Complications Of Gastroesophageal Reflux Research Articles

Diagnosis of Columnar Metaplasia of the Esophageal Mucosa in Patients with Complicated Gastroesophageal Reflux Disease

Aim: to improve methods of diagnostics of esophageal mucosal forms of metaplasia and dysplasia in patients with complicated forms of gastroesophageal reflux disease (GERD) using multidisciplinary approach.Material and methods. Overall, 131 patients aged 18 to 84 years (mean age — 55.8 ± 16.7 years) with confirmed diagnosis of GERD complicated by development of metaplasia of mucosa of distal esophagus were included in retroand prospective study. At the prehospital stage the patients' complaints were estimated, anamnesis was taken. At the first stage of the diagnostic program all patients underwent detailed esophagogastroduodenoscopy in high resolution with white light. The region of esophageal mucosa with signs of metaplasia and determination of its prevalence was examined and evaluated with special attention. Ultrashort segment was revealed in 26 patients, short segment — in 47 patients, long segment of mucosal metaplasia was revealed in 58 patients. Then to reveal the signs of dysplasia we used specifying endoscopic methods: the structure of pitted and microvascular pattern was estimated in narrow spectral mode using BING classification system. If an irregular type of metaplasized epithelium structure was detected in the process of BING assessment, the areas suspicious for dysplasia were marked, followed by aim forceps biopsy from them. The next stage was staining of the metaplasized segment with 1.5 % ethanic acid solution — acetowhitening. PREDICT classification system was used to evaluate the stained mucosal sections with metaplasia. Targeted forceps biopsy was performed from the altered areas that most quickly lost their coloring. The final stage of the diagnostic program in all patients was a forceps biopsy of the mucosa of the metaplasic segment according to the Seattle protocol, which requires increasing the number of fragments as the metaplasic segment lengthens in a “blind” biopsy. The biopsy material was stained with hematoxylin and eosin, and periodic acid Schiff reaction was performed in combination with alcyanine blue according to the standard technique.Results. Endoscopic examination in white light and evaluation of metaplasia extent revealed ultrashort segment (<1 cm) in 26/131 (19.9 %) patients; short segment (1–3 cm) — in 47/131 (35.9 %); long segment (> 3 cm) — in 58/131 (44.3 %) patients. Among the diagnostic techniques used, the BING and PREDICT classifications had the highest accuracy, sensitivity, and specificity (accuracy — 88.9 and 95.3 %, sensitivity — 90.5 and 91.3 %, and specificity — 86.7 and 100 %, respectively), which significantly exceeded the Seattle protocol also used in this work. The results showed a low level of specificity (31.2 %), accuracy (54.5 %), and sensitivity (76.8 %) of the Seattle protocol. The use of BING and PREDICT classifications provided marking of compromised zones, allowing targeted histological sampling.Conclusions. The original study demonstrated the greatest sensitivity, specificity, and accuracy of PREDICT and BING methods in the diagnosis of metaplasia with signs of dysplasia in patients with complicated GERD. It is also important that the use of BING and PREDICT classification systems allows to reduce the number of biopsy samples in comparison with their unreasonably large number according to the Seattle protocol, thereby reducing mucosal and submucosal trauma of the esophagus and the risk of complications.

GERD surgery in non-neurologic patients: Modified Laparoscopic Hill-Snow Repair is a valid alternative to Nissen fundoplication. Results of a 20 years of follow-up

Nowadays laparoscopic Nissen fundoplication represents the gold standard in surgical treatment of complicated Gastro-Esophageal-Reflux Disease (GERD), above all in cerebral palsy patients. In non-neurological patients without gastrostomy Nissen fundoplication can create some problems (gas bloat syndrome, dysphagia). Laparoscopic Hill-Snow repair is an established surgical alternative, but it is reported only in adult population. We describe our modification of Hill-Snow technique and our experience in a large series of non-neurological children in order to report its effectiveness and applicability in pediatric patients affected by complicated GERD. Between 2000 and 2022, 319 children underwent surgical correction of gastro-esophageal reflux at our Department. All were affected by complicated gastro-esophageal reflux unresponsive to PPI (Proton Pump Inhibitors). 251 underwent laparoscopic Nissen fundoplication; 68 non-neurological patients underwent laparoscopic Hill-Snow repair. Of these 68 children 48 were males (71%) and 20 females (29%); median age was 5years (3 months-11 years). Weight range was 4-37kg. 52 patients (76.5%) presented the following symptoms: retrosternal pain, dysphagia, regurgitation, coughing, failure to thrive, persisting reflux esophagitis. 16 (23.5%) had chronic respiratory problems (aspiration, apneic-spells, dysphagia, coughing, choking, gagging). For 8 (11.8%) symptoms were expression of chronic recurrent gastric volvulus. All underwent modified-laparoscopic-Hill-Snow repair. Contrast study showed sliding hiatal hernia in 55 patients (81%), while endoscopy demonstrated 16 cases of histologically severe esophagitis (23.5%) and 52 of mild esophagitis (76.5%). No intraoperative/postoperative complications were recorded. 60patients had a complete follow-up (range 1-20 years). 60/68 patients were evaluated with barium-swallow-study at 6-12 months; 40/68 patients with upper-gastrointestinal-endoscopy at 12months. No relapse was reported. 50 patients (73.7%) were symptom-free. 18 (26.3%) referred occasional epigastric pain, associated with vomit in 2 cases. 64 (94.1%) referred ability to vomit; 4 temporary difficulty to swallow (average 30 days). All patients reported being able to burp. 3(4.5%) presented episodes of gas-air-bloat during the first 2 months with spontaneous resolution. No case of dumping syndrome was recorded. This technique's modification yields excellent results in term of relapse and side effects at long-term follow-up. We reported the first and largest pediatric series in non-neurological children with encouraging results.

Long-term efficacy of peroral endoscopic circular myotomy and full-thickness myotomy on treatment of achalasia of cardia

Objective To compare the long-term efficacy and complications of peroral endoscopic circular myotomy and full-thickness myotomy for patients with achalasia of cardia. Methods A retrospective analysis was performed on the data of 53 patients with achalasia of cardia, who underwent peroral endoscopic myotomy in the First Affiliated Hospital of Zhengzhou University from June 2012 to December 2014 and were followed-up regularly.Twenty-one patients underwent circular myotomy, and the other 32 patients underwent full-thickness myotomy. The postoperative long-term efficacy and gastroesophageal reflux complications of the two groups were compared. Results The effective rate of the circular myotomy group and the full-thickness myotomy group was 90.5% (19/21) and 100.0% (32/32), respectively(P=0.152). There were no significant differences between the two groups on postoperative Eckardt scores, lower esophageal sphincter pressure and 4 s integrated relaxation pressure(P>0.05). The incidence of clinically relevant gastroesophageal reflux of full-thickness myotomy group was higher than that of circular myotomy group (40.6% VS 14.3%, χ2=4.174, P=0.041). Conclusion The long-term efficacy of circular myotomy is similar to that of full-thickness myotomy, but the incidence of clinically relevant gastroesophageal reflux is higher in full-thickness myotomy. Key words: Achalasia, cardia; Peroral endoscopic myotomy; Circular myotomy; Full-thickness myotomy; Long-term efficacy

Prevalence of Erosive Tooth Sensitivity in Patients with GERD

Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus, and GERD is symptom or complication of GER. The most common extra oral manifestation of GERD is a progressive, irreversible loss of dental hard tissues due to a chemical process not involving bacteria. Tooth sensitivity is a common complaint in local population. Because of dietary habits, GERD is a prevalent condition in local region as well. To study the prevalence of dental wear and sensitivity in patients with gastric problems, an observational study was conducted. Sample size was 210 patients examined in different dental clinics and hospitals of Lahore. A questionnaire was used to collect data covering various aspects. Out of recruited subjects showing symptoms of GERD, only 38% people were diagnosed with GERD. All the recruited subjects were having dental problems and out of them 38% considered visiting dentist. The study showed that many respondents used to consume citrus fruits, carbonated drinks; tea/coffee frequently. Effective outcome of dental erosion treatment requires counseling and oral hygiene information. This study determined the GERD patients were at higher risk of developing dental erosion com¬pared to the healthy individuals in a sample of Pakistani population

Does Nissen fundoplication improve deglutition in children?

Soyer T, Yalçın Ş, Demir N, Karhan AN, Saltık-Temizel İN, Demir H, Tanyel FC. Does Nissen fundoplication improve deglutition in children? Turk J Pediatr 2017; 59: 28-34. A prospective study was performed to evaluate the effect of Nissen fundoplication (NF) on deglutition in children. Children who underwent NF between 2011-2015 were evaluated for demographic features, clinical findings, diagnostic methods for gastroesophageal reflux (GER) and indications for NF. Penetration aspiration scale (PAS), functional oral intake scale (FOIS) and esophageal functions were evaluated by videoflouroscopy (VFS). Preoperative and postoperative VFS findings were compared to evaluate the effect of NF on clinical findings and deglutition. Twenty-three children with a mean age of 5.08 ± 3.7 years were included. Female to male ratio was 15:8. Recurrent respiratory infections (RTI) (n: 14, 60.8%), swallowing dysfunction (n:13, 56.5%) and vomiting (n:10, 43.4%) were the most common symptoms. Preoperatively GER was diagnosed with barium swallowing study (BSS) contrast graphs (n:20, 87%) and with 24-hour esophageal pH monitorization (n:8, 34.8%). In 39.1% of patients, medical treatment for GER was used with a mean duration of 8 ± 5.8 months. Indications for NF were swallowing dysfunction (n: 18, 78%), GER complications (n:6, 26%), associated anatomical problems (n:4, 17.3%) and unresponsiveness to medical treatment (n: 3, 13%). Postoperative barium swallowing study and 24-hour esophageal pH monitorization showed no GER after NF in 95% of patients. Number of RTI were significantly decreased after NF (preoperative vs postoperative infection rate 4.21 vs 1.6 respectively, p < 0.05). VFS findings showed that PAS was significantly decreased after NF during both liquid and semi-liquid swallowing (p < 0.05). After NF, upper esophageal opening (UEO) was decreased when compared to preoperative VFS findings (p < 0.05 Esophageal cleaning, esophageal motility, esophageal backflow and lower esophageal sphincter narrowing did not alter after NF (p > 0.05). FOIS were significantly improved after NF (p < 0.05). VFS findings showed that penetration and aspiration were significantly decreased after NF and children had less RTI. Although, esophageal motility evaluated by VFS did not changed after NF, functional oral intake significantly improved in children.

Gastroesophageal reflux disease with Thal fundoplication

Gastroesophageal reflux (GER) is a common phenomenon among heathy infants, with approximately 50% of infants aged 0 to 3 months and 67% of infants aged 4 months experiencing at least one episode of vomiting per day. GER defined as regurgitation of gastric contents into the esophagus or mouth. GER typically improves through the first postnatal year, with only 5% of healthy 12 month old infants experiencing vomiting.1,2 Complicated GER or gastroesophageal reflux disease (GERD) has been reported to affect up to 8% of infants and children with GER.l,3 Antireflux procedures (ARPs) are increasingly offered to control GERD symptoms. We report a case of a baby with GERD and treated with ThaI fundoplication procedures. Fundoplication procedure is rarely performed in management of GERD, and this is the first fundoplication procedure in children with GERD at M. Djamil Hospital.

Idiopathic Pulmonary Fibrosis: Novel Concepts of Proton Pump Inhibitors as Antifibrotic Drugs.

The prevalence of abnormal acid gastroesophageal reflux (GER) is higher in patients with idiopathic pulmonary fibrosis (IPF) than in matched control subjects. Several studies demonstrated that more than one-third of patients with IPF have abnormal esophageal acid exposures. In addition, many of these studies indicate that the majority of patients with IPF have silent reflux with no symptoms of GER. Findings of abnormal reflux persist in a large proportion of patients with IPF placed on antacid therapy such as proton pump inhibitors (PPIs). This seemingly paradoxical observation suggests that either patients with IPF are somehow resistant to PPI-based intervention or PPIs are inherently unable to suppress acid GER. By contrast, patients with IPF who undergo Nissen fundoplication surgery are effectively relieved from the complications of GER, and retrospective studies suggest improved lung function. Retrospective, anecdotal data suggest a beneficial role of PPIs in IPF including stabilization of lung function, reduction in episodes of acute exacerbation, and enhanced longevity. The recent evidence-based guidelines for treatment of IPF approved conditional recommendation of PPIs for all patients with IPF regardless of their GER status. Recently, we have reported that PPIs possess antiinflammatory and antifibrotic activities by directly suppressing proinflammatory cytokines, profibrotic proteins, and proliferation of lung fibroblasts. Our study provides an alternative explanation for the beneficial effect of PPIs in IPF. In this Perspective, we reviewed emerging progress on antifibrotic effect of PPIs using IPF as a disease model. In addition, we summarized surgical and pharmacological interventions for GER and their downstream effect on lung physiology.

The most common errors in the management of gastroesophageal reflux

Gastro-Esophageal Reflux (GER) occurs in more than two-thirds of otherwise healthy children and is one of the major reason for referral to paediatricians; in fact, a quarter of all paediatric visits in the first six months of life [1] and numerous accesses to the paediatric gastroenterologist services are secondary to GER. GER is defined as the passage of gastric contents into the esophagus and is different from gastroesophageal reflux disease (GERD), which includes all the symptoms and/or complications associated with GER [2]. GER is considered a physiological normal process which occurs several times a day in healthy infants, children and adults. GER is usually associated with transient lower esophageal sphincter relaxations independent from swallowing, which allow the passage of gastric contents into the esophagus. Episodes of GER in healthy adults tend to occur after meals, lasting less than three minutes and usually do not cause symptoms. Although we know less on the normal physiology of newborns and infants, regurgitation is the most visible symptom and tends to occur daily in 50% of all infants with a peak incidence between 4 and 6 months of life [3]. For the majority of paediatric patients (especially in infants), the clinical history and the objective appraisal, in the absence of danger signals, are sufficient to reliably diagnose a not complicated GER and initiate conservative treatment strategies; in general, the diagnostic tests are not always necessary. The reliability of the symptoms to make the clinical diagnosis of GERD is higher in children younger than 8 years, reporting heartburn: only in this case, the doctor can make a diagnosis of Gastro Esophageal Reflux Syndrome and give an indication for therapy [4]. To date, no single symptom or set of symptoms can be trusted, and then used to diagnose GERD in children or to predict which patients are more likely to respond to therapy [2]. The only exception is the child (age> 8y.o.) reporting a history of long-term heartburn with or without vomiting. The new ESPGHAN/NASPGHAN guidelines [2] describe different treatment options for the treatment of infants / children with GER and GERD. In particular, they emphasized the changes in lifestyle, because it can effectively reduce the symptoms of both infants and children. They are based on a combination of changes of milk formulas and positional therapy. In infants with GER, it can be effective the changes to the mother's diet if children are breastfed, change the formula in use, reducing the volume of the single meal associated with an increased frequency of feedings. In particular, the guidelines stress that the allergy to milk proteins may have a clinical presentation similar to GERD. A strategy of nutritional intervention involves the use of thickened formulas that are able to decrease the regurgitation. A recent meta-analysis has shown that the anti regurgitation formula have the following functions: a) increase the number of infants without regurgitation; b) reduce the number of episodes of regurgitation and vomiting daily; c); increase the weight recovery of the infant, d) although they do not change the 24 hours pH study [4].

Esophageal Strictures during Treatment with a Proton Pump Inhibitor

Background: The development of esophageal stricture during treatment with high dose chemotherapeutic agents is well known and documented in the literature. With the introduction of proton pumps inhibitors (PPI), the gastroesophageal reflux disease (GERD) induced stricture has shown significant improvement. The aim of this report is to remind of the fact that the chemotherapy induced strictures show poor response and their treatment is still a challenge. Case presentation: Here, we reported a boy with Down syndrome and congenital heart disease who developed acute lymphoblastic leukemia and subsequent esophageal stricture during treatment with a PPI. Conclusion: It is important to be aware of this potential complication of gastroesophageal reflux or antineoplastic treatment, even in cases thought to be adequately treated with a proton pump inhibitor, and that the start of PPI’s is also the start of an evaluation of the use of this medication.

Prevalence of Gastroesophageal Reflux during First Year of Life in Infants Admitted in Pediatric Department of Imam Reza Hospital-Mashhad

Introduction: Gastroesophageal reflux (GER) is the most common of esophageal disorder in all ages. GER defined as passage of gastric contents into the esophagus, and GER disease (GERD), (symptoms or complications of GER), are common pediatric problems. Clinical manifestations of GERD in infants include regurgitation, irritability, choking, gagging vomiting, poor weight gain and respiratory disorder. The purpose of this study is evaluation prevalence of Gastroesophageal reflux and its symptoms in infants during first year of life. Materials and Method: This study was performed on 75 infants younger than one year old, who were admitted in pediatric department of Imam Reza Hospital in Mashhad during 3 months. Results: In this study in a three- month period, GER was assessed in 75 infants younger than one year who were admitted in pediatric department of Imam Reza Hospital. Their parents reported GER in 66% of these infants. The most common symptom of reflux was regurgitation. Regurgitation was reported at least once a day to seven times a day. The other reported symptoms were respectively: irritability (16%), choking (10%), and failure to thrive (0.3%). Peak reported regurgitation was 60% at 3.5 months. Conclusion: Gastroesophageal reflux is a common problem in infancy. Complaints of regurgitation are common during the first year of life. So understanding the symptoms of GER and recognition of GERD should be considred. Keyword: Infant,Gastroesophageal Reflux, Prevalence.

The role of endoscopy in the evaluation and management of dysphagia

The role of endoscopy in the evaluation and management of dysphagia

Tu1782 Weak Peristalsis With Large Breaks Is Associated With Higher Acid Exposure and Delayed Reflux Clearance in the Supine Position in GERD Patients

INTRODUCTION It has been demonstrated that among esophageal motor abnormalities, impaired peristalsis of the esophageal body may account for delayed bolus transit and impaired esophageal refl ux clearance in patients with complicated gastroesophageal refl ux disease (GERD) ( 1,2 ). In particular, several studies have shown that ineffective esophageal motility (IEM), defi ned as the presence of peristaltic waves at the distal esophagus with amplitude < 30 mm Hg and / or nontransmitted proximal contractions, is frequently observed in GERD patients; however, the functional relevance remains controversial ( 3 ). In GERD patients, increasing degrees of esophageal mucosal damage have been reported either to cause, or be the result of, severe worsening of esophageal function ( 4,5 ). Nevertheless, even if IEM has been associated with prolonged acid exposure time (AET) ( 6 ), it has been demonstrated that in GERD patients, only severe, but not mild IEM, is associated with prolonged clearance and AET, particularly when in the supine position ( 7 ). Th e recent development of high-resolution manometry (HRM) has led to an improvement of our knowledge regarding esophageal motility and is considered the gold standard in the study of esophageal motor disorders ( 8 ). Indeed, HRM combined with multichannel impedance (HRM-MI) monitoring allows simultaneous recording and analysis of the esophageal motility and of the bolus transit. Fox et al. ( 9 )demonstrated, using HRM coupled with videofl uoroscopy, that HRM pressure topography plots predict bolus transit more accurately than conventional manometry. Moreover, these authors reported that, as a consequence of the increased spatial resolution, HRM is also able to detect segmental breaks of the esophageal peristalsis that would otherwise have been missed with conventional manometry. More recently, Bulsiewicz et al. ( 10 ) showed in healthy subjects and in patients with nonobstructive dysphagia that peristaltic breaks of < 2 cm in the 20 mm Hg or < 3 cm in the 30 mm Hg isobaric contour are associated with complete bolus clearance, whereas larger breaks predict delayed bolus clearance. Moreover, it has been proposed that weak peristalsis could be defi ned Weak Peristalsis With Large Breaks Is Associated With Higher Acid Exposure and Delayed Refl ux Clearance in the Supine Position in GERD Patients

518 Incidence and Clinical Course of Barrett's Esophagus Pre- and Post-Lung Transplantation

Patients with advanced lung disease often have gastro-esophageal reflux (GER) or develop GER post lung transplantation. GER has been postulated to be associated with rejection after lung transplantation. However, the incidence or natural history of Barrett's esophagus, a complication of GER and a risk factor for development for esophageal carcinoma in this patient population is unknown.

Nissen Fundoplication in Infants and Children: A Long Term Clinical Study

Methodology: Twenty six neurologically normal children (16 boys and 10 girls between 6 months and 11 years old) underwent Nissen fundoplication for intractable or complicated gastroesophageal reflux between October 1982 and February 2002. Before surgery and at follow up visits, all children were subjected to thorough history, barium meal study and gastroscopy with multiple esophageal biopsies. The mean duration of follow up was 68 ± 64 months (range: 3 months - 19 years).Results: Persistent vomiting or regurgitation since birth was the main symptom (24 patients, 92.3%), chest symptoms occurred in 5 patients (19.2%), malnutrition and retarded growth were found in 4 patients (15.4%), haematemesis and/or melena occurred in 2 patients (7.7%) and dysphagia due to esophageal stricture occurred in 4 patients (15.4%). There was no mortality. The mean hospital stay was 4.1days. Twenty two patients (84.6%) had no recurrent reflux. Reflux symptoms recurred in 4 cases (15.4%). One of these cases had no evidence of recurrent pathological reflux, 2 cases with preoperative stricture developed wrap disruption, recurrent reflux and restricture. Both refused second operation. The fourth case developed melena and reflux esophagitis due to wrap herniation through the hiatus and was successfully managed by second operation.Conclusion: Nissen fundoplication is an effective operation to correct gastroesophageal reflux in infants and children when the drug therapy fails. The operation should be done before occurrence of complications to decrease the recurrence of reflux.

Gastroesophageal Reflux Is Not Associated With Dental Erosion in Children

Dental erosion is a complication of gastroesophageal reflux (GER) in adults; in children, it is not clear if GER has a role in dental pathologic conditions. Dietary intake, oral hygiene, high bacterial load, and decreased salivary flow might contribute independently to GER development or dental erosion, but their potential involvement in dental erosion from GER is not understood. We investigated the prevalence of dental erosion among children with and without GER symptoms, and whether salivary flow rate or bacterial load contribute to location-specific dental erosion. We performed a cross-sectional study of 59 children (ages, 9-17 y) with symptoms of GER and 20 asymptomatic children (controls); all completed a questionnaire on dietary exposure. Permanent teeth were examined for erosion into dentin, erosion locations, and affected surfaces. The dentist was not aware of GER status, and the gastroenterologist was not aware of dental status. Stimulated salivary flow was measured and salivary bacterial load was calculated for total bacteria, Streptococcus mutans, and Lactobacilli. Controlling for age, dietary intake, and oral hygiene, there was no association between GER symptoms and dental erosion by tooth location or affected surface. Salivary flow did not correlate with GER symptoms or erosion. Erosion location and surface were independent of total bacteria and levels of Streptococcus mutans and Lactobacilli. Location-specific dental erosion is not associated with GER, salivary flow, or bacterial load. Prospective studies are required to determine the pathogenesis of GER-associated dental erosion and the relationship between dental caries to GER and dental erosion.

Verrucous carcinoma of the esophagus: a complex diagnosis

We present the case of a 71-year-old woman with complicated gastroesophageal reflux disease with a peptic stricture located 30 cm from the incisors. There was no history of caustic ingestion or alcohol, or use of tobacco. Following four attempts at endoscopic dilation, a self-expanding, removable plastic stent had been placed previously. After 4 months of the placement of the stent, the patient experienced progressive dysphagia, retrosternal pain, and hematemesis. Esophagogastroduodenoscopy (EGD) showed clots in the esophageal lumen. After stent removal, an exophytic mass causing partial stenosis was identified in the mid-esophagus ([Fig. 1]). Histological evaluation revealed only inflammatory changes. Endoscopic ultrasound showed invasion through the muscularis propria, with a nonspecific paraesophageal lymph node. Fine-needle aspiration cytology was also negative for malignancy. Thoracoabdominal computed tomography (CT) showed no distant lesions.

Review: A clinical guide to using intravenous proton-pump inhibitors in reflux and peptic ulcers

Intravenous (IV) proton-pump inhibitors (PPIs) are potent gastric acid suppressing agents, and their use is popular in clinical practice. Both IV and oral PPIs have similarly short half-lives, and their effects on acid secretion are similar, thus their dosing and dosage intervals appear to be interchangeable. The possible exception is when sustained high pHs are required to promote clot stabilization in bleeding peptic ulcers. Continuous infusion appears to be the only form of administration that reliably achieves these high target pHs. IV PPI is indicated in the treatment of high-risk peptic ulcers, complicated gastroesophageal reflux, stress-induced ulcer prophylaxis, Zollinger-Ellison syndrome, and whenever it is impossible or impractical to give oral therapy. The widespread use of PPIs has been controversial. IV PPIs have been linked to the development of nosocomial pneumonia in the intensive care setting and to spontaneous bacterial peritonitis in cirrhotic patients. This review discusses the use of IV PPI in different clinical scenarios, its controversies, and issues of appropriate use.

Effect of Zolpidem on the Sleep Arousal Response to Nocturnal Esophageal Acid Exposure

Nocturnal acid reflux is associated with complicated gastroesophageal reflux (GER) disease. Nocturnal GER initiates a protective arousal reflex, which induces a swallow to clear esophageal acid. The purpose of this study was to determine the effect of zolpidem on the sleep arousal mechanism and acid clearance in patients with documented GER, compared with control subjects with normal acid exposure. Eight controls and 16 GER patients were enrolled in a randomized, double-blind, placebo-controlled study. Zolpidem or placebo was given on separate nights. Reflux events and reflux-associated arousals or awakenings were recorded using simultaneous esophageal pH recording and standard polysomnography. Nocturnal acid exposure resulted in a sleep arousal 89% of the time in participants (with and without GER) given placebo but only 40% in those given zolpidem (P < .01). In controls given placebo, acid reflux events lasted 1.15 +/- 0.28 seconds; in controls given zolpidem, they lasted 15.67 +/- 12.42 seconds (P < .01). In GER patients given placebo, the acid reflux events lasted 37.8 +/- 17.2 seconds compared with 363.3 +/- 139.3 seconds with zolpidem (P < .01). With zolpidem reflux events lasted 630.6 +/- 236.5 seconds when no arousal occurred and 49.2 +/- 19.11 seconds when an arousal was recorded (P < .001). Zolpidem reduced the arousal response to nocturnal acid exposure and increased the duration of each esophageal acid reflux event in healthy individuals and patients with GER. Because nocturnal acid exposure was prolonged, hypnotic use by patients with GER could lead to increased risk for complicated disease.

Prevalence of Complicated Gastroesophageal Reflux Disease and Barrett’s Esophagus Among Racial Groups in a Multi-Center Consortium

The Clinical Outcomes Research Initiative database was used to evaluate ethnic trends in complicated reflux disease and suspected Barrett's esophagus among various racial groups. Endoscopic findings for procedures performed January 2000-December 2005 for any indication and for reflux-related indications were reviewed by racial group. Of 280,075 procedures examined, Hispanics were the most likely to have esophagitis (Hispanic 19.6%, white 17.3%, black 15.8%, Asian/Pacific Islander 9.5%, P-value<0.0001), and white subjects were most likely to have suspected BE (white 5.0%, Hispanic 2.9%, Asian/Pacific Islander 1.8%, black 1.5%, P-value<0.0001). Endoscopies performed for reflux-related indications had similar trends for esophagitis and esophageal stricture. Among reflux/Barrett's screening procedures adjusted for age and gender, Hispanics were most likely to have esophagitis (OR=1.28, P-value<0.0001) compared to Caucasians. Our results demonstrate an association of suspected Barrett's esophagus and stricture with white patients and esophagitis with Hispanic patients. These findings need to be followed-up with further study.

Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center

Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty-two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.