erosive esophagitis included 10 studies (15,316 patients) (except for omeprazole-sodium bicarbonate and dexlansoprazole) (59). At 8 weeks, there was a 5% (RR, 1.05; 95% CI 1.02–1.08) relative increase in the probability of healing of erosive esophagitis with esomeprazole, yielding an absolute risk reduction of 4% and number needed to treat (NNT) of 25. The calculated NNTs by LA grade of erosive esophagitis (grades A–D) were 50, 33, 14, and 8, respectively. Esomeprazole conferred an 8% (RR, 1.08; 95% CI 1.05–1.11) relative increase in the probability of GERD symptom relief at 4 weeks. The clinical importance of this small difference is unclear. All of the PPIs with the exception of omeprazole-sodium bicarbonate and dexlansoprazole, should be administered 30–60 min before meals to assure maximal efficacy. Omeprazole-sodium bicarbonate, an immediate-release PPI, has been demonstrated to more effectively control nocturnal gastric pH in the first 4 h of sleep compared with other PPIs when each is administered at bedtime (60). Whether this effect leads to any superior clinical outcomes including symptom control, requires further study. Dexlansoprazole is a dual delayed release PPI released in 2009. Comparative trials of dexlansoprazole compared only with lansoprazole 30 mg demonstrated superior control in esophageal pH values in one trial, and the convenience of being able to dose the drug any time of the day regardless of food intake (61). Superiority to lansoprazole in healing of erosive esophagitis was demonstrated in one trial, with non-inferiority in another study (62). As stated above, it would be expected that ∼70–80% of patients with ERD would demonstrate complete relief on PPI therapy and 60% of patients with NERD. Partial relief of GERD symptoms after a standard 8-week course of PPI therapy has been found in 30–40% of patients and does not differ in patients taking PPI once or twice daily. The evaluation and management of patients with incomplete response are discussed in the refractory GERD section. Risk factors for lack of symptom control have included patients with longer duration of disease, presence of hiatal hernia, extraesophageal symptoms, and lack of compliance (63). Delayed release PPIs are most effective in controlling intragastric pH when taken before a meal (64) and are generally less effective when taken at bedtime. The exceptions to this rule appear to be for the administration of dexlansoprazole (65), which appears to have similar efficacy in pH control regardless of meal timing, and omeprazole-sodium bicarbonate, which can control night-time pH when given at bedtime. Suboptimal dosing is common in practice (66). Although PPI switching is common in clinical practice, there is limited data to support this practice. Data from one randomized controlled trial demonstrated that in GERD patients refractory to once-daily lansoprazole, switching patients to esomeprazole therapy once daily was as effective as increasing to twice daily lansoprazole (67). There is no data to support switching PPIs more than once in partial or non-responders. Maintenance PPI therapy should be administered for GERD patients who continue to have symptoms after PPI is discontinued and in patients with complications including erosive esophagitis and Barrett's esophagus. In patients found to have NERD, two-third of the patients will demonstrate symptomatic relapse off of PPIs over time (68). For patients found to have LA grade B–C esophagitis, nearly 100% will relapse by 6 months (69). In patients found to have any length of BE, retrospective studies have suggested a decreased risk for dysplasia in patients continuing PPI usage (70). On the other hand, studies have demonstrated that patients with NERD and otherwise non-complicated GERD can be managed successfully with on-demand or intermittent PPI therapy. In a randomized controlled trial (71) published in 1999, 83% of NERD patients randomized to 20 mg of omeprazole on demand were in remission at 6 months compared with 56% of patients on placebo. In a systematic review of randomized controlled trials comparing on-demand PPI vs. placebo, 17 studies were included (5 in NERD patients, 4 with NERD and mild esophagitis, and 2 studies with ERD) (72). The symptom-free days for patients in the on-demand arms were equivalent to rates for patients on continuous PPI therapy and superior to placebo in patients with NERD, but not for patients with ERD. Step-down therapy to H2RAs is another acceptable option for NERD patients (73). Medical options for GERD patients with incomplete response to PPI therapy are limited. The addition of bedtime H2RA has been recommended for patients with symptoms refractory to PPI. This approach gained popularity after multiple intragastric pH studies demonstrated overnight pH control. One well-done study suggested potential tachyphylaxis of pH control occurring after a month of therapy (74). In light of this study and a lack of prospective clinical trial use of a bedtime H2RA might be most beneficial if dosed on as needed basis in patients with provocable night-time symptoms and patients with objective evidence on pH monitoring of overnight esophageal acid reflux despite optimal PPI use. Prokinetic therapy with metoclopramide in addition to PPI therapy is another option often considered for these patients. Metoclopramide has been shown to increase LESP, enhance esophageal peristalsis and augment gastric emptying (75). Clinical data showing additional benefit of metoclopramide to PPI therapy has not been adequately studied. Combination therapy of metoclopramide with H2RA has not been shown to be more effective compared with H2RA or prokinetic therapy alone (76). The usage of metoclopramide has been limited by central nervous system side effects including drowsiness, agitation, irritability, depression, dystonic reactions, and tardive dyskinesia in <1% of patients (77). Practically speaking, in the absence of gastroparesis, there is no clear role for metoclopramide in GERD. For the small number of patients who may benefit from a prokinetic, another option is domperidone, a peripherally acting dopamine agonist, which

Body-Mass Index and Symptoms of Gastroesophageal Reflux in Women

2006-05-31

Brian C. Jacobson , Samuel C. Somers , Charles S. Fuchs +2 more

Overweight and obese persons are at increased risk for gastroesophageal reflux disease. An association between body-mass index (BMI)--the weight in kilograms divided by the square of the height in meters … Overweight and obese persons are at increased risk for gastroesophageal reflux disease. An association between body-mass index (BMI)--the weight in kilograms divided by the square of the height in meters - and symptoms of gastroesophageal reflux disease in persons of normal weight has not been demonstrated.In 2000, we used a supplemental questionnaire to determine the frequency, severity, and duration of symptoms of gastroesophageal reflux disease among randomly selected participants in the Nurses' Health Study. After categorizing women according to BMI as measured in 1998, we used logistic-regression models to study the association between BMI and symptoms of gastroesophageal reflux disease.Of 10,545 women who completed the questionnaire (response rate, 86 percent), 2310 (22 percent) reported having symptoms at least once a week, and 3419 (55 percent of those who had any symptoms) described their symptoms as moderate in severity. We observed a dose-dependent relationship between increasing BMI and frequent reflux symptoms (multivariate P for trend <0.001). As compared with women who had a BMI of 20.0 to 22.4, the multivariate odds ratios for frequent symptoms were 0.67 (95 percent confidence interval, 0.48 to 0.93) for a BMI of less than 20.0, 1.38 (95 percent confidence interval, 1.13 to 1.67) for a BMI of 22.5 to 24.9, 2.20 (95 percent confidence interval, 1.81 to 2.66) for a BMI of 25.0 to 27.4, 2.43 (95 percent confidence interval, 1.96 to 3.01) for a BMI of 27.5 to 29.9, 2.92 (95 percent confidence interval, 2.35 to 3.62) for a BMI of 30.0 to 34.9, and 2.93 (95 percent confidence interval, 2.24 to 3.85) for a BMI of 35.0 or more. Even in women with a normal baseline BMI, an increase in BMI of more than 3.5, as compared with no weight changes, was associated with an increased risk of frequent symptoms of reflux (odds ratio, 2.80; 95 percent confidence interval, 1.63 to 4.82).BMI is associated with symptoms of gastroesophageal reflux disease in both normal-weight and overweight women. Even moderate weight gain among persons of normal weight may cause or exacerbate symptoms of reflux.

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Mechanism of gastroesophageal reflux in recumbent asymptomatic human subjects.

1980-02-01

John Dent , W. J. Dodds , R.H. Friedman +4 more

We investigated the mechanism of gastroesophageal reflux (GER) in 10 health volunteer subjects. Continuous recordings of intraluminal esophageal pH and pressure were obtained on two consecutive nights from 6:00 p.m. … We investigated the mechanism of gastroesophageal reflux (GER) in 10 health volunteer subjects. Continuous recordings of intraluminal esophageal pH and pressure were obtained on two consecutive nights from 6:00 p.m. to 6:30 a.m. in each subject. During each study, the subject remained recumbent, except to eat a standardized meal after 1 h of basal recording. A manometric assembly with seven recording lumens monitored: (a) lower esophageal sphincter (LES) pressure via a sleeve device 6.5 cm in length, (b) esophageal-body motor activity, (c) swallowing activity in the pharynx, and (d) gastric pressure. An electrode 5 cm above the LES recorded esophageal pH. Sleep was monitored by electroencephalogram. All subjects showed wide variations of basal LES pressure. GER was not related to low steady-state basal LES pressure, but rather occurred during transient 5-30 s episodes of inappropriate complete LES relaxation. The inappropriate LES relaxations were usually either spontaneous or immediately followed appropriate sphincter relaxation induced by swallowing. The majority of GER episodes occurred within the first 3 h after eating. During the night LES relaxation and GER occurred only during transient arousals from sleep or when the subjects were fully awake, but not during stable sleep. After GER the esophagus was generally cleared of refluxed acid by primary peristalsis and less frequently by secondary peristalsis. Nonperistaltic contractions were less effective than peristalsis for clearing acid from the esophagus. We conclude that in asymptomatic recumbent subjects GER is related to transient inappropriate LES relaxations rather than to low steady-state basal LES pressure and also, that primary perstalsis is the major mechanism that clears the esophagus of refluxed material.

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Measurement of gastrointestinal pH profiles in normal ambulant human subjects.

1988-08-01

D. F. Evans , Geoffrey W. Pye , R Bramley +3 more

Gastrointestinal (GI) pH has been measured in 66 normal subjects using a pH sensitive radiotelemetry capsule passing freely through the gastrointestinal tract. Signals were recorded with a portable solid state … Gastrointestinal (GI) pH has been measured in 66 normal subjects using a pH sensitive radiotelemetry capsule passing freely through the gastrointestinal tract. Signals were recorded with a portable solid state receiver and recording system, enabling unconstrained measurements with normal ambulatory activities for up to 48 h during normal GI transit. Capsule position in the gut was monitored by surface location using a directional detector. Gastric pH was highly acidic (range 1.0-2.5) in all subjects. The mean pH in the proximal small intestine was 6.6 (0.5) for the first hour of intestinal recording. By comparison the mean pH in the terminal ileum was 7.5 (0.4) (p less than 0.001). In all subjects there was a sharp fall in pH to a mean of 6.4 (0.4) (p less than 0.001) as the capsule passed into the caecum. Values are means (SD). pH then rose progressively from the right to the left colon with a final mean value of 7.0 (0.7) (p less than 0.001).

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Epidemiology of gastro-oesophageal reflux disease: a systematic review

2005-04-14

John Dent

A systematic review of the epidemiology of gastro-oesophageal reflux disease (GORD) has been performed, applying strict criteria for quality of studies and the disease definition used. The prevalence and incidence … A systematic review of the epidemiology of gastro-oesophageal reflux disease (GORD) has been performed, applying strict criteria for quality of studies and the disease definition used. The prevalence and incidence of GORD was estimated from 15 studies which defined GORD as at least weekly heartburn and/or acid regurgitation and met criteria concerning sample size, response rate, and recall period. Data on factors associated with GORD were also evaluated. An approximate prevalence of 10-20% was identified for GORD, defined by at least weekly heartburn and/or acid regurgitation in the Western world while in Asia this was lower, at less than 5%. The incidence in the Western world was approximately 5 per 1000 person years. A number of potential risk factors (for example, an immediate family history and obesity) and comorbidities (for example, respiratory diseases and chest pain) associated with GORD were identified. Data reported in this systematic review can be interpreted with confidence as reflecting the epidemiology of "true" GORD. The disease is more common in the Western world than in Asia, and the low rate of incidence relative to prevalence reflects its chronicity. The small number of studies eligible for inclusion in this review highlights the need for global consensus on a symptom based definition of GORD.

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The forced oscillation technique in clinical practice: methodology, recommendations and future developments

2003-12-01

Ellie Oostveen , D MacLeod , H. Lorino +4 more

The forced oscillation technique (FOT) is a noninvasive method with which to measure respiratory mechanics. FOT employs small-amplitude pressure oscillations superimposed on the normal breathing and therefore has the advantage … The forced oscillation technique (FOT) is a noninvasive method with which to measure respiratory mechanics. FOT employs small-amplitude pressure oscillations superimposed on the normal breathing and therefore has the advantage over conventional lung function techniques that it does not require the performance of respiratory manoeuvres. The present European Respiratory Society Task Force Report describes the basic principle of the technique and gives guidelines for the application and interpretation of FOT as a routine lung function test in the clinical setting, for both adult and paediatric populations. FOT data, especially those measured at the lower frequencies, are sensitive to airway obstruction, but do not discriminate between obstructive and restrictive lung disorders. There is no consensus regarding the sensitivity of FOT for bronchodilation testing in adults. Values of respiratory resistance have proved sensitive to bronchodilation in children, although the reported cutoff levels remain to be confirmed in future studies. Forced oscillation technique is a reliable method in the assessment of bronchial hyperresponsiveness in adults and children. Moreover, in contrast with spirometry where a deep inspiration is needed, forced oscillation technique does not modify the airway smooth muscle tone. Forced oscillation technique has been shown to be as sensitive as spirometry in detecting impairments of lung function due to smoking or exposure to occupational hazards. Together with the minimal requirement for the subject's cooperation, this makes forced oscillation technique an ideal lung function test for epidemiological and field studies. Novel applications of forced oscillation technique in the clinical setting include the monitoring of respiratory mechanics during mechanical ventilation and sleep.

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Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease

2005-01-01

Kenneth R. DeVault , Donald O. Castell

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be … Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.

The Montreal Definition and Classification of Gastroesophageal Reflux Disease: A Global Evidence-Based Consensus

2006-08-01

Nimish Vakil , Sander Veldhuyzen van Zanten , Peter J. Kahrilas +2 more

A globally acceptable definition and classification of gastroesophageal reflux disease (GERD) is desirable for research and clinical practice. The aim of this initiative was to develop a consensus definition and … A globally acceptable definition and classification of gastroesophageal reflux disease (GERD) is desirable for research and clinical practice. The aim of this initiative was to develop a consensus definition and classification that would be useful for patients, physicians, and regulatory agencies.A modified Delphi process was employed to reach consensus using repeated iterative voting. A series of statements was developed by a working group of five experts after a systematic review of the literature in three databases (Embase, Cochrane trials register, Medline). Over a period of 2 yr, the statements were developed, modified, and approved through four rounds of voting. The voting group consisted of 44 experts from 18 countries. The final vote was conducted on a 6-point scale and consensus was defined a priori as agreement by two-thirds of the participants.The level of agreement strengthened throughout the process with two-thirds of the participants agreeing with 86%, 88%, 94%, and 100% of statements at each vote, respectively. At the final vote, 94% of the final 51 statements were approved by 90% of the Consensus Group, and 90% of statements were accepted with strong agreement or minor reservation. GERD was defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The disease was subclassified into esophageal and extraesophageal syndromes. Novel aspects of the new definition include a patient-centered approach that is independent of endoscopic findings, subclassification of the disease into discrete syndromes, and the recognition of laryngitis, cough, asthma, and dental erosions as possible GERD syndromes. It also proposes a new definition for suspected and proven Barrett's esophagus.Evidence-based global consensus definitions are possible despite differences in terminology and language, prevalence, and manifestations of the disease in different countries. A global consensus definition for GERD may simplify disease management, allow collaborative research, and make studies more generalizable, assisting patients, physicians, and regulatory agencies.

Long-term Outcome of Medical and Surgical Therapies for Gastroesophageal Reflux Disease

2001-05-09

Stuart J. Spechler , Edward Lee , Dennis J. Ahnen +7 more

ContextSevere gastroesophageal reflux disease (GERD) is a lifelong problem that can be complicated by peptic esophageal stricture and adenocarcinoma of the esophagus.ObjectiveTo determine the long-term outcome of medical and surgical … ContextSevere gastroesophageal reflux disease (GERD) is a lifelong problem that can be complicated by peptic esophageal stricture and adenocarcinoma of the esophagus.ObjectiveTo determine the long-term outcome of medical and surgical therapies for GERD.Design and SettingFollow-up study conducted from October 1997 through October 1999 of a prospective randomized trial of medical and surgical antireflux treatments in patients with complicated GERD. Mean (median) duration of follow-up was 10.6 years (7.3 years) for medical patients and 9.1 years (6.3 years) for surgical patients.ParticipantsTwo hundred thirty-nine (97%) of the original 247 study patients were found (79 were confirmed dead). Among the 160 survivors (157 men and 3 women; mean [SD] age, 67 [12] years), 129 (91 in the medical treatment group and 38 in the surgical treatment group) participated in the follow-up.Main Outcome MeasuresUse of antireflux medication, Gastroesophageal Reflux Disease Activity Index (GRACI) scores, grade of esophagitis, frequency of treatment of esophageal stricture, frequency of subsequent antireflux operations, 36-item Short Form health survey (SF-36) scores, satisfaction with antireflux therapy, survival, and incidence of esophageal adenocarcinoma, compared between the medical antireflux therapy group and the fundoplication surgery group. Information on cause of death was obtained from autopsy results, hospital records, and death certificates.ResultsEighty-three (92%) of 90 medical patients and 23 (62%) of 37 surgical patients reported that they used antireflux medications regularly (P<.001). During a 1-week period after discontinuation of medication, mean (SD) GRACI symptom scores were significantly lower in the surgical treatment group (82.6 [17.5] vs 96.7 [21.4] in the medical treatment group; P = .003). However, no significant differences between the groups were found in grade of esophagitis, frequency of treatment of esophageal stricture and subsequent antireflux operations, SF-36 standardized physical and mental component scale scores, and overall satisfaction with antireflux therapy. Survival during a period of 140 months was decreased significantly in the surgical vs the medical treatment group (relative risk of death in the medical group, 1.57; 95% confidence interval, 1.01-2.46; P = .047), largely because of excess deaths from heart disease. Patients with Barrett esophagus at baseline developed esophageal adenocarcinomas at an annual rate of 0.4%, whereas these cancers developed in patients without Barrett esophagus at an annual rate of only 0.07%. There was no significant difference between groups in incidence of esophageal cancer.ConclusionThis study suggests that antireflux surgery should not be advised with the expectation that patients with GERD will no longer need to take antisecretory medications or that the procedure will prevent esophageal cancer among those with GERD and Barrett esophagus.

The endoscopic assessment of esophagitis: A progress report on observer agreement

1996-07-01

David Armstrong , J R Bennett , A.L. Blum +7 more

Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography<sup>1</sup>

2012-01-16

Albert J. Bredenoord , Mark Fox , Peter J. Kahrilas +3 more

The Chicago Classification of esophageal motility was developed to facilitate the interpretation of clinical high resolution esophageal pressure topography (EPT) studies, concurrent with the widespread adoption of this technology into … The Chicago Classification of esophageal motility was developed to facilitate the interpretation of clinical high resolution esophageal pressure topography (EPT) studies, concurrent with the widespread adoption of this technology into clinical practice. The Chicago Classification has been an evolutionary process, molded first by published evidence pertinent to the clinical interpretation of high resolution manometry (HRM) studies and secondarily by group experience when suitable evidence is lacking.This publication summarizes the state of our knowledge as of the most recent meeting of the International High Resolution Manometry Working Group in Ascona, Switzerland in April 2011. The prior iteration of the Chicago Classification was updated through a process of literature analysis and discussion. The major changes in this document from the prior iteration are largely attributable to research studies published since the prior iteration, in many cases research conducted in response to prior deliberations of the International High Resolution Manometry Working Group. The classification now includes criteria for subtyping achalasia, EGJ outflow obstruction, motility disorders not observed in normal subjects (Distal esophageal spasm, Hypercontractile esophagus, and Absent peristalsis), and statistically defined peristaltic abnormalities (Weak peristalsis, Frequent failed peristalsis, Rapid contractions with normal latency, and Hypertensive peristalsis). The Chicago Classification is an algorithmic scheme for diagnosis of esophageal motility disorders from clinical EPT studies. Moving forward, we anticipate continuing this process with increased emphasis placed on natural history studies and outcome data based on the classification.

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Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification

1999-08-01

Lars Lundell , John Dent , J R Bennett +7 more

BACKGROUND Endoscopic oesophageal changes are diagnostically helpful and identify patients exposed to the risk of disease chronicity. However, there is a serious lack of agreement about how to describe and … BACKGROUND Endoscopic oesophageal changes are diagnostically helpful and identify patients exposed to the risk of disease chronicity. However, there is a serious lack of agreement about how to describe and classify the appearance of reflux oesophagitis AIMS To examine the reliability of criteria that describe the circumferential extent of mucosal breaks and to evaluate the functional and clinical correlates of patients with reflux disease whose oesophagitis was graded according to the Los Angeles system. METHODS Forty six endoscopists from different countries used a detailed worksheet to evaluate endoscopic video recordings from 22 patients with the full range of severity of reflux oesophagitis. In separate studies, Los Angeles system gradings were correlated with 24 hour oesophageal pH monitoring (178 patients), and with clinical trials of omeprazole treatment (277 patients). RESULTS Evaluation of circumferential extent of oesophagitis by the criterion of whether mucosal breaks extended between the tops of mucosal folds, gave acceptable agreement (mean κ value 0.4) among observers. This approach is used in the Los Angeles system. An alternative approach of grouping the circumferential extent of mucosal breaks as occupying 0–25%, 26–50%, 51–75%, 76–99%, or 100% of the oesophageal circumference, gave unacceptably high interobserver variation (mean κ values 0–0.15) for all but the lowest category of extent (mean κ value 0.4). Severity of oesophageal acid exposure was significantly (p<0.001) related to the severity grade of oesophagitis. Preteatment oesophagitis grades A–C were related to heartburn severity (p<0.01), outcomes of omeprazole (10 mg daily) treatment (p<0.01), and the risk for symptom relapse off therapy over six months (p<0.05). CONCLUSIONS Results add further support to previous studies for the clinical utility of the Los Angeles system for endoscopic grading of oesophagitis.

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Pneumatic Dilation versus Laparoscopic Heller's Myotomy for Idiopathic Achalasia

2011-05-11

Guy E. Boeckxstaens , Vito Annese , Stanislas Bruley des Varannes +7 more

Many experts consider laparoscopic Heller's myotomy (LHM) to be superior to pneumatic dilation for the treatment of achalasia, and LHM is increasingly considered to be the treatment of choice for … Many experts consider laparoscopic Heller's myotomy (LHM) to be superior to pneumatic dilation for the treatment of achalasia, and LHM is increasingly considered to be the treatment of choice for this disorder.We randomly assigned patients with newly diagnosed achalasia to pneumatic dilation or LHM with Dor's fundoplication. Symptoms, including weight loss, dysphagia, retrosternal pain, and regurgitation, were assessed with the use of the Eckardt score (which ranges from 0 to 12, with higher scores indicating more pronounced symptoms). The primary outcome was therapeutic success (a drop in the Eckardt score to ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for retreatment, pressure at the lower esophageal sphincter, esophageal emptying on a timed barium esophagogram, quality of life, and the rate of complications.A total of 201 patients were randomly assigned to pneumatic dilation (95 patients) or LHM (106). The mean follow-up time was 43 months (95% confidence interval [CI], 40 to 47). In an intention-to-treat analysis, there was no significant difference between the two groups in the primary outcome; the rate of therapeutic success with pneumatic dilation was 90% after 1 year of follow-up and 86% after 2 years, as compared with a rate with LHM of 93% after 1 year and 90% after 2 years (P=0.46). After 2 years of follow-up, there was no significant between-group difference in the pressure at the lower esophageal sphincter (LHM, 10 mm Hg [95% CI, 8.7 to 12]; pneumatic dilation, 12 mm Hg [95% CI, 9.7 to 14]; P=0.27); esophageal emptying, as assessed by the height of barium-contrast column (LHM, 1.9 cm [95% CI, 0 to 6.8]; pneumatic dilation, 3.7 cm [95% CI, 0 to 8.8]; P=0.21); or quality of life. Similar results were obtained in the per-protocol analysis. Perforation of the esophagus occurred in 4% of the patients during pneumatic dilation, whereas mucosal tears occurred in 12% during LHM. Abnormal exposure to esophageal acid was observed in 15% and 23% of the patients in the pneumatic-dilation and LHM groups, respectively (P=0.28).After 2 years of follow-up, LHM, as compared with pneumatic dilation, was not associated with superior rates of therapeutic success. (European Achalasia Trial Netherlands Trial Register number, NTR37, and Current Controlled Trials number, ISRCTN56304564.).

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Gastro-oesophageal reflux monitoring: review and consensus report on detection and definitions of acid, non-acid, and gas reflux

2004-06-12

Daniel Sifrim , D Castell , J Dent +1 more

To date, most concepts on the frequency of gastro-oesophageal reflux episodes and the efficiency of the antireflux barrier have been based on inferences derived from measurement of oesophageal pH. The … To date, most concepts on the frequency of gastro-oesophageal reflux episodes and the efficiency of the antireflux barrier have been based on inferences derived from measurement of oesophageal pH. The development of intraluminal impedance monitoring has highlighted the fact that pH monitoring does not detect all gastro-oesophageal reflux events when little or no acid is present in the refluxate, even if special pH tracing analysis criteria are used. In November 2002, a workshop took place at which 11 specialists in the field of gastro-oesophageal reflux disease discussed and criticised all currently available techniques for measurement of reflux. Here, a summary of their conclusions and recommendations of how to achieve the best results from the various techniques now available for reflux measurement is presented.

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Achalasia: A New Clinically Relevant Classification by High-Resolution Manometry

2008-07-23

John E. Pandolfino , Monika A. Kwiatek , Thomas B. Nealis +3 more

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Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review

2013-07-13

Hashem B. El–Serag , Stephen Sweet , Christopher Winchester +1 more

<h3>Objective</h3> To update the findings of the 2005 systematic review of population-based studies assessing the epidemiology of gastro-oesophageal reflux disease (GERD). <h3>Design</h3> PubMed and Embase were screened for new references … <h3>Objective</h3> To update the findings of the 2005 systematic review of population-based studies assessing the epidemiology of gastro-oesophageal reflux disease (GERD). <h3>Design</h3> PubMed and Embase were screened for new references using the original search strings. Studies were required to be population-based, to include ≥200 individuals, to have response rates ≥50% and recall periods <12 months. GERD was defined as heartburn and/or regurgitation on at least 1 day a week, or according to the Montreal definition, or diagnosed by a clinician. Temporal and geographic trends in disease prevalence were examined using a Poisson regression model. <h3>Results</h3> 16 studies of GERD epidemiology published since the original review were found to be suitable for inclusion (15 reporting prevalence and one reporting incidence), and were added to the 13 prevalence and two incidence studies found previously. The range of GERD prevalence estimates was 18.1%–27.8% in North America, 8.8%–25.9% in Europe, 2.5%–7.8% in East Asia, 8.7%–33.1% in the Middle East, 11.6% in Australia and 23.0% in South America. Incidence per 1000 person-years was approximately 5 in the overall UK and US populations, and 0.84 in paediatric patients aged 1–17 years in the UK. Evidence suggests an increase in GERD prevalence since 1995 (p<0.0001), particularly in North America and East Asia. <h3>Conclusions</h3> GERD is prevalent worldwide, and disease burden may be increasing. Prevalence estimates show considerable geographic variation, but only East Asia shows estimates consistently lower than 10%.

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Meta-Analysis: Obesity and the Risk for Gastroesophageal Reflux Disease and Its Complications

2005-08-02

Howard Hampel , Neena S. Abraham , Hashem B. El–Serag

Background: The association of body mass index and gastroesophageal reflux disease (GERD), including its complications (esophagitis, Barrett esophagus, and esophageal adenocarcinoma), is unclear. Purpose: To conduct a systematic review and … Background: The association of body mass index and gastroesophageal reflux disease (GERD), including its complications (esophagitis, Barrett esophagus, and esophageal adenocarcinoma), is unclear. Purpose: To conduct a systematic review and meta-analysis to estimate the magnitude and determinants of an association between obesity and GERD symptoms, erosive esophagitis, Barrett esophagus, and adenocarcinoma of the esophagus and of the gastric cardia. Data Sources: MEDLINE search between 1966 and October 2004 for published full studies. Study Selection: Studies that provided risk estimates and met criteria on defining exposure and reporting outcomes and sample size. Data Extraction: Two investigators independently performed standardized search and data abstraction. Unadjusted and adjusted odds ratios for individual outcomes were obtained or calculated for each study and were pooled by using a random-effects model. Data Synthesis: Nine studies examined the association of body mass index (BMI) with GERD symptoms. Six of these studies found statistically significant associations. Six of 7 studies found significant associations of BMI with erosive esophagitis, 6 of 7 found significant associations with esophageal adenocarcinoma, and 4 of 6 found significant associations with gastric cardia adenocarcinoma. In data from 8 studies, there was a trend toward a dose–response relationship with an increase in the pooled adjusted odds ratios for GERD symptoms of 1.43 (95% CI, 1.158 to 1.774) for BMI of 25 kg/m2 to 30 kg/m2 and 1.94 (CI, 1.468 to 2.566) for BMI greater than 30 kg/m2. Similarly, the pooled adjusted odds ratios for esophageal adenocarcinoma for BMI of 25 kg/m2 to 30 kg/m2 and BMI greater than 30 kg/m2 were 1.52 (CI, 1.147 to 2.009) and 2.78 (CI, 1.850 to 4.164), respectively. Limitations: Heterogeneity in the findings was present, although it was mostly in the magnitude of statistically significant positive associations. No studies in this review examined the association between Barrett esophagus and obesity. Conclusion: Obesity is associated with a statistically significant increase in the risk for GERD symptoms, erosive esophagitis, and esophageal adenocarcinoma. The risk for these disorders seems to progressively increase with increasing weight.

Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture

2006-12-26

Yu‐Xiao Yang , James D. Lewis , Solomon Epstein +1 more

Context Proton pump inhibitors (PPIs) may interfere with calcium absorption through induction of hypochlorhydria but they also may reduce bone resorption through inhibition of osteoclastic vacuolar proton pumps.Objective To determine … Context Proton pump inhibitors (PPIs) may interfere with calcium absorption through induction of hypochlorhydria but they also may reduce bone resorption through inhibition of osteoclastic vacuolar proton pumps.Objective To determine the association between PPI therapy and risk of hip fracture. Design, Setting, and PatientsA nested case-control study was conducted using the General Practice Research Database (1987-2003), which contains information on patients in the United Kingdom.The study cohort consisted of users of PPI therapy and nonusers of acid suppression drugs who were older than 50 years.Cases included all patients with an incident hip fracture.Controls were selected using incidence density sampling, matched for sex, index date, year of birth, and both calendar period and duration of up-to-standard follow-up before the index date.For comparison purposes, a similar nested case-control analysis for histamine 2 receptor antagonists was performed. Main Outcome Measure The risk of hip fractures associated with PPI use.Results There were 13 556 hip fracture cases and 135 386 controls.The adjusted odds ratio (AOR) for hip fracture associated with more than 1 year of PPI therapy was 1.44 (95% confidence interval [CI], 1.30-1.59).The risk of hip fracture was significantly increased among patients prescribed long-term high-dose PPIs (AOR, 2.65; 95% CI, 1.80-3.90;PϽ.001).The strength of the association increased with increasing duration of PPI therapy (AOR for 1 year, 1.22 [95% CI, 1.15-1.30]; 2 years, 1.41 [95% CI, 1.28-1.56];3 years, 1.54 [95% CI, 1.37-1.73];and 4 years, 1.59 [95% CI, 1.39-1.80];PϽ.001 for all comparisons). ConclusionLong-term PPI therapy, particularly at high doses, is associated with an increased risk of hip fracture.

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines

2018-01-26

Rachel Rosen , Yvan Vandenplas , Maartje Singendonk +7 more

ABSTRACT This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) … ABSTRACT This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3‐day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.

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Proton pump inhibitors alter the composition of the gut microbiota

2015-12-30

Matthew Jackson , Julia K. Goodrich , Maria-Emanuela Maxan +7 more

<h3>Objective</h3> Proton pump inhibitors (PPIs) are drugs used to suppress gastric acid production and treat GI disorders such as peptic ulcers and gastro-oesophageal reflux. They have been considered low risk, … <h3>Objective</h3> Proton pump inhibitors (PPIs) are drugs used to suppress gastric acid production and treat GI disorders such as peptic ulcers and gastro-oesophageal reflux. They have been considered low risk, have been widely adopted, and are often over-prescribed. Recent studies have identified an increased risk of enteric and other infections with their use. Small studies have identified possible associations between PPI use and GI microbiota, but this has yet to be carried out on a large population-based cohort. <h3>Design</h3> We investigated the association between PPI usage and the gut microbiome using 16S ribosomal RNA amplification from faecal samples of 1827 healthy twins, replicating results within unpublished data from an interventional study. <h3>Results</h3> We identified a significantly lower abundance in gut commensals and lower microbial diversity in PPI users, with an associated significant increase in the abundance of oral and upper GI tract commensals. In particular, significant increases were observed in Streptococcaceae. These associations were replicated in an independent interventional study and in a paired analysis between 70 monozygotic twin pairs who were discordant for PPI use. We propose that the observed changes result from the removal of the low pH barrier between upper GI tract bacteria and the lower gut. <h3>Conclusions</h3> Our findings describe a significant impact of PPIs on the gut microbiome and should caution over-use of PPIs, and warrant further investigation into the mechanisms and their clinical consequences.

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The Esophagogastric Junction

1997-03-27

Ravinder K. Mittal , David H. Balaban

The lower esophageal sphincter regulates the flow of food between the esophagus and the stomach. It is now clear that both the intrinsic smooth muscle of the distal esophagus and … The lower esophageal sphincter regulates the flow of food between the esophagus and the stomach. It is now clear that both the intrinsic smooth muscle of the distal esophagus and the skeletal muscle of the crural diaphragm constitute the sphincter mechanism at the lower end of the esophagus.1 Furthermore, in normal subjects and patients with reflux esophagitis, transient relaxation of both sphincters rather than diminished lower esophageal sphincter pressure is the major mechanism of gastroesophageal reflux.2 In this article we review the current understanding of the physiology of the sphincter mechanism at the esophagogastric junction and its relation to esophageal . . .

Gastroduodenal Disorders

2016-05-01

Vincenzo Stanghellini , Francis K.L. Chan , William L. Hasler +4 more

Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux.

1974-10-01

Johnson Lf , DeMeester Tr

The Risks and Benefits of Long-term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association

2017-03-01

Daniel E. Freedberg , Lawrence S. Kim , Yu‐Xiao Yang

Modern diagnosis of GERD: the Lyon Consensus

2018-02-03

C. Prakash Gyawali , Peter J. Kahrilas , Edoardo Savarino +7 more

Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. … Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.

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Esophageal motility disorders on high‐resolution manometry: Chicago classification version 4.0<sup>©</sup>

2020-12-29

Rena Yadlapati , Peter J. Kahrilas , Mark Fox +7 more

Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal … Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.

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Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

2009-10-01

Yvan Vandenplas , Colin D. Rudolph , Carlo Di Lorenzo +7 more

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management … To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

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Mid-term outcomes of the patients of achalasia cardia undergoing laparoscopic Heller’s myotomy with angle of his accentuation versus laparoscopic Heller’s myotomy with Toupet’s fundoplication

2025-06-25

Sonali Mittal , Aditya Kumar , Manjunath Bale +4 more | Surgical Endoscopy

Pathophysiology of GERD

2025-06-25

Luisa Bertin , Vincenzo Savarino , Elisa Marabotto +3 more | Digestion

Background: Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disorder caused by the retrograde flow of gastric contents into the esophagus, leading to bothersome symptoms and complications. Its pathophysiology is … Background: Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disorder caused by the retrograde flow of gastric contents into the esophagus, leading to bothersome symptoms and complications. Its pathophysiology is complex and multifactorial, and recent research has aimed to explain the heterogeneity of GERD phenotypes, each influenced by different underlying mechanisms that contribute to symptom presentation and disease progression. Summary: GERD arises from an imbalance between defensive mechanisms and disruptive factors. Key pathophysiological contributors include esophageal gastric junction dysfunction, transient lower esophageal sphincter (LES) relaxations, esophageal motility abnormalities, delayed gastric emptying, and thoraco-abdominal pressure gradients. Mucosal damage is exacerbated by prolonged exposure to acid and bile, pepsin activity, and impaired esophageal volume and chemical clearance. Additionally, central and peripheral neural modulation influence symptom perception, with heightened visceral sensitivity and esophageal hypervigilance playing significant roles in symptom severity and treatment response. Emerging diagnostic techniques such as high-resolution manometry (HRM), impedance-pH monitoring, and EndoFLIP® are improving our ability to identify specific pathophysiological abnormalities, leading to more personalized approaches to GERD management.

Gastric-Emptying Pitfalls in Nuclear Medicine

2025-06-24

Sara G. Johnson | Journal of Nuclear Medicine Technology

How to do a Thoracoscopic-Laparoscopic Surgery for a Middle Thoracic Esophageal Diverticulum with Underlying Achalasia

2025-06-24

Sabine Rinaldi , Pietro Maria Lombardi , Paolo De Martini +7 more | Indian Journal of Surgery

DOENÇA DO REFLUXO GASTROESOFÁGICO: FISIOPATOLOGIA, DIAGNÓSTICO E TRATAMENTO

2025-06-24

LETÍCIA SCORTEGAGNA , GABRIELA SEQUEIRA DE CAMPOS MORAIS , MARIA FERNANDA FLORES BARBOSA +6 more | Editora Pasteur eBooks

DOENÇA DO REFLUXO GASTROESOFÁGICO: FISIOPATOLOGIA, DIAGNÓSTICO E TRATAMENTO

2025-06-24

Andrea Vásquez-García , EDUARDA EICKHOFF GIRARDI , EDUARDA SCHLEDER PICCOLI +7 more | Editora Pasteur eBooks

Does Anti-Reflux Surgery Improve Outcomes in Isolated Laryngopharyngeal Reflux? A Systematic Review

2025-06-23

Ramesh De Silva , Amy Hort , Mina Guirgis +1 more | Current Surgery Reports

Clinical Indications and Diagnostic Yield of Transfontanelle Ultrasound in 346 Infants: A Retrospective Single-Center Study

2025-06-23

Selcan Öztürk , Ümmügülsüm Özgül Gümüş | The Journal of Pediatric Academy

Multilayered oesophageal flow in the presence of a balloon catheter: application to achalasia

2025-06-23

Sanjay Kumar Pandey , Anupam Kumar Pandey | The European Physical Journal Plus

Outcome reporting in studies of paediatric achalasia: A systematic review

2025-06-22

Jonathan J. Neville , Sierra Schaffer , Simon Eaton +1 more | Journal of Pediatric Gastroenterology and Nutrition

Abstract Objectives Paediatric achalasia is a rare condition associated with significant morbidity. A core outcome set (COS) would standardise reporting, enable comparison of data sets, and focus research efforts; ultimately … Abstract Objectives Paediatric achalasia is a rare condition associated with significant morbidity. A core outcome set (COS) would standardise reporting, enable comparison of data sets, and focus research efforts; ultimately improving care for children with achalasia. We aimed to identify outcomes currently reported in studies of paediatric achalasia to inform outcomes for a COS. Methods A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐analysis guidelines. Studies investigating children ≤18 years of age with a diagnosis of achalasia were included. Primary and secondary outcomes were recorded and assigned to OMERACT core areas. The study was pre‐registered (PROSPERO: CRD42024509855). Results Sixty‐two studies were included in this review, consisting of 54 retrospective and 8 prospective studies. Median cohort size was 20 patients (inter‐quartile range: 13–28). Forty‐eight unique outcomes were reported. The most common outcomes reported were intra‐operative complications (65%, 40 studies), post‐operative complications (58%, 36 studies) and length of stay (58%, 36 studies). A primary outcome was specified in 12 studies (19%), the most common was the Eckardt score (13%) in 8 studies. Studies least frequently reported outcomes in the death (21%, 13 studies) and pathophysiological manifestations (35%, 22 studies) core areas. Conclusions The studies included in this review were predominantly small and retrospective. Of the few studies that specified a primary outcome, the majority used the Eckardt score, which is unvalidated in children. Outcomes relevant to pathophysiological manifestations, life impact and survival were under‐reported. A COS for paediatric achalasia, involving key stakeholders, would ensure that patient‐relevant outcomes were reported, reduce heterogeneity and facilitate meta‐analysis.

Correction to Pyloroplasty With Fundoplication in the Treatment of Combined Gastroesophageal Reflux Disease and Bloating

2025-06-22

| World Journal of Surgery

Response to “Weight‐loss drugs like Wegovy could lead to an increased risk of fragility fractures in population at risk”

2025-06-22

Robert F. Kushner , Donna H. Ryan , Nina M. Harder‐Lauridsen +4 more | Obesity

Promoting the application of gastric tube tip pressure measurement in neurocritical care – Letter on Chen et al.

2025-06-21

Zhenkun Zhuang , Zekai Yu , Guanhu Yang +2 more | Intensive and Critical Care Nursing

Clinical outcomes of Botox injection according to subgroups of esophagogastric junction outflow obstruction: A single institutional retrospective analysis

2025-06-20

Geon Woo Lee , Su Jin Kim , Cheol Woong Choi +3 more | Medicine

The Chicago Classification version 4.0 categorizes esophagogastric junction outflow obstruction (EGJOO) into 4 subgroups based on peristalsis patterns. Recent proposals introduce new terminology, grouping EGJOO with distal esophageal spasm and … The Chicago Classification version 4.0 categorizes esophagogastric junction outflow obstruction (EGJOO) into 4 subgroups based on peristalsis patterns. Recent proposals introduce new terminology, grouping EGJOO with distal esophageal spasm and a hypercontractile esophagus as major mixed motility disorders (MMMDs), while classifying ineffective esophageal motility and normal peristalsis as isolated or ineffective esophagogastric junction outflow obstruction (IEGJOO). Botulinum toxin (Botox) injection is considered a cost-effective, minimally invasive treatment option for EGJOO. This study aimed to investigate clinical outcomes of Botox injection based on these subgroups. We included all patients over 18 years old who underwent high-resolution manometry at our institution between May 2019 and December 2023. Patients diagnosed with EGJOO and treated with Botox injections were categorized into subgroups. Clinical outcomes were assessed using Eckardt scores (ESs) at diagnosis and 2 months posttreatment. Among 180 patients, 31 met the Chicago Classification 4.0 criteria for EGJOO, and 22 of these received Botox injections. Six of these patients had MMMD, and 16 had ineffective esophagogastric junction outflow obstruction. MMMD showed a higher distal contractile integral, but no other significant differences in high-resolution manometry were observed. Patients with MMMD had higher posttreatment ESs (5.50 [2.75-6.25] vs 2.00 [1.00-2.75]; P = .009) and lower changes in ESs (1.00 [0.75-2.50] vs 4.00 [2.25-4.75]; P =.010) when compared to those with IEGJOO. This study suggests that Botox injection is less effective in treating MMMD compared to IEGJOO, which may impact treatment strategies for different EGJOO subgroups.

ERCP outcomes in an aging population: single-center observations

2025-06-20

İdris Kurt | Kastamonu Medical Journal

Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is a critical procedure for diagnosing and treating biliary and pancreatic disorders, particularly in elderly populations where these conditions are prevalent. This study aims to … Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is a critical procedure for diagnosing and treating biliary and pancreatic disorders, particularly in elderly populations where these conditions are prevalent. This study aims to evaluate the outcomes and complications of ERCP in an elderly cohort at a single center. Methods: This retrospective study included 169 patients who underwent ERCP, with a mean age of 66 years (range 19-92). The majority were female (51.5%). Indications, procedural success rates, and complications were analyzed, with a focus on the presence of periampullary diverticula and previous sphincterotomies. Results: The overall procedural success rate was 85.8%. The most common indication was cholangitis (63.9%), followed by biliary pancreatitis (15.4%) and asymptomatic choledocholithiasis (11.2%). Periampullary diverticula were present in 16.3% of patients, predominantly among older individuals. Difficult cannulation occurred in 20% of cases, with successful biliary cannulation achieved using various techniques. Stones were found in the common bile duct in 95% of patients and were successfully cleared in the same percentage. The overall complication rate was 13.8%, with bleeding (9.5%), pancreatitis (1.8%), and perforation (0.6%) being the most common. Complication rates were not significantly associated with age, gender, or the presence of diverticula, but were lower in patients with prior sphincterotomies. Conclusion: ERCP is effective in managing biliary and pancreatic diseases in elderly patients, with a high success rate and manageable complication profile. Prior sphincterotomy significantly reduces the risk of complications. These findings underscore the importance of experienced endoscopists and tailored approaches for elderly patients undergoing ERCP.

Food passageway-related sequelae in the RefluxStop prospective multicenter trial: patient-centric outcomes of dysphagia, odynophagia, gas-bloating, and inability to belch and/or vomit at 5 years

2025-06-20

László Harsányi , Zsolt Kincses , Milan Veselinović +2 more | Surgical Endoscopy

Abstract Introduction Standard surgical management of GERD may result in troublesome postoperative food passageway-related sequelae (i.e., dysphagia, odynophagia, gas-bloat syndrome, inability to belch/vomit), significantly impacting quality of life. Five-year results … Abstract Introduction Standard surgical management of GERD may result in troublesome postoperative food passageway-related sequelae (i.e., dysphagia, odynophagia, gas-bloat syndrome, inability to belch/vomit), significantly impacting quality of life. Five-year results after the RefluxStop procedure are presented, involving reconstruction of the anti-reflux barrier without encircling the food passageway, reducing such related sequelae. Methods RefluxStop surgery was evaluated in a prospective, single-arm, multicenter study with 50 GERD subjects. This report focuses on food passageway-related outcomes. Other basic outcomes (e.g., 24-h pH, PPI usage) are presented in a separate report with brief clinical correlation herein. Results Forty-four subjects completed 5-year follow-up; three participants were missing due to COVID-19 (i.e., two deaths and one bedbound with long-COVID) and three terminated early. Data from 3- and 4-year follow-up were carried forward in COVID-affected cases. Food passageway-related adverse events (AEs) between 2 weeks of surgical recovery and 5-year follow-up included: one case (2.1%) of dysphagia (and another case, mild dysphagia for 2 weeks postoperatively, viewed as normal recovery); one case (2.1%) of odynophagia; zero (0%) cases of inability to belch/vomit; and gas-bloating none/improved in 42 cases with only two worsening. These outcomes were well-aligned with improvement in total GERD-HRQL score (i.e., median 29.5 at baseline to 3.0 at 5 years), PPI usage (2.1%), and 24-h pH monitoring (i.e., mean 1.57% acid exposure time at 5 years). Conclusion RefluxStop surgery resulted in a favorable profile of food passageway-related outcomes throughout the 5-year study: no AE dysphagia in 97.9% of subjects; no AE odynophagia in 97.9%; whereof at 5 years: gas-bloating none/improved in 95.7%, and no inability to belch/vomit in 100%. For clinical correlation, 97.9% of subjects did not take PPIs at 5 years. These outcomes add resolution to the overall treatment effect of RefluxStop and may show potential preference in GERD patients who prioritize minimization of postoperative sequelae.

Combined Lyon and Milan Scores Predict Gerd Management Outcome Better Than Either Score Alone or Their Individual Components

2025-06-20

Stefano Siboni , Marco Sozzi , Pierfrancesco Visaggi +7 more | Alimentary Pharmacology & Therapeutics

ABSTRACT Background Confidence in gastro‐oesophageal reflux disease (GERD) diagnosis is crucial to improve outcomes from escalation of treatment. The Lyon score phenotypes patients through endoscopy and pH‐impedance (MII‐pH). The Milan … ABSTRACT Background Confidence in gastro‐oesophageal reflux disease (GERD) diagnosis is crucial to improve outcomes from escalation of treatment. The Lyon score phenotypes patients through endoscopy and pH‐impedance (MII‐pH). The Milan score quantifies antireflux barrier through high‐resolution manometry (HRM) parameters. Aim To explore the relationship between the Lyon and Milan scores and their combined performance in predicting clinical outcomes. Methods We collected clinical and follow‐up data of consecutive patients with HRM and MII‐pH from nine centres. Clinical improvement was defined as a 50% reduction in global symptoms. The relationship between Lyon and Milan scores and the rate of patients improved in Lyon phenotypes and Milan categories were explored. The ability of the Lyon, Milan, DeMeester scores and acid exposure time (AET) in predicting outcomes was assessed through receiver operating characteristics (ROC) analysis. Results Among 532 patients (50.6% female, age 50 years), 47.7% had pathologic GERD. A stepwise increase in the Milan score in Lyon phenotypes was observed. Sixty‐three patients had surgical treatment, and 131 medical. Clinical improvement in Lyon phenotypes Conclusive and Severe was 81% and 83%; in Milan categories very likely and extremely likely was 88.5% and 100%. If Lyon and Milan scores were positive, improvement was 89%; if discordant, 63%; if both negative, 19% ( p < 0.001). ROC analysis showed an AUC of 0.790 for Lyon score, 0.835 for Milan score, 0.736 for DeMeester score and 0.741 for AET. Conclusions The Lyon and Milan scores outperformed AET and DeMeester scores in predicting outcomes in GERD patients. When concordant, they provide optimal predictive accuracy, guiding escalation of therapy.

Recent advances in machine learning for precision diagnosis and treatment of esophageal disorders

2025-06-19

Shaowen Liu , Peng Li , Xiaoqing Li +5 more | World Journal of Gastroenterology

The complex pathophysiology and diverse manifestations of esophageal disorders pose challenges in clinical practice, particularly in achieving accurate early diagnosis and risk stratification. While traditional approaches rely heavily on subjective … The complex pathophysiology and diverse manifestations of esophageal disorders pose challenges in clinical practice, particularly in achieving accurate early diagnosis and risk stratification. While traditional approaches rely heavily on subjective interpretations and variable expertise, machine learning (ML) has emerged as a transformative tool in healthcare. We conducted a comprehensive review of published literature on ML applications in esophageal diseases, analyzing technical approaches, validation methods, and clinical outcomes. ML demonstrates superior performance: In gastroesophageal reflux disease, ML models achieve 80%-90% accuracy in potential of hydrogen-impedance analysis and endoscopic grading; for Barrett's esophagus, ML-based approaches show 88%-95% accuracy in invasive diagnostics and 77%-85% accuracy in non-invasive screening. In esophageal cancer, ML improves early detection and survival prediction by 6%-10% compared to traditional methods. Novel applications in achalasia and esophageal varices demonstrate promising results in automated diagnosis and risk stratification, with accuracy rates exceeding 85%. While challenges persist in data standardization, model interpretability, and clinical integration, emerging solutions in federated learning and explainable artificial intelligence offer promising pathways forward. The continued evolution of these technologies, coupled with rigorous validation and thoughtful implementation, may fundamentally transform our approach to esophageal disease management in the era of precision medicine.

Development and validation of a risk prediction model for gastroesophageal reflux disease: Gastroesophageal Reflux Disease Risk Scoring System

2025-06-19

Shanmathi Subramanian , Umashri Sundararaju , Hamrish Kumar Rajakumar +4 more | World Journal of Gastrointestinal Pathophysiology

The rising global prevalence of gastroesophageal reflux disease (GERD) has been closely linked to lifestyle changes driven by globalization. GERD imposes a substantial public health burden, affecting quality of life … The rising global prevalence of gastroesophageal reflux disease (GERD) has been closely linked to lifestyle changes driven by globalization. GERD imposes a substantial public health burden, affecting quality of life and leading to potential complications. Early intervention through lifestyle modification can prevent disease onset; however, there is a lack of effective risk prediction models that emphasize primary prevention. To develop and validate a GERD Risk Scoring System (GRSS) aimed at identifying high-risk individuals and promoting primary prevention strategies. A 45-item questionnaire encompassing major lifestyle and demographic risk factors was developed and validated. It was administered to healthy controls and GERD patients. Two regression models-one using continuous variables and another using categorized variables-were used to develop a computational prediction equation and a clinically applicable scoring scale. An independent validation cohort of 355 participants was used to assess model performance in terms of discrimination (C-index), calibration, sensitivity, specificity, internal consistency (Cronbach's alpha), and test-retest reliability (intraclass correlation coefficient, Bland-Altman analysis). Significant associations were observed between GERD and key lifestyle factors. The derived GRSS equation and scoring scale demonstrated strong discriminative ability, with high sensitivity and specificity. The scoring system exhibited excellent internal consistency (Cronbach's alpha) and strong test-retest reliability. The C-index indicated excellent predictive accuracy in both derivation and validation cohorts. GRSS offers a novel and validated approach to GERD risk prediction, combining a robust equation for digital applications and a practical scale for clinical use. Its ability to accurately identify at-risk individuals supports a paradigm shift toward primary prevention, underscoring its significance in addressing the growing burden of GERD at the population level.

Assessment of Burden of Partial Response to Standard Doses of Proton Pump Inhibitors in Patients with Clinically Diagnosed Gastroesophageal Reflux Disease: A Real-World Evidence Study in India

2025-06-19

Yogesh Garje , Rajiv Saikia , Sunil Gupta +7 more | Drugs - Real World Outcomes

Partial response to standard-dose proton pump inhibitors (PPIs) in gastroesophageal reflux disease (GERD) is common, yet real-world data on its burden and management in Indian settings remain limited. This study … Partial response to standard-dose proton pump inhibitors (PPIs) in gastroesophageal reflux disease (GERD) is common, yet real-world data on its burden and management in Indian settings remain limited. This study aimed to understand the burden, clinical profile, drug utilization patterns across specialties, the effectiveness of Pantoprazole 80 mg dual delayed-release (DDR) formulation, and management strategies used in the treatment of partial responders with clinically diagnosed GERD in Indian settings. This was a multicentric, retrospective observational study. Data on adult patients with GERD with a follow-up duration of at least 4 weeks from baseline were extracted from electronic medical records (EMR) of outpatient settings from five centers, which included drug utilization patterns, clinical and treatment profiles, and effectiveness of PPIs. Among EMRs of 5205 patients with GERD, 38.0% were on rabeprazole and 36.6% on pantoprazole (mean age: 53.3 years; standard deviation: 14.3 years), and 55.0% were male. Heartburn was the primary complaint in 76.0% of cases. Cardiovascular co-morbidities with dyslipidemia were reported in 66.7% (1742/2610) patients. Pantoprazole and rabeprazole were preferred across specialties, where 31.1% (592/1906) and 17.7% (350/1979) adhered to treatment, respectively. Total burden of partial responders was 41.7%, including patients who switched PPIs, changed PPI dosage, or added other medications. Pantoprazole 40 mg twice daily (BD) showed 49.1% improvement in heartburn and 50.9% in abdominal pain. Pantoprazole 80 mg DDR once daily demonstrated significantly higher symptom relief, with a 60.2% reduction in heartburn (p < 0.001) and a 66.1% reduction in abdominal pain (p < 0.001). These findings suggest that higher-dose pantoprazole therapy may be a clinically effective strategy for managing partial responders to standard-dose PPIs. A significant proportion of patients with GERD were partial responders to PPIs. Pantoprazole and rabeprazole had high patient adherence across disciplines. Both pantoprazole DDR 80 mg once daily (OD) and 40 mg BD demonstrated significant symptom reduction in partial responders, supporting their use in optimizing GERD management in Indian clinical settings.

Weight loss drugs like Wegovy could lead to an increased risk of fragility fractures in population at risk

2025-06-19

Léa Karam , Julien Paccou | Obesity

The incidence of postoperative atelectasis following gastrointestinal procedures in pediatric population

2025-06-18

Emi Yuki , Sulpicio G. Soriano , Miho Shibamura‐Fujiogi +1 more | Perioperative Care and Operating Room Management

Antireflux mucosal intervention for refractory gastroesophageal reflux disease after multiple Nissen fundoplications

2025-06-18

Masachika Saino , Haruhiro Inoue , Kei Ushikubo +4 more | Endoscopy

Improvement in Health-related Quality of Life and Patient Satisfaction after Pneumatic Dilatation in Achalasia Patients

2025-06-18

Shahid Rasool , Sofia Hanif , Umair Shafqat +1 more | Euroasian Journal of Hepato-Gastroenterology

Comorbid patient with gastroesophageal reflux disease: Features of the choice of proton pump inhibitor

2025-06-18

Г. Б. Селиванова , Н. Г. Потешкина | Meditsinskiy sovet = Medical Council

The high prevalence of gastroesophageal reflux disease (GERD) and ageing of the population makes the issue of GERD pharmacotherapy a challenge for a comorbid patient, taking into account the choice … The high prevalence of gastroesophageal reflux disease (GERD) and ageing of the population makes the issue of GERD pharmacotherapy a challenge for a comorbid patient, taking into account the choice of an effective proton pump inhibitor (PPI) that has a stable and long-term acid suppression, metabolic neutrality and a low risk of drug interactions. The combination of classic esophageal manifestations of GERD, such as heartburn and regurgitation with extraesophageal manifestations due to high gastroesophageal reflux resulting in the development of ENT and respiratory symptoms, contributes to the complexity of issues of differential diagnosis and pharmacotherapy. The occurrence of chest pain and heart rhythm disturbances in a patient with GERD requires differentiation from cardiovascular diseases and the choice of therapy affecting all pathogenetic components in the context of comorbidity. Proton pump inhibitors as the mainstay of pharmacological acid suppression in GERD treatment regimens should be prescribed as the primary therapeutic course and part of maintenance therapy regimens, the duration of which is determined on a patient-by-patient basis and often amounts to years of use, which should take into account not only the effectiveness, but also the safety of a particular drug. Pantoprazole is a selective PPI for the gastric parietal cells, in which the pH reaches the lowest values, provides a long-term acid-reducing effect and is metabolically neutral when administered together with other drugs in comorbid patients. Evaluation of the safety of long-term use of the drug for up to 15 years based on the results of clinical studies showed the absence of a risk of malignant neoplasms. Moderate hypergastrinemia was not accompanied by clinically significant changes in the mucous membrane throughout the entire period of pantoprazole therapy. In conclusion, daily maintenance therapy with pantoprazole for up to 15 years is effective, well tolerated and does not raise safety concerns.

In Reference to <i>Laryngopharyngeal Reflux and Upper Airway Obstruction Patterns in Nonobese Sleep Apnea Patients</i>

2025-06-18

Jérôme R. Lechien , Carlos M. Chiesa‐Estomba , Rania Filali Ansary +3 more | The Laryngoscope

The role of mucosal impedance in the assessment of the reflux barrier after Nissen fundoplication

2025-06-18

Sven Eriksson , İnanç Şamil Sarıcı , Johnathan Nguyen +3 more | Journal of Gastrointestinal Surgery

Mucosal impedance (MI) is a novel diagnostic tool that quantifies esophageal mucosal integrity by measuring tissue conductivity. Previous studies have demonstrated that healthy individuals exhibit high, stable MI values throughout … Mucosal impedance (MI) is a novel diagnostic tool that quantifies esophageal mucosal integrity by measuring tissue conductivity. Previous studies have demonstrated that healthy individuals exhibit high, stable MI values throughout the esophagus and that those with gastroesophageal reflux disease (GERD) exhibit low distal MI values and a steep axial gradient. The role of MI in the postoperative setting has not been evaluated, and it is unknown whether antireflux surgery (ARS) restores mucosal integrity to normal levels. This study aimed to determine whether MI differentiates between intact and failed Nissen fundoplication and objectively assesses reflux barrier function after ARS. Patients who underwent Nissen fundoplication and had either intact or failed (slipped, disrupted, or herniated) fundoplication on endoscopy at ≥1 year were offered MI testing. In addition, a non-GERD control group (n = 10) with no previous foregut surgery and normal endoscopy and pH monitoring underwent MI testing. MI was measured at 1-cm intervals along the distal esophagus. Axial MI patterns were compared between the groups. The study included 25 post fundoplication patients (60% female, mean age of 61.3 ± 13.7 years, and mean body mass index of 28.2 ± 4.7 kg/m2), 11 with intact fundoplication and 14 with anatomical failure. Patients with intact fundoplication had significantly higher MI values at 1 (P =.0326), 2 (P =.005), 3 (P <.05), and 5 (P =.018) cm above the squamocolumnar junction (SCJ). All MI values and patterns in patients with intact fundoplication were comparable with those of non-GERD controls (P >.05). Patients with failed fundoplication had a steeper axial MI gradient than those with intact fundoplication (251 vs 23 Ω/cm, respectively; P <.05). In addition, the distal MI value was significantly lower in patients with failed fundoplication than in those with intact fundoplication (2706 vs 4921 Ω, respectively; P <.05). MI demonstrates that an intact Nissen fundoplication restores mucosal integrity to levels comparable to those of individuals without GERD. Failed fundoplications exhibit persistent GERD-like MI patterns. Therefore, MI provides an objective physiologic marker of surgical success and may aid in postoperative management.

The Global, Regional and National Burden of Gastroesophageal Reflux Disease in 204 Countries and Territories, 1990–2021 a Retrospective Cohort Study

2025-06-18

Lina Du , Yan Gao , Ru Gao | Annals of Medicine and Surgery

Introduction Gastroesophageal reflux disease (GERD) is a common condition involving recurrent reflux of stomach contents, causing symptoms and complications that impact quality of life. This study aimed to assess the … Introduction Gastroesophageal reflux disease (GERD) is a common condition involving recurrent reflux of stomach contents, causing symptoms and complications that impact quality of life. This study aimed to assess the global GERD burden from 1990 to 2021. Methods We used the Global Burden of Disease (GBD) 2021 data to analyze the incidence, prevalence, and years lived with disability (YLDs) for GERD across 204 countries. We estimated the population-level distributions by age and sex, using age-standardized incidence rate (ASIR) and age-standardized YLDs (ASYLDs). The average annual percent change (AAPC) in incidence, prevalence, and YLDs was calculated along with 95% uncertainty intervals (UIs). Results In 2021, the global ASIR of GERD was 3,881.86 per 100,000, reflecting an AAPC increase of 3.80% since 1990. The prevalence also increased, with an AAPC of 3.38%, reaching 9,838.60 per 100,000. Global ASYLDs rose to 75.56 per 100,000, showing an AAPC increase of 3.49%. GERD burden varied by region; high-income areas like North America and East Asia saw declines, while Western Sub-Saharan Africa and Central Europe showed increases. India and China had the highest recorded incidences, with 36,567,410 and 20,863,747, respectively. Decomposition analyses revealed that population growth and aging contributed most to the increase in YLDs. Conclusion The global GERD burden significantly increased from 1990 to 2021, especially in low and middle-income regions. This highlights the urgent need for enhanced public health measures, early diagnosis, and improved healthcare access to manage the growing disease burden and improve patient outcomes.

In Response to “Laryngopharyngeal Reflux and Upper Airway Obstruction Patterns in Nonobese Sleep Apnea Patients”

2025-06-18

Fatih Gül | The Laryngoscope

Efficacy and safety of pantoprazole in the treatment of patients with gastroesophageal reflux disease in real-world clinical practice: A multicenter observational study

2025-06-18

И. В. Маев , A. V. Zaborovsky , L. G. Yurenev +7 more | Meditsinskiy sovet = Medical Council

Introduction. Gastroesophageal reflux disease (GERD) is a common condition leading to a considerable decrease in the quality of life of patients. Proton pump inhibitors (PPI), including pantoprazole, represent the mainstay … Introduction. Gastroesophageal reflux disease (GERD) is a common condition leading to a considerable decrease in the quality of life of patients. Proton pump inhibitors (PPI), including pantoprazole, represent the mainstay of medical treatment of GERD. This study assessed the efficacy and safety of pantoprazole (Nolpaza®) in clinical practice. Aim. To evaluate the clinical efficacy, safety and tolerability of pantoprazole in patients with GERD, as well as the impact of therapy on quality of life and treatment adherence. Materials and methods. A multicenter observational study included 10,883 patients with GERD (with and without esophagitis) who received pantoprazole (40 mg/day) for 4–8 weeks. The following parameters of treatment were assessed: changes in symptoms, check-up EGD findings, frequency of adverse reactions, physician and patient satisfaction, and treatment adherence. Results. The study results allowed us to evaluate the efficacy and safety of the therapy used. Improvement was noted in more than 99% of patients (complete disappearance of symptoms in 73.4%). According to EGDS, 74.45% achieved complete remission, 25.08% partial. Adverse events (AE) were registered in 0.28% (headache, constipation, abdominal discomfort). During therapy, adherence to the drug was more than 86%, satisfaction with treatment was more than 94% among doctors and more than 95% among patients. Conclusions. Pantoprazole demonstrated high efficacy in relieving GERD symptoms and healing mucosal lesions, a high safety profile with a minimal risk of adverse events, as well as good tolerability and high patient adherence to this therapy. Our findings favoured the use of pantoprazole as a standard therapy for GERD in real-world clinical practice.

The Diagnostic Accuracy of the Nasopharyngeal Reflux Endoscopic Score (NRES) for Identifying Laryngopharyngeal Reflux Disease in Chronic Rhinosinusitis

2025-06-17

Kalamkas Sagandykova , Nataliya Papulova , Gul’mira Muhamadieva +2 more | Journal of Clinical Medicine

Background: Chronic rhinosinusitis with or without nasal polyps (CRSwNPs/CRSsNPs) is an inflammatory disease that is becoming increasingly associated with laryngopharyngeal reflux disease (LPRD). Although symptom-based questionnaires, such as the Reflux … Background: Chronic rhinosinusitis with or without nasal polyps (CRSwNPs/CRSsNPs) is an inflammatory disease that is becoming increasingly associated with laryngopharyngeal reflux disease (LPRD). Although symptom-based questionnaires, such as the Reflux Symptom Index (RSI) and Reflux Symptom Score (RSS), are widely used, there is a lack of objective endoscopic tools for assessing the nasopharyngeal and nasal manifestations of reflux. The Nasopharyngeal Reflux Endoscopic Score (NRES) is a novel endoscopic scoring system that was developed to address this issue. Objective: The objective of this study was to evaluate the diagnostic accuracy of the NRES in identifying LPRD in patients with CRS, compared with a clinical reference standard. Methods: A prospective diagnostic accuracy cohort study was conducted at two tertiary care centers in Astana, Kazakhstan, from September 2023 to February 2025. A total of 216 adults were enrolled and divided into three groups: CRS with suspected LPRD (n = 116), CRS without LPRD (n = 69), and healthy controls (n = 31). CRS was diagnosed according to the EPOS 2020 criteria. LPRD was defined using a composite reference standard comprising clinical assessment, RSS > 13, RSI, and selective 24 h pH monitoring and gastrointestinal endoscopy. All participants underwent nasopharyngeal and laryngeal endoscopy, with NRES, L-K, RFS, RSI, and RSS assessments at baseline and at 6 and 12 months. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic performance, and Wilcoxon tests were used to analyze the changes in scores. Correlation and regression analyses were used to explore associations between scales and predictive factors. Results: At baseline, NRES scores were significantly higher in the CRS with LPRD group (mean: 11.59) than in the CRS without LPRD group (mean: 3.10) and the healthy control group (mean: 2.16) (p < 0.001). ROC analysis demonstrated excellent diagnostic accuracy, with an area under the curve (AUC) of 0.998 (95% confidence interval (CI): 0.994-1.000), a sensitivity of 98% (95% CI: 94-100%) and a specificity of 96% (95% CI: 91-99%) at an optimal cut-off point of 8.5. NRES scores showed strong correlations with RSI, RSS, and RFS scores (r > 0.76, p < 0.001). A longitudinal assessment revealed significant reductions in all scores after treatment with proton pump inhibitors and lifestyle modifications, with sustained improvement at 12 months. Regression analysis found no significant effect of age, gender, or GERD severity (LA classification) on NRES scores. Conclusions: The NRES is a highly sensitive and specific endoscopic tool for identifying nasopharyngeal changes associated with LPRD in CRS patients. It demonstrates strong correlations with established symptom-based and laryngoscopic reflux assessments and responds to anti-reflux therapy over time. The NRES may, therefore, be a valuable objective adjunct in the comprehensive evaluation and longitudinal monitoring of LPRD-associated CRS.

A Review on Formulation and pharmacological activity assessment of Oral Disintegration Tablets of Antiulcer Using Super Natural Disintegrant

2025-06-17

Rinku Rangari , Khusbhu Rahangdale , Rudhali Lilhare | International Journal For Multidisciplinary Research

Orally disintegrating tablets (ODTs) have gained significant attention in the pharmaceutical industry due to their convenience, especially for patients with dysphagia, pediatric, and geriatric populations. The formulation of antiulcer ODTs … Orally disintegrating tablets (ODTs) have gained significant attention in the pharmaceutical industry due to their convenience, especially for patients with dysphagia, pediatric, and geriatric populations. The formulation of antiulcer ODTs using super natural disintegrants is a novel approach aimed at improving drug dissolution, bioavailability, and patient compliance. Omeprazole is a proton pump inhibitor (PPI) widely used in the treatment and prevention of peptic ulcers, gastroesophageal reflux disease (GERD), and other acid-related disorders. The pharmacological assessment of omeprazole for its antiulcer activity involves Omeprazole irreversibly inhibits the H⁺/K⁺ ATPase enzyme (proton pump) in the gastric parietal cells. This review provides a comprehensive analysis of the formulation techniques, selection of natural superdisintegrants, and in-vitro evaluation methods for antiulcer ODTs. Based on that review study formulation & invitro as well as invivo evaluation of OTDs will plan. The study demonstrated that the incorporation of the super natural disintegrant significantly enhanced the disintegration time and drug release profile compared to synthetic disintegrants

Timing and Predictors for Vonoprazan Dose Escalation in Refractory Gastroesophageal Reflux Disease: A Long-Term Observational Study

2025-06-17

Satoshi Shinozaki , Hirotsugu Sakamoto , Hiroyuki Osawa +3 more | Digestion

Background: Vonoprazan (VPZ) therapy has become one of the standard treatments for gastroesophageal reflux disease (GERD). When GERD symptoms persist despite the maintenance dose therapy (10 mg daily), dose escalation … Background: Vonoprazan (VPZ) therapy has become one of the standard treatments for gastroesophageal reflux disease (GERD). When GERD symptoms persist despite the maintenance dose therapy (10 mg daily), dose escalation to 20 mg daily is generally recommended. This study aims to clarify the proper timing and predictors for dose escalation of VPZ therapy in patients with refractory GERD treated with the maintenance dose. Methods: This retrospective observational study included 257 patients with symptomatic GERD. Data from medical records, including endoscopic findings and Izumo scale scores, were analyzed. Results: The mean follow-up period was 3.3 years. Throughout the follow-up period, VPZ dose escalation (from 10 to 20 mg daily) was required in 56 of 257 patients (22%). Kaplan-Meier analysis showed cumulative dose-escalation-free rates at 6 months, 1 year, and 2 years were 87%, 81%, and 78%, respectively. Predictive factors for VPZ dose escalation were analyzed using a Cox proportional hazards regression model. Multivariate analysis revealed that pre-existing epigastric pain was a significant positive predictor for dose escalation, whereas pre-existing constipation was identified as a significant negative predictor. Kaplan-Meier analysis indicated that the one-year dose-escalation-free rates were 69% in patients with epigastric pain compared to 88% in those without (p=0.001). GERD symptom scores showed a significant improvement one month after dose escalation. Conclusion: The incidence of refractory GERD requiring VPZ dose escalation is relatively low. Epigastric pain prior to VPZ initiation independently predicts the need for dose escalation. VPZ dose escalation effectively improves GERD symptoms.

Concurrent Diagnosis of Superficial Esophageal Cancer and Esophageal Achalasia: A Case Report and Literature Review

2025-06-17

Ai Katsumi , Hideki Mori , Noriko Matsuura +7 more | DEN Open

ABSTRACT We report a case of a 70‐year‐old woman with esophageal achalasia and concurrent superficial esophageal squamous cell carcinoma. Three adjacent superficial lesions were resected en bloc by endoscopic submucosal … ABSTRACT We report a case of a 70‐year‐old woman with esophageal achalasia and concurrent superficial esophageal squamous cell carcinoma. Three adjacent superficial lesions were resected en bloc by endoscopic submucosal dissection (ESD), with no lymphovascular invasion. Given that the patient's dysphagia was effectively controlled with medication and dietary modifications, peroral endoscopic myotomy (POEM) was deferred following a careful assessment of the risk–benefit balance. As both ESD and POEM involve submucosal intervention, this case highlights the importance of individualized treatment based on symptom severity and lesion characteristics.

Anti-Reflux Mucosa Ablation in the Treatment of Refractive Gastroesophageal Reflux Disease

2025-06-17

V. О. Yakovenko | Perioperaciina Medicina

The article is devoted to antireflux mucosal ablation (ARMA) — a new endoscopic method of treatment of refractory gastroesophageal reflux disease (GERD), unresponsive to standard therapy. ARMA restores cardia function … The article is devoted to antireflux mucosal ablation (ARMA) — a new endoscopic method of treatment of refractory gastroesophageal reflux disease (GERD), unresponsive to standard therapy. ARMA restores cardia function through controlled scarring. The method is indicated for patients with refractory GERD, proton pump inhibitor (PPI) dependence, impaired valve function of the gastroesophageal junction grade II–III according to Hill, and small diaphragmatic hernia (up to 2–3 cm). Contraindications include large hernias, previous gastroesophageal junction surgery, achalasia, severe erosive esophagitis, and Barrett’s esophagus. The procedure includes a diagnostic examination, submucosal injection of saline to create a «cushion» and thermal ablation of the mucosa. Argon plasma ablation, coagulation forceps (e.g. Coagrasper) and a submucosal dissection knife in the Forced Coag mode (effect 2, 40 W) are used for coagulation, creating a white surface without carbonization. Postoperative management involves restriction of physical activity, diet and drug therapy (double dose of PPI). Control endoscopy is performed after 2–3 months. Clinical experience of the «Oberig» clinic (58 patients) showed significant and long-term clinical improvement and improvement of the Hill valve degree in 56 of 58 patients (97%). ARMA is an effective and safe minimally invasive method that requires further study.

Childhood gastroesophageal reflux disease

2025-06-16

Anand Pandey | World Journal of Clinical Pediatrics

The diagnosis of gastroesophageal reflux (GERD) in children is a complex and challenging task that requires meticulous attention to detail and a deep understanding of pediatric physiology. It is absolutely … The diagnosis of gastroesophageal reflux (GERD) in children is a complex and challenging task that requires meticulous attention to detail and a deep understanding of pediatric physiology. It is absolutely crucial to distinguish between the benign chalasia of infancy and the more serious pathologic GERD. Recent advancements have shown that Combined Multichannel Intraluminal Impedance and pondus hydrogenii measurement offer superior diagnostic accuracy. The role of nuclear scans in diagnosing GERD remains an area of ongoing research. The management of GERD in children follows a stepwise approach, starting with medical therapy and progressing to surgical intervention if necessary.

Role of endoscopy in achalasia

2025-06-16

Noriyuki Kawami , Yoshimasa Hoshikawa , Eri Momma +2 more | Digestion

Background: Esophagogastroduodenoscopy is often performed as an initial examination in patients with symptoms such as dysphagia or chest pain, which may suggest esophageal motility disorders. However, its current role is … Background: Esophagogastroduodenoscopy is often performed as an initial examination in patients with symptoms such as dysphagia or chest pain, which may suggest esophageal motility disorders. However, its current role is largely limited to ruling out organic diseases. Summary: High-resolution manometry (the gold standard for diagnosing primary esophageal motility disorders such as achalasia) along with esophagography is extremely useful for diagnosis. In recent years, however, several new endoscopic findings—esophageal rosette, gingko leaf sign, champagne glass sign, corona appearance, and pinstripe pattern—have been reported, making it increasingly possible to strongly suspect achalasia through endoscopy. Additionally, the presence of multiple annular contractions, spiral (corkscrew) contractions, or narrowing (poor distensibility) in the esophageal body during endoscopy may suggest abnormal motility of the esophageal body. Key Messages: When performing endoscopic examinations in patients with symptoms such as dysphagia or chest pain, it is important to consider the possibility of esophageal motility disorders. Careful endoscopic observation may allow for the suspicion of such disorders during the examination itself.

Incidence of gastro-esophageal reflux disease in mechanically ventilated full-term Egyptian neonates by detection of pepsin in endotracheal aspirate

2025-06-16

Amira Elrefaee , Abdel-Rahman A Abdel-Razek , Zeinab S Abdelkhalek +2 more | World Journal of Clinical Pediatrics

BACKGROUND Gastroesophageal reflux disease (GERD) is common among neonates, particularly those requiring mechanical ventilation. Pepsin, a reliable marker of gastric aspiration, may help detect GER episodes in ventilated neonates and … BACKGROUND Gastroesophageal reflux disease (GERD) is common among neonates, particularly those requiring mechanical ventilation. Pepsin, a reliable marker of gastric aspiration, may help detect GER episodes in ventilated neonates and assess associated clinical outcomes. AIM To determine the incidence of GERD, associated risk factors, and morbidities among full-term mechanically ventilated neonates by detecting pepsin in endotracheal aspirates (ETA). METHODS This study included 97 full-term neonates admitted to the neonatal intensive care unit at Cairo University Hospitals from April 2023 to March 2024. ETA samples were collected at three intervals: Immediately post-intubation (Sample A), 48 hours after intubation (Sample B), and just before extubation (Sample C). Pepsin concentration was measured using enzyme-linked immunosorbent assay. Clinical data, including hospital stay duration and feeding parameters, were correlated with pepsin levels. RESULTS Pepsin was detected in 76 (78.4%) of Sample A, 78 (81.3%) of Sample B, and 47 (68.1%) of Sample C. A significant positive correlation was found between pepsin levels and FiO2 in Sample B (r = 0.203, P = 0.047). Prolonged hospital stay was also associated with pepsin detection in Samples B and C (P < 0.05). A negative correlation was observed between feeding amount and pepsin levels across all samples (P < 0.05). CONCLUSION The incidence of GERD in full-term mechanically ventilated neonates is high, correlating with pepsin levels, FiO2, feeding intolerance, and hospital stay, highlighting the importance of early detection.

Comment on “<i>Twenty-four-hour pH monitoring of gastric conduit in post-esophagectomy patients: correlation with clinical and endoscopic parameters in a prospective cohort study from India</i>”

2025-06-15

Dongjae Jeon | Daehan nae'si'gyeong bog'gang'gyeong oe'gwa haghoeji/Journal of minimally invasive surgery

Prevalence and association of diabetes with long-term proton pump inhibitor use: A cross-sectional study

2025-06-14

Madhavi Eerike , Anand Pyati , Sai Priyanka Daggu +4 more | International Journal of Diabetes in Developing Countries

Pulmonary Aspiration and Its Prevention in Patients with Small Bowel Obstruction After Roux-en-Y Gastric Bypass: A Case Report

2025-06-14

Ulrich Limper , Jürgen Meyer-Zillekens , Antonia-Maria Jahnert +1 more | SN Comprehensive Clinical Medicine

Abstract Bariatric Roux-en-Y gastric bypass (RYGB) alters the visceral anatomy and physiology substantially and complicates airway management. Small bowel obstruction, a serious late complication of RYGB, bears a high risk … Abstract Bariatric Roux-en-Y gastric bypass (RYGB) alters the visceral anatomy and physiology substantially and complicates airway management. Small bowel obstruction, a serious late complication of RYGB, bears a high risk of anaesthesia associated pulmonary aspiration. However, the optimal procedure to prevent pulmonary aspiration is unknown. We detail the anaesthesiologic management of three patients with small bowel obstruction after RYGB and discuss specific aspects of pulmonary aspiration. Whereas in the first two cases, pulmonary aspiration appeared despite rapid sequence induction and intubation (RSII), which was likely due to pathophysiological peculiarities of RYGB and anatomical difficulties in placing a nasogastric tube (NGT) within the congested bowel, in the third patient, advancing an NGT beyond the gastric pouch into the alimentary limb, confirmed by abdominal x-ray, allowed for optimized evacuation of enteral content and safe RSII. However, there is still no scientific evidence that in individuals with prior RYGB suffering small bowel obstruction an NGT should be advanced beyond the gastric pouch on a regular basis and confirmed by abdominal x-ray.

Achalasia

2025-06-13

Zinah Alsharshahi | Radiopaedia.org

ASSOCIATIONS BETWEEN ESOPHAGEAL MOTILITY, REFLUX, AND LUNG MECHANICS AND FUNCTION ARE DISEASE SPECIFIC, BOTH BETWEEN AND WITHIN RESTRICTIVE AND OBSTRUCTIVE LUNG DISEASE.

2025-06-13

Ali Alghubari , Caroline Olson , Jessica Bradley +6 more | Clinical and Translational Gastroenterology

INTRODUCTION: Gastroesophageal reflux is common in respiratory disease, but the inter-play between gastrointestinal mechanisms that expose individuals to reflux and potentially aspiration, and lung mechanics and function remain incompletely understood. … INTRODUCTION: Gastroesophageal reflux is common in respiratory disease, but the inter-play between gastrointestinal mechanisms that expose individuals to reflux and potentially aspiration, and lung mechanics and function remain incompletely understood. Our aim was to investigate this in patients with chronic obstructive pulmonary disease (COPD) and non-IPF interstitial lung disease (non-IPF ILD), and compare with our published findings in idiopathic pulmonary fibrosis (IPF). METHODS: 57 patients with COPD (aged: 34-75yrs) and 64 with non-IPF ILD (22-75yrs) who underwent high-resolution impedance manometry and 24-hour pH-impedance, together with pulmonary function assessment were compared with 35 IPF patients (51-84yrs). RESULTS: COPD patients were less likely to exhibit ineffective esophageal motility (IEM) and/or absent contractility (p=0.009; p=0.028), and tended to exhibit esophagogastric junction outflow obstruction (EGJOO) and/or hyper-contractility (p=0.09, p=0.14) than IPF and non-IPF ILD patients. Notably, integrated relaxation pressure correlated with esophageal length index (ELI) (p=0.048) and inspiratory LESP (p=0.003), with latter two correlating with each other (p<0.001). EGJOO patients tended to have fewer proximal reflux events and reduced pulmonary function; the latter inversely correlating with ELI (p<0.05). Non-IPF ILD patients were less likely to exhibit EGJOO than COPD patients (p=0.27), and less likely to exhibit IEM (p=0.07) than IPF patients. However, those with IEM or EGJOO, exhibited greater proportions of reflux events reaching the proximal esophagus than those with normal motility (p<0.03), which in contrast to IPF, appeared not to associate with worse pulmonary function. CONCLUSIONS: Associations between esophageal motility, and lung mechanics and function, and consequently reflux, are very disease specific.

Reassessing proton pump inhibitor safety: a comment

2025-06-13

Hajir Mehrbani , Abdollah Keshavarz | Internal and Emergency Medicine

Methodological Considerations in Outcome Studies of LSG with HHR

2025-06-13

Xiao‐Ming Xu | Obesity Surgery

Current status of Esophagogastroduodenoscopy (EGD) with sedatives for late-stage elderly of outpatient and inpatient

2025-06-13

Reona Kawamura , Seiichiro Abe , T. Yamazaki +5 more | Progress of Digestive Endoscopy

Successful endoscopic balloon dilation for superior duodenal angulus stricture induced by nonsteroidal anti-inflammatory drug therapy

2025-06-13

Tomohiro Mogi , Hirohito Sano , Tsubasa Tateishi +4 more | Progress of Digestive Endoscopy

Dynamic changes in the anti-reflux mechanism observed by endoscopy: The phase concept

2025-06-13

Mayo Tanabe , Haruhiro Inoue | Progress of Digestive Endoscopy

Is mesh essential in laparoscopic hiatal hernia repair? analysis of 30-day outcomes from the ACS-NSQIP database over eight years

2025-06-13

Clayton Wyland , Sonia Parievsky , R. Madani +3 more | Frontiers in Surgery

Introduction Use of mesh to reinforce laparoscopic hiatal hernia repair (LHHR) has been a popular topic of debate among foregut surgeons in recent years. Augmentation with mesh appears to reduce … Introduction Use of mesh to reinforce laparoscopic hiatal hernia repair (LHHR) has been a popular topic of debate among foregut surgeons in recent years. Augmentation with mesh appears to reduce short-term recurrence rates; however, little is known about other important short-term outcomes. Such information is critical to delineating the optimal treatment approach for hiatal hernia. Therefore, this study evaluated various 30-day outcomes in patients who underwent LHHR, both with and without mesh. Methods American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent LHHR from 2010–2017. Patients were sorted into one of two cohorts: LHHR with mesh or LHHR without mesh. 30-day postoperative mortality, morbidity, length of hospital stay (LOS), operative time, reoperation, and readmission rates were analyzed using SPSS. Results A total of 24,488 patients underwent LHHR—9,710 (37.4%) with mesh and 15,318 (62.6%) without mesh. Both groups had similar demographic characteristics. At 30-days, there were no differences between the groups regarding mortality (0.6% vs. 0.6%, p = .990), serious morbidity (3.8% vs. 3.5%, p = .135), overall morbidity (6.4% vs. 6.2%, p = .468), and return to the operating room (2.6% vs. 2.6%, p = .945). However, patients in the mesh group had an increased readmission rate (6.6% vs. 5.8%, p = .013), median [IQR] operative time (147 [108,197] vs. 130 [91,175] minutes, p &lt; .001), and mean LOS (2.9 vs. 2.7 days, p = .002). Conclusion In this large retrospective cohort study, LHHR with mesh was associated with increased operative time, LOS, and hospital readmission. However, there were no differences in mortality or overall morbidity. These findings provide much needed context to consider prior to employing mesh in LHHR.

Recent Advances in the Diagnosis and Treatment of Gastroesophageal Reflux Disease

2025-06-13

Boram Cha , Ju Yup Lee | Gyemyeong uidae haksulji

Gastroesophageal reflux disease (GERD) is a common, chronic condition that significantly affects patient quality of life and may lead to complications such as erosive esophagitis, Barrett’s esophagus, and peptic strictures. … Gastroesophageal reflux disease (GERD) is a common, chronic condition that significantly affects patient quality of life and may lead to complications such as erosive esophagitis, Barrett’s esophagus, and peptic strictures. In recent years, diagnostic approaches to GERD have evolved, with the updated Lyon Consensus 2.0 and the 2020 Seoul Consensus providing more structured, evidence-based criteria. These include not only conventional endoscopic and pH-monitoring findings but also impedance-based parameters such as the mean nocturnal baseline impedance (MNBI) and the post-reflux swallow-induced peristaltic wave (PSPW) index, which enhance diagnostic accuracy and allow better phenotyping of GERD. In terms of treatment, lifestyle modification remains the cornerstone of GERD management and is essential for reducing long-term dependence on pharmacologic therapy. Proton pump inhibitors (PPIs) are the mainstay of pharmacologic treatment, and their effectiveness can be improved through modified-release or immediate-release buffered formulations. Recently, potassium-competitive acid blockers (P-CABs) such as tegoprazan, fexuprazan, and zastaprazan have emerged as effective alternatives to PPIs, offering advantages such as rapid onset of action, prolonged acid suppression, and more predictable pharmacokinetics, particularly in East Asian populations. However, concerns remain regarding long-term safety, including the risk of hypergastrinemia. This review summarizes recent advances in GERD diagnosis and treatment, highlighting the importance of individualized management strategies that incorporate updated diagnostic criteria and the evolving pharmacologic landscape.