Absence Of Gastroesophageal Reflux Disease Research Articles

A Multicenter Long-Term Cohort Study of Eosinophilic Esophagitis Variants and Their Progression to Eosinophilic Esophagitis Over Time.

Eosinophilic esophagitis (EoE) variants have been recently characterized as conditions with symptoms of esophageal dysfunction resembling EoE, but absence of significant esophageal eosinophilia. Their disease course and severity have yet to be determined. Patients from 6 EoE centers with symptoms of esophageal dysfunction, but peak eosinophil counts of <15/hpf in esophageal biopsies and absence of gastroesophageal reflux disease with at least one follow-up visit were included. Clinical, (immuno)histological, and molecular features were determined and compared with EoE and healthy controls. We included 54 patients with EoE variants (EoE-like esophagitis 53.7%; lymphocytic esophagitis 13.0%; and nonspecific esophagitis 33.3%). In 8 EoE-like esophagitis patients, EoE developed after a median of 14 months (interquartile range 3.6-37.6). Such progression increased over time (17.6% year 1, 32.0% year 3, and 62.2% year 6). Sequential RNA sequencing analyses revealed only 7 genes associated with this progression (with TSG6 and ALOX15 among the top 3 upregulated genes) with upregulation of a previously attenuated Th2 pathway. Immunostaining confirmed the involvement of eosinophil-associated proteins (TSG6 and ALOX15) and revealed a significantly increased number of GATA3-positive cells during progression, indicating a Th1/Th2 switch. Transition from one EoE variant (baseline) to another variant (during follow-up) was seen in 35.2% (median observation time of 17.3 months). Transition of EoE variants to EoE suggests the presence of a disease spectrum. Few genes seem to be associated with the progression to EoE with upregulation of a previously attenuated Th2 signal. These genes, including GATA3 as a Th1/Th2 switch regulator, may represent potential therapeutic targets in early disease pathogenesis.

Prevalence of asthma control in adult patients in Kirkuk City

Abstract Background: Asthma is one of the most common chronic diseases that is widely prevalent worldwide affecting different age groups. Many factors are involved in the pathogenesis and there are many trigger factors that can precipitate acute attacks or interfere with the disease control. Disease controlling inhalers are required to be taken for long duration to control the symptoms, and this is a real problem with the patients to maintain remission and prevent relapse or deterioration in the lung function. Objective: The aim of this study is to know the prevalence of asthma control in adult patients in Kirkuk city. Materials and Methods: Two thousand and five hundreds asthmatic patients were collected from Azadi teaching hospital and private clinics at Kirkuk city during the period from January 2017 to October 2022 (1775 were men and 725 were women. A proper history was taken from the patients regarding the duration of the asthma, treatment used and compliance, smoking, and presence or absence of gastroesophageal reflux disease (GERD). The body mass index (BMI) of the patients was also measured. Regarding the asthma control during the past 4 weeks, this was assessed by using the asthma control test. Results: From the total 2500 asthmatic patients: 2280 (91.2%) were not well-controlled, 220 (8.8%) at least well-controlled, 1590 (63.9%) of patients were on treatment, 1370 (86%) of those on treatment were not well-controlled, and 220 (14%) were at least well-controlled. Obesity, smoking, passive smoking GERD, and non-adherence to inhalers are all associated with poorly controlled asthma. Conclusion: The study shows that most of the asthmatic patients with uncontrolled smoking exposure, GERD, obesity, and non-adherence to controlling inhalers were significantly associated factors. Most of the patients were not on regular controlling inhaler therapy. Rejection of the diagnosis, cost, and technique were all causes for the non-adherence to disease-controlling inhalers.

Safety of Intravenous Pantoprazole Sodium in Pediatric Patients Aged 1 Month to < 1 Year: A Real-World Retrospective Cohort Study.

To estimate the incidence rates (IR) of prespecified outcomes of interest in pediatric patients (1month to < 1year) treated with intravenous (IV) pantoprazole using Optum's longitudinal electronic health records database (Optum Market Clarity) from the United States (US). This real-world, non-interventional, retrospective cohort study was conducted from 01 January 2007 to 31 December 2020 in patients who received IV pantoprazole. Premature patients and those weighing < 2.36kg were excluded. Patients were categorized based on diagnosis of gastroesophageal reflux disease (GERD) and erosive esophagitis (EE) into: Subgroup 1 (GERD and EE), Subgroup 2 (GERD and no EE), and Subgroup 3 (absence of GERD and EE). Overall IRs (per 1000 person-years [PY]) and 95% confidence intervals (CI) of outcomes were estimated (overall and subgroups) and stratified by duration of IV pantoprazole treatment (< 4days versus ≥ 4days). Of 1879 eligible patients, none were identified in Subgroup 1; 851 (45.3%) and 1028 (54.7%) patients were identified in Subgroups 2 and 3, respectively. IRs of outcomes of interest ranged from 0.0 to 742.8 per 1000 PY. IRs were highest for vomiting (742.80), diarrhea (377.77), abdominal distension (214.31), hyponatremia (204.99), and hypokalemia (203.49). IRs were comparable between Subgroups 2 and 3. For most outcomes, IRs were higher among patients treated with IV pantoprazole for ≥ 4days versus those treated for < 4days. These results are consistent with the known safety profile of pantoprazole and emphasize the utility of using real-world data from pediatric populations for assessment of safety outcomes.

Reflux and Barrett's esophagus after sleeve gastrectomy: analysis of a statewide database.

Recent studies have suggested that sleeve gastrectomy (SG) is associated with the development of Barrett esophagus (BE) even in the absence of gastroesophageal reflux disease (GERD) symptoms. The aim of this study was to assess the rates of upper endoscopy and incidence of new BE diagnoses in patients undergoing SG. This was a claims-data study of patients who underwent SG between 2012 and 2017 while enrolled in a U.S. statewide database. Diagnostic claims data were used to identify pre- and postoperative rates of upper endoscopy, GERD, reflux esophagitis, and BE. Time-to-event analysis using a Kaplan-Meier approach was performed to estimate the cumulative postoperative incidence of these conditions. We identified 5562 patients who underwent SG between 2012 and 2017. Of these, 1972 patients (35.5%) had at least 1 diagnostic record of upper endoscopy. The preoperative incidences of a diagnosis of GERD, esophagitis, and BE were 54.9%, 14.6%, and .9%, respectively. The predicted postoperative incidences of GERD, esophagitis, and BE, respectively, were 18%, 25.4%, and 1.6% at 2 years and 32.1%, 85.0%, and 6.4% at 5 years. In this large statewide database, rates of esophagogastroduodenoscopy remained low after SG, but the incidence of a new postoperative esophagitis or BE diagnosis in patients who underwent esophagogastroduodenoscopy was higher than in the general population. Patients undergoing SG may have a disproportionately high risk of developing reflux complications including BE after surgery.

Impact of Omalizumab in Patients with Severe Uncontrolled Asthma and Possible Predictive Biomarkers of Response: A Real-Life Study

Most patients with asthma can control their symptoms with a basic standard of medical care and with maintenance and rescue medication. However, between 5% and 10% of asthmatics worldwide do not achieve control of their symptoms and have recurrent exacerbations and respiratory difficulties. The objective of the study was the real-life evaluation of the clinical improvement of patients with severe eosinophilic asthma treated with omalizumab, together with the search for biomarkers associated with the response. An observational retrospective cohort study was conducted that included patients with severe uncontrolled allergic asthma being treated with omalizumab. Three types of response were evaluated: lower use of oral corticosteroids, improvement in lung function, and reduction in exacerbations. A total of 110 patients under treatment with omalizumab were included, with a mean age of 48 ± 16 years. After 12 months had elapsed, significant reductions were found in the number of exacerbations, use of oral cortico-steroids and doses of inhaled corticosteroids (p < 0.001). Lung function and asthma control improved significantly (p < 0.001; p = 0.004) and eosinophil levels were significantly reduced (p = 0.004). Low scores in the Asthma Control Test were associated with the oral corticosteroid-saving effect; lower previous FEV1 levels and absence of chronic obstructive pulmonary disease (COPD) were related to improvement in lung function, and prior FEV1 values higher than 80% and absence of gastroesophageal reflux disease (GERD) with a reduction in exacerbations. The results of this study confirm the clinical benefit obtained after the introduction of omalizumab and the possible predictive biomarkers of response to the treatment.

The Evaluation of Gastric Emptying Using the 13 C-Acetate Breath Test in Neurologically Impaired Patients - A Focus on the Stomach Function and Morphology.

We explored factors affecting gastric emptying in neurologically impaired (NI) patients using the 13C-acetate breath test. Twenty-four NI patients were classified by the presence of gastroesophageal reflux disease (GERD), which was treated by fundoplication plus gastrostomy, or the absence of GERD, which was treated by gastrostomy alone, along with gastric malposition involving cascade stomach and organoaxial gastric volvulus (OGV). Gastric emptying parameters (GEPs), which were the emptying half time (T 1/2 , minute), the lag phase time (T lag , minute), and the gastric emptying coefficient (GEC), were measured before and after surgery. We evaluated the relationship between GEPs and GERD, gastric malposition, and surgical intervention. All data were expressed as the median (interquartile range). The T1/2 and GEC of patients with OGV were significantly worse than in those without OGV before surgery (T1/2 with OGV: 241.3 [154.9, 314.3] vs. T1/2 without OGV: 113.7 [105.2, 151.4], p = 0.01, GEC with OGV: 3.19 [2.46, 3.28] vs. GEC without OGV: 3.65 [3.24, 3.90], p = 0.02). GERD and cascade stomach were not associ ated with GEPs. The GEPs of all NI patients showed no significant difference between before and after surgery. The surgical change in T1/2 (ΔT 1/2 ) in the patients with OGV was significantly lower than in those without OGV (ΔT1/2 with OGV: -47.1 [-142.7, -22.1] vs. ΔT1/2 without OGV: -3.78 [-26.6, 12.0], p = 0.03). Stomach malposition, such as OGV, seems to affect gastric emptying and may be improved by surgi cal intervention.

The prevalence of gastroesophageal reflux disease in named manometric patterns of dysmotility according to the Chicago Classification 4.0.

Esophageal motility disorders (EMD) may be considered primary disorders only in the absence of gastroesophageal reflux disease (GERD). If GERD is present, treatment should be directed toward correction of the abnormal reflux. The actual prevalence of GERD in manometric dysmotility patterns according to the new Chicago Classification 4.0 (CC4) is still elusive. This study aims to evaluate the prevalence of GERD in patients with esophageal motility disorders according to the CC4. We reviewed 400 consecutive patients that underwent esophageal manometry and pH monitoring. Esophageal motility was classified according to the CC4 and GERD + was defined by a DeMeester score > 14.7. Normal motility or unclassified dysmotility was present in 290 (73%) patients, with GERD+ in 184 of them (63%). There were a total of 110 patients (27%) with named esophageal motility disorders, with GERD+ in 67 (61%). The incidence of ineffective esophageal motility was 59% (n = 65) with 69% GERD +, diffuse esophageal spasm was 40% (n = 44) with 48% GERD +, and hypercontractile esophagus was 0.01% (n = 1) with 100% GERD +. There was no correlation between the presence of GERD and the number of non-peristaltic swallows. Our results show that: (i) manometry only is not enough to select patients' treatment as >60% of patients with named esophageal motility disorders have GERD; (ii) there was no correlation between the presence of GERD and the number of non-peristaltic swallows.

Characterization of eosinophilic esophagitis variants by clinical, histological, and molecular analyses: A cross-sectional multi-center study.

ObjectivePhysicians are increasingly confronted with patients presenting with symptoms of esophageal dysfunction resembling eosinophilic esophagitis (EoE), but absence of significant esophageal eosinophilia. The purpose of this study was to characterize and classify this group of EoE variants.DesignPatients from six EoE‐centers with symptoms of esophageal dysfunction, but peak eosinophil counts of <60/mm2 (<15/hpf) in esophageal biopsies and absence of gastro‐esophageal reflux disease (GERD) were included. Clinical, endoscopic, (immuno)‐histological, and molecular features were determined and compared with EoE, GERD, and healthy controls.ResultsWe included 69 patients with EoE variants. Endoscopic abnormalities were found in 53.6%. We identified three histological subtypes: EoE‐like esophagitis (36/69, 52.2%), lymphocytic esophagitis (14/69, 20.3%), and non‐specific esophagitis (19/69, 27.5%). Immunohistochemistry revealed—in contrast to EoE—no significant increase in inflammatory cell infiltrates compared with GERD and healthy controls, except for lymphocytes in lymphocytic esophagitis. EoE‐typical Th2‐response was absent in all EoE variants. However, considerable structural changes were detected based on histology and protein expression. Using next generation mRNA sequencing, we found the three EoE variants to have distinct molecular fingerprints partially sharing pronounced traits of EoE. Hierarchical sample clustering of RNA sequencing data confirmed the presence of an EoE‐like (characterized by eotaxin‐3 expression), non‐specific, and lymphocytic variant cluster (characterized by CD3 cells and TSLP expression).ConclusionAll EoE variants are clinically and histologically active conditions despite the absence of esophageal eosinophilia. EoE variants appear to be part of a disease spectrum, where classical EoE represents the most common and apparent phenotype.

ID: 3524509 BARRETT'S ESOPHAGUS AFTER SLEEVE GASTRECTOMY: AN ANALYSIS OF INCIDENCE AND DIAGNOSTIC UPPER ENDOSCOPY RATES USING STATEWIDE CLAIMS DATA

Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery performed in the US and abroad. Recent studies have suggested that LSG is associated with the development of Barrett’s Esophagus (BE) even in the absence of gastroesophageal reflux disease (GERD) symptoms. Despite this, there is no current consensus on performing upper endoscopy (EGD) to screen for BE in patients who have undergone LSG. The aim of this study was to assess the rates of EGD and incidence of new BE diagnoses in patients undergoing LSG.

Changes in the Treatment of Primary Esophageal Motility Disorders Imposed by the New Classification for Esophageal Motility Disorders on High Resolution Manometry (Chicago Classification 4.0).

The Chicago Classification is the most used classification for primary esophageal motility disorders (PEMD). This classification was recently updated to the 4.0 version. This opinion piece focuses on the possible implications for the treatment of PMED determined by the new classification. Chicago Classification 4.0 included two new concepts for the diagnosis of achalasia: (1) type III achalasia diagnosis demands 100% absent peristalsis defined as either failed peristalsis or spasm; (2) “inconclusive diagnosis of achalasia” was added as a possibility. Both may decrease unnecessary treatment. Esophagogastric junction outflow obstruction, distal esophageal spasm, and hypercontractile esophagus were only considered clinically significant when correlated to supportive testing and relevant clinical symptoms and in the absence of gastroesophageal reflux disease. This may decrease the surge of treatment, especially peroral endoscopic myotomy, based solely on manometric diagnosis.

Effectiveness of Laparoscopic Sleeve Gastrectomy in Super-obese and Non-Super-obese Patients.

The primary aim of this study was to assess the effectiveness of sleeve gastrectomy (SG) in super-obese patients. The secondary aim was to identify patient characteristics associated with worse SG outcomes in this group. A retrospective analysis was carried out of our electronic prospective bariatric surgery patient database, including all patients who underwent SG between January 2007 and January 2017. The sample was divided according to the initial body mass index (BMI) (> or <50 kg/m). The initial characteristics and results in terms of weight loss and comorbidity resolution between the groups were compared. A subanalysis of the variable distributions was carried out according to whether or not the final BMI in the super-obese group had reached <35 kg/m. Data analysis was carried out using STATA 13.1, with a P-value <0.05 considered to be significant. The mean initial BMI was 42.8 kg/m in group 1 (<50 kg/m) and 55 kg/m in group 2 (>50 kg/m). The median follow-up (FU) was 56.2 months. Maximum weight loss was attained at the 18-month FU in both groups (BMI: 28.8 and 34.7 kg/m, respectively). At the 5-year FU, percentage of total weight loss was higher in group 2 and percentage of excess weight loss was statistically higher in group 1 (29.6% vs. 33.1% and 67% vs. 59%, respectively). Outcomes for type 2 diabetes mellitus, hypertension, and dyslipidemia were similar in both groups. The variables associated with attaining a final BMI <35 kg/m in the super-obese group were lower initial BMI, absence of baseline weight-related conditions (type 2 diabetes mellitus, obstructive sleep apnea syndrome, home continuous positive airway pressure, arthropathy, heart disease), and absence of gastroesophageal reflux disease. We observed a statistically significant increase in poor outcomes in patients with a higher initial BMI and with weight-related comorbidities. These parameters could be considered to be potentially good predictors of less satisfactory outcomes in the super-obese patients.

Metabolic syndrome and risk of esophageal adenocarcinoma in elderly patients in the United States: An analysis of SEER-Medicare data.

Metabolic syndrome (MetS) is associated with cancer risk and increases the risk of Barrett esophagus, which is the precursor lesion of esophageal adenocarcinoma (EA), primarily in the absence of gastroesophageal reflux disease (GERD). However, to the authors' knowledge, little is known regarding whether MetS is associated with the risk of EA. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database, the authors evaluated whether MetS was associated with EA. A total of 3167 cases of EA were compared with individually matched population controls (5:1); a subset of 575 EA cases were able to be individually matched with 575 Barrett esophagus controls. MetS was defined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in the period 1 to 3 years before the diagnosis of EA or control selection. Unconditional logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals. Potential effect modification by GERD symptoms and sex was examined in stratified models. EA was found to be significantly associated with MetS (odds ratio, 1.16; 95% confidence interval, 1.06-1.26) compared with population controls. In males, the association was restricted to those individuals without prior GERD; however, in females, MetS was found to be associated with EA regardless of GERD status. Effect modification by sex was observed (P for interaction = .01). MetS was not found to be associated with EA risk when compared with Barrett esophagus controls. In this older population, MetS was found to be associated with an increased risk of EA in males without GERD and females regardless of GERD status. Given the lack of an association when compared with Barrett esophagus controls, MetS may impact EA risk by primarily increasing the risk of the precursor lesion, Barrett esophagus. Cancer 2017;123:657-665. © 2016 American Cancer Society.

Metabolic syndrome in relation to Barrett⿿s esophagus and esophageal adenocarcinoma: Results from a large population-based case-control study in the Clinical Practice Research Datalink

Gastroesophageal reflux disease (GERD) causes local chronic inflammation that increases risks of Barrett⿿s esophagus (BE) and esophageal adenocarcinoma (EA), yet symptomatic GERD is absent in approximately half of all such patients. Obesity exacerbates GERD and is also a component of metabolic syndrome (MetS). We evaluated the hypothesis that MetS is a GERD-independent mechanism by which obesity is associated with increased risks of BE and EA using data from the UK Clinical Practice Research Datalink. BE cases (n=10,215) and EA cases (n=592) were each individually matched to five population controls based on age, sex, and general practice. MetS was defined as occurrence of at least three of the following: obesity, type 2 diabetes, hypertension, and high cholesterol. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression. MetS was marginally associated with BE (OR=1.12, 95%CI 1.00⿿1.25). Similar effects were found for the individual component factors of obesity, hypertension, and high cholesterol. History of GERD modified the association (P-effect modification <1E⿿5), with the MetS-BE association confined to patients without a history of GERD (OR=1.33, 95%CI 1.12⿿1.58). No association between MetS and risk of EA was detected in the main or stratified analyses. In this large population-based case-control study, individuals with MetS had a marginally increased risk of BE in the absence of GERD. The systemic inflammatory state (MetS) may represent a reflux-independent inflammatory pathway that increases the risk of BE. MetS did not increase risk of EA in this study population.

PH values in the pharynx of the patients presenting with compromised nasal breathing of inflammatory and non-inflammatory genesis concomitant with gastroesophageal reflux disease

The objective of the present study was to estimate the influence of gastroesophageal reflux disease (GERD) on the pH values in the pharynx and nose. It included 87 patients at the age varying from 18 to 81 years admitted to the Irkutsk-based Railway Clinical Hospital and allocated to four groups. Group 1 was comprised of 25 patients presenting with gastroesophageal reflux disease and chronic rhinosinusitis (CRS), group 2 consisted of 29 patients with CRS in the absence of GERD, group 3 included 22 patients with nasal septum deformations (NSD) and GERD, group 4 included 11 patients with NSD and motor rhinitis without GERD. The control group was formed from 10 volunteers. pH was measured by the contact method with the use ofEkokhim indicator paper. Gastroesophageal reflux disease was diagnosed following the recommendations of the Montreal consensus. It was shown that pH values in the pharynx of the patients with compromised nasal breathing of any origin in combination with GERD were lower than in the absence of GERD and in the healthy volunteers. The study groups did not differ in terms of pH values in the nasal cavity. It is concluded that pH values 4 or lower may serve as the criterion for pharyngo-laryngeal reflux (PLR) concomitant with HERD while pH 5 occurs more frequently in the patients with compromised nasal breathing of any etiology, regardless of the presence or absence of GERD.Disordered nasal breathing of any genesis in the patients presenting with gastroesophageal reflux disease was associated with the feeling of the lump in the throat, congestion of the respiratory tract and the nose, pain in the ears, cardialgia, and irregular heartbeat. It isrecommended to use pH measurements as a criterion for diagnostics of pharyngo-laryngeal reflux in the patients presenting with gastroesophageal reflux disease.

Azithromycin and COPD Exacerbations in the Presence or Absence of Symptoms or Active Treatment for Gastroesophageal Reflux.

Introduction: Gastroesophageal reflux disease (GERD) is common in chronic obstructive pulmonary disease (COPD) and is associated with COPD exacerbations. Since macrolides have prokinetic effects and consequently may decrease GERD, we hypothesized that azithromycin may decrease exacerbations by decreasing GERD. Methods: We conducted a retrospective review of data collected in a prospective, randomized, controlled trial of azithromycin for preventing COPD exacerbations. Participants were classified as having GERD on the basis of having a history of GERD or having a history or being treated for GERD. Results: We analyzed 1116 participants, 478 (43%) and 568 (51%) had GERD on the basis of history and history or treatment respectively. Individuals with GERD developed exacerbations sooner and more frequently, and were more likely to be hospitalized than those without GERD but the difference only reached significance when GERD was defined by history or treatment (P = 0.02, 0.02, and 0.03, respectively). Azithromycin reduced exacerbations regardless of the presence of GERD, but had a greater effect in those without GERD. Conclusions: GERD is associated with more frequent and severe COPD exacerbations. Azithromycin reduces COPD exacerbations regardless of the presence or absence of GERD but does so to a greater degree in individuals without GERD.

Association of MDM2 T309G and p53 Arg72Pro polymorphisms and gastroesophageal reflux disease with survival in esophageal adenocarcinoma

Although gastroesophageal reflux disease (GERD) is a risk factor for esophageal adenocarcinoma (EAC), some patients develop EAC in the absence of GERD. A putative mechanism of reflux-induced tumorigenesis involves disruptions in the p53 pathway. We assessed the interaction of GERD and p53 pathway polymorphisms on EAC prognosis. In a prospective cohort of 358 EAC patients, clinical data (including GERD history and survival) were collected. Germline DNA was genotyped for MDM2 T309G and p53 Arg72Pro. Cox proportional hazards models were used to determine adjusted hazard ratios (AHR) for associations between genotype, GERD, and genotype-GERD interactions with survival. Compared with other genotypes, MDM2 G/G (median overall survival 21 vs 30 months; P < 0.001) and p53 Pro/Pro (12 vs 30 months; P = 0.004) were associated with shorter survival. When analyzed by GERD, MDM2 G/G was associated with shorter survival in patients without GERD (AHR 3.4, 95% CI 2.0-6.0), but not in patients with GERD (AHR 1.1 [0.7-1.8]); the MDM2-GERD interaction was significant (P = 0.003). A similar trend was seen for p53 Pro/Pro (AHRs 2.5 without GERD vs 1.4 with GERD). Combined analysis of at-risk variants (MDM2 G or p53 Pro), revealed each additional at-risk variant was associated with shorter survival in patients without GERD (AHR 1.6) but not with GERD (AHR 1.0). MDM2 G/G and the combination of MDM2 G and p53 Pro were negative prognostic factors for EAC patients without GERD but not for those with GERD. There may be biological differences between GERD positive and GERD negative EAC.

2013 Update on Celiac Disease and Eosinophilic Esophagitis

Celiac disease is a chronic, immune-mediated disorder, characterized by small intestinal inflammation and villous atrophy after the ingestion of gluten by genetically susceptible individuals. Several extraintestinal manifestations have been associated to celiac disease. Eosinophilic esophagitis is a primary disorder of the esophagus characterized by upper gastrointestinal symptoms, absence of gastroesophageal reflux disease and more than 15 eosinophils per high-power field in biopsy specimens. Both celiac disease and eosinophilic esophagitis are caused by aberrant, but distinct, immune responses to ingested antigens and can be responsive to restricted food intake. The aim of this review is to assess whether there is an association between these two pathologies. In the majority of the studies examined, including the studies in pediatric population, the prevalence of eosinophilic esophagitis in subjects with celiac disease was about 10-times that of the general population. We suggest searching for eosinophilic esophagitis in all children undergoing endoscopy for suspicious celiac disease.

Overlap Between Postprandial Distress and Epigastric Pain Syndromes in Functional Dyspepsia: Its Implications for Research and Clinical Practice (Am J Gastroenterol 2013;108:767-774)

The Rome criteria have been the most widely used criteria for defining dyspepsia. The Rome III criteria have divided functional dyspepsia into postprandial distress syndrome (PDS), characterized by postprandial fullness and early satiation, and epigastric pain syndrome (EPS), characterized by epigastric pain or burning.1 PDS and EPS are thought to have different pathophysiology, so these 2 syndromes might have different responses to medication, allowing a more rational approach to drug discovery and development. In the present study, Vakil et al2 evaluated the Rome III criteria for functional dyspepsia taking into consideration of the degree of symptom overlap between the 2 subtypes, PDS and EPS. In addition, the proportion of patients with gastroesophageal reflux disease (GERD) who met the criteria for PDS and/or EPS was also evaluated to determine if these subtypes have value in separating GERD and functional dyspepsia in clinical practice. Primary care patients with one or more upper gastrointestinal symptoms at least twice a week for a month or longer were enrolled and underwent esophageal endoscopy and 24-hour pH-metry. GERD was defined as the presence of at least one of the following: reflux esophagitis, pathological esophageal acid exposure, and positive symptom association probability ≥ 95% for association of symptoms with acid reflux. Functional dyspepsia was defined by the absence of GERD and peptic ulcer disease on investigation, and PDS and/or EPS were diagnosed according to the Rome III criteria. Of the 336 study participants, 9 had peptic ulcer disease and were excluded from the study. One hundred and eighty-nine patients were diagnosed with GERD and 159 (84%) of them also met the criteria for PDS and/or EPS: 36 (19%) had PDS alone, 42 (22%) had EPS alone and 81 (43%) met the criteria for both PDS and EPS. The remaining 138 patients had upper gastrointestinal symptoms with normal endoscopy, pH-metry, and symptom association probability results, consistent with the presence of functional dyspepsia. Of these patients, 130 (94%) met the criteria for PDS and/or EPS: 13 (10%) had PDS alone, 31 (24%) had EPS alone, and 86 (66%) had both PDS and EPS. Heartburn and/or regurgitation were the predominant symptoms (most or second most bothersome symptoms reported on physician-administered symptom assessment) in 90 (57%) of 159 GERD patients with concomitant PDS and/or EPS, and in 39 (30%) of 130 functional dyspepsia patients with PDS and/or EPS (P < 0.0001). In multivariate analysis, PDS is not predictive of functional dyspepsia vs. GERD (OR, 1.120; 95% CI, 0.657-1.911); EPS is a weak predictor of functional dyspepsia (OR 2.910; 95% CI, 1.596-5.306). In summary, there was considerable overlap between PDS and EPS in patients with functional dyspepsia. The distinction of functional dyspepsia into the subgroups of PDS and EPS may not be effective in clinical trials or clinical practice. New strategies are required for the classification of functional dyspepsia.

The Los Angeles Classification of Gastroesophageal Reflux Disease

Endoscopic assessment of the esophagus for the presence or absence of gastroesophageal reflux disease (GERD) as well as the assessment of its severity is crucial to formulating decisions about the patient's management and prognosis. Therefore, a validated tool is required to ensure agreement among different endoscopists. The Los Angeles classification system of GERD is by far the most widely used system to describe the endoscopic appearance of reflux esophagitis and grade its severity.1 This article is part of an expert video encyclopedia.

A pregnant patient with excessive belching

We present a patient that developed severe belching during pregnancy. Esophageal pH-impedance monitoring revealed frequent supragastric belching, but not gastroesophageal reflux disease (GERD). Thus, severe belching during pregnancy can be due to a behavioral disorder in the absence of GERD. Belching complaints during pregnancy should therefore not always be treated as GERD.