Endoscopic Reflux Esophagitis Research Articles

Lifestyle factors affecting gastroesophageal reflux disease symptoms: a cross-sectional study of healthy 19864 adults using FSSG scores

BackgroundGastroesophageal reflux disease (GERD) is a very common disorder worldwide, comprised of reflux esophagitis (RE) and non-erosive reflux disease (NERD). As more than half of GERD patients are classified into the NERD group, precise evaluation of bothersome epigastric symptoms is essential. Nevertheless, compared with many reports targeting endoscopic reflux esophagitis, large-scale studies focusing on GERD symptoms have been very scarce.MethodsTo elucidate lifestyle factors affecting GERD symptoms, 19,864 healthy adults in Japan were analyzed. Sub-analyses of 371 proton pump inhibitor (PPI) users and 539 histamine H2-receptor antagonist (H2RA) users were also performed. Using the FSSG (Frequency Scale for the Symptoms of GERD) score as a response variable, 25 lifestyle-related factors were univariately evaluated by Student's t-test or Pearson's correlation coefficient, and were further analyzed with multiple linear regression modelling.ResultsAverage FSSG scores were 4.8 ± 5.2 for total subjects, 9.0 ± 7.3 for PPI users, and 8.2 ± 6.6 for H2RA users. Among the total population, positively correlated factors and standardized coefficients (β) for FSSG scores are inadequate sleep (β = 0.158), digestive drug users (β = 0.0972 for PPI, β = 0.0903 for H2RA, and β = 0.104 for others), increased body weight in adulthood (β = 0.081), dinner just before bedtime (β = 0.061), the habit of midnight snack (β = 0.055), lower body mass index (β = 0.054), NSAID users (β = 0.051), female gender (β = 0.048), lack of breakfast (β = 0.045), lack of physical exercise (β = 0.035), younger age (β = 0.033), antihyperglycemic agents non-users (β = 0.026), the habit of quick eating (β = 0.025), alcohol drinking (β = 0.025), history of gastrectomy (β = 0.024), history of cardiovascular disease (β = 0.020), and smoking (β = 0.018). Positively correlated factors for PPI users are female gender (β = 0.198), inadequate sleep (β = 0.150), lack of breakfast (β = 0.146), antihypertensive agent non-users (β = 0.134), and dinner just before bedtime (β = 0.129), whereas those for H2RA users are inadequate sleep (β = 0.248), habit of midnight snack (β = 0.160), anticoagulants non-users (β = 0.106), and antihypertensive agents non-users (β = 0.095).ConclusionsAmong many lifestyle-related factors correlated with GERD symptoms, poor quality of sleep and irregular dietary habits are strong risk factors for high FSSG scores. At present, usual dose of PPI or H2RA in Japan cannot fully relieve GERD symptoms.

Effect of Helicobacter pylori treatment on gastroesophageal reflux disease (GERD): meta-analysis of randomized controlled trials

Objective. Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of acidic gastric contents into the esophagus leading to tissue damage and symptoms. The role of H. pylori in the pathogenesis of GERD is controversial. Therefore, we performed a meta-analysis on the effect of H. pylori treatment on symptomatic as well as endoscopic changes associated with GERD. Material and methods. Multiple medical databases were searched (4/2011). Randomized controlled trials (RCTs) comparing H. pylori treatment with no treatment on symptomatic adults with GERD were included. The effects of H. pylori eradication were analyzed by calculating pooled estimates for new onset or changes in the symptoms of GERD or endoscopic reflux esophagitis. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency. Results. Ten trials met the inclusion criteria. No statistically significant effect was found for symptomatic GERD (OR 0.81, 95% CI 0.56–1.17, p = 0.27) or endoscopic evidence of reflux esophagitis (OR 1.13; 95% CI: 0.72–1.78, p = 0.59) between the two groups. A subgroup analysis of eradication data revealed a statistically significant lower incidence of GERD symptoms in the eradicated group (13.8%) compared with the non-eradicated group (24.9%) (OR 0.55; 95% CI: 0.35–0.87, p = 0.01). Funnel plot revealed no publication bias. Conclusions. Treatment of H. pylori does not seem to increase GERD symptoms or reflux esophagitis. However, documented eradication of H. pylori appears to significantly improve GERD symptoms.

Epidemiology of Gastroesophageal Reflux Disease in Asia: A Systematic Review

Ethnic and geographical differences are important factors in studying disease frequencies, because they may highlight the environmental or genetic influences in the etiology. We retrieved the studies which have been published regarding the epidemiologic features of gastroesophageal reflux disease (GERD) in Asia, based on the definitions of GERD, study settings, publication years and geographical regions. From the population-based studies, the prevalence of symptom-based GERD in Eastern Asia was found to be 2.5%-4.8% before 2005 and 5.2%-8.5% from 2005 to 2010. In Southeast and Western Asia, it was 6.3%-18.3% after 2005, which was much higher than those in Eastern Asia. There were robust epidemiologic data of endoscopic reflux esophagitis in medical check-up participants. The prevalence of endoscopic reflux esophagitis in Eastern Asia increased from 3.4%-5.0% before 2000, to 4.3%-15.7% after 2005. Although there were only limited studies, the prevalence of extra-esophageal syndromes in Asia was higher in GERD group than in controls. The prevalence of Barrett's esophagus was 0.06%-0.84% in the health check-up participants, whereas it was 0.31%-2.00% in the referral hospital settings. In summary, the prevalence of symptom-based GERD and endoscopic reflux esophagitis has increased in Asian countries. However, the prevalence of Barrett's esophagus in Asia has not changed and also still rare.

Effect of Helicobacter pylori Eradication on Gastroesophageal Reflux Disease (GERD): Meta-Analysis of Randomized Controlled Trials

Purpose: Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of acidic gastric contents into the esophagus leading to tissue damage and symptoms. The role of H. pylori in the pathogenesis of GERD is controversial. Some studies indicate a protective role, whereas others fail to show any beneficial effect. Therefore, we performed a meta-analysis on the effect of H. pylori. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (5/2010). Randomized controlled trials (RCTs) comparing H. pylori eradication versus no eradication on symptomatic as well as endoscopic changes with GERD were included. Standard forms were used to extract data by two independent reviewers. The effects of H. pylori eradication were analyzed by calculating pooled estimates for new onset or changes in symptoms or endoscopic reflux esophagitis. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. All were graded by Jadad score. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency. Results: Eight trials met the inclusion criteria. Trials were of adequate quality (Jadad score ≥ 2). No significant heterogeneity was noted for the primary outcome. A trend of lower incidence of esophagitis was noted in non-eradicated group (3.97%) versus eradicated group (4.77%) but did not reach significant level on pooled analysis (OR 1.26; 95% CI: 0.81-1.99, p=0.31). Similar results of lower trend with non-eradicated group were obtained on subgroup analysis for new-onset esophagitis or worsening of existing esophagitis but did not reach significant level. Non-significant effect was noted in symptomatic GERD (OR 0.82; 95% CI: 0.48-1.38, p=0.45). Funnel plot revealed no publication bias. Conclusion: Although trends were observed for new-onset or worsening esophagitis in the eradicated group, results were insignificant. Therefore, H. pylori does not appear to have a protective role in GERD.

Brief Questioning by Nursing Staffs before Endoscopic Examination May Not Always Pick Up Clinical Symptoms of Endoscopic Reflux Esophagitis

The clinical features of patients reflux esophagitis without any symptoms have not been clearly demonstrated. This study evaluated the clinical features of patients with endoscopy-positive reflux esophagitis, who did not complain of symptoms, as detected by brief questioning by nursing staffs. Eight thousand and thirty-one patients not taking medication for gastrointestinal disease, were briefly asked about the presence of heartburn, dysphagia, odynophagia and acid regurgitation by nursing staffs before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification. Endoscopically, 1199 (14.9%) patients were classified as positive for reflux esophagitis. The endoscope positive subjects who complain heartburn were 539/1199 (45.0%).The endoscope positive subjects who do not complain symptoms were 465 in 1199 positive reflux esophagitis (38.8%). We compared endoscopic positive subjects without any complain by brief question by nursing staffs to endoscopic positive subjects with heartburn. Male gender, no obesity, absence of hiatus hernia, and low-grade esophagitis were associated with endoscopy-positive patients who do not complain of symptoms. The results of this study indicated correct detection of clinical symptoms of reflux esophagitis might be not easy with brief questioning by nursing staffs before endoscopic examination.

Gastric Emptying Function in Patients 5 Years After Pylorus‐Preserving Distal Gastrectomy With or Without Preserving Pyloric and Hepatic Branches of the Vagal Nerve for Early Gastric Cancer

To clarify the significance of preserving pyloric and hepatic branches of the vagal nerve (PHV) after pylorus preserving distal gastrectomy (PPG) for early gastric cancer, the author investigated the postgastrectomy syndrome and gastric emptying function at 5 years in PPG patients with or without preserving the PHV. A total of 18 subjects (mucosal cancers) who underwent PPG with D1 lymph node dissection and preserving the PHV; they comprised group A-12 men and 6 women aged 38-68 years (mean 58.9 years). They were interviewed to inquire about gastrointestinal symptom (appetite, weight loss, gastric fullness, reflux esophagitis, early dumping syndrome) and then were compared with 24 PPG patients (submucosal cancers) with D2 lymph node dissection without preserving the PHV (group B-16 men and 8 women aged 33 to 69 years, mean 60.1 years). Esophagogastric endoscopy, abdominal ultrasonography, and gastric emptying function tests (GET) were undertaken, the latter by both radioisotope (solid diet) and acetaminophen (liquid diet) methods. There were no differences in the postoperative gastrointestinal symptoms, endoscopic reflux esophagitis, or endoscopic mucosal edema and redness (gastropathy) between groups A and B. However, more cholecystolithiasis (gallbladder stones) was found in group A than in group B, with the difference being significant (P < 0.0391). The GET for solid diet and liquid diet were the almost same among groups A and B. There were no significant differences in the postoperative QOL and GET between PPG patients with preserving PHV and those without preserving PHV. Cholecystolithiasis was only found in patients without preserving PHV.

Clinical Spectrum of Reflux Esophagitis Among 25,536 Koreans Who Underwent a Health Check-up

Gastroesophageal reflux is a commonly encountered condition, but detailed data on reflux symptoms in Asian countries are lacking. To evaluate the prevalence and to document the clinical spectrum of endoscopic reflux esophagitis (RE). A total 25,536 subjects underwent an upper gastrointestinal endoscopic examination as part of a health check, and completed a gastroesophageal reflux questionnaire. Endoscopic findings classified according to the Los Angeles (LA) classification and the data from gastroesophageal reflux questionnaire were analyzed. On the basis of endoscopic findings, 2019 subjects (7.91%) were found to have RE: 5.87% in LA-A; 1.84% in LA-B; 0.18% in LA-C; and 0.02% in LA-D. Heartburn, acid regurgitation, chest pain, hoarseness, globus sensation, cough, and epigastric soreness were found to be associated with RE (P<0.05). Heartburn, acid regurgitation, and epigastric soreness were more frequent in LA-B than in LA-A (P<0.05). Epigastric soreness was most bothersome in LA-A and LA-B, and acid regurgitation was most bothersome in LA-C and LA-D (P<0.01). Heartburn, hoarseness, and globus sensation were more frequent in men with RE, and acid regurgitation was most common in women. The prevalence of RE was found to be 7.91% in Korea, and the profiles of reflux symptoms were found to depend on grade of RE and sex.

Association of heartburn and laryngopharyngeal symptoms with endoscopic reflux esophagitis, smoking, and drinking

Objectives This study was conducted to investigate the association of laryngopharyngeal symptoms and heartburn with endoscopic esophagitis, smoking, and drinking. The clinical importance of the Reflux Symptom Index (RSI) in predicting endoscopic esophagitis was also evaluated. Study Design Case series with planned data collection. Subjects and Methods From November 2006 to February 2007, 156 adults received a whole-body physical check-up. They filled out the RSI questionnaire and were dichotomized into either a “no problem group” or a “possible patients group” according to their scores on the RSI. All subjects received an esophagoscopy. The relationship between RSI score and endoscopic esophagitis, smoking, and drinking was analyzed. Results Voice change, but not heartburn, was significantly associated with endoscopic reflux esophagitis. Based on the RSI scores, some items in addition to voice change were significantly associated with smoking or drinking but not with endoscopic esophagitis. Conclusions While screening patients for reflux esophagitis by using the RSI questionnaire, there is little value in using heartburn to predict endoscopic esophagitis in Taiwanese people. On the other hand, a husky voice might be a good clinical indicator of patients at risk of having reflux esophagitis.

Bleeding and stenosis caused by reflux esophagitis was not common in emergency endoscopic examinations: a retrospective patient chart review at a single institution in Japan

Bleeding and stenosis are serious complications of reflux esophagitis, although few studies have been performed in Japan regarding these complications. This study aimed to indicate the characteristics of reflux esophagitis observed during emergency endoscopic examination in Japan. All subjects who had emergency endoscopic examination performed between 1990 and 2004 at Saga Medical School Hospital were evaluated. Patients with endoscopic reflux esophagitis were evaluated with a retrospective patient chart review. A total of 1621 subjects underwent emergency endoscopy; 1420 of the endoscopies were because of hematemesis or melena. Endoscopic examination revealed that 19 cases with bleeding were caused by reflux esophagitis (19/1621, 1.2%). The 19 patients with bleeding and the four patients with stenosis (0.2%) had emergency endoscopy performed for complications of reflux esophagitis. The Los Angeles classification of these 23 cases showed that most were severe esophagitis (grade A, 0; B, 2; C, 8; and D, 13). The frequency of comorbidity with diabetes mellitus and collagen disease and the proportion of heavy drinkers were higher in patients who received emergency endoscopy because of reflux esophagitis than in those diagnosed with reflux esophagitis but who received emergency endoscopy because of other diseases. Relatively small numbers of patients with reflux esophagitis undergo emergency endoscopy in Japan, and most such patients have underlying diseases, including diabetes mellitus and collagen disease. This finding is supported by a previous report that severe esophagitis is not common in Japan.

Endoscopic reflux esophagitis in patients with upper abdominal pain‐predominant dyspepsia

Reflux symptom assessment had reliable accuracy in the diagnosis of gastroesophageal reflux disease (GERD). However, patients may recognize heartburn or regurgitation as dyspepsia because of inaccurate understanding or atypical presentation. The aim of the present study was to estimate endoscopic reflux esophagitis in patients with upper abdominal pain as a predominant symptom in the absence of heartburn or regurgitation. Two hundred and sixty-three consecutive patients presenting dyspepsia without heartburn or regurgitation were enrolled. Patients with heartburn or regurgitation were excluded using the symptom interviewer method. Dyspepsia was categorized into pain-predominant or dysmotility-predominant groups according to the Rome II proposal. Endoscopic reflux esophagitis was graded using the Los Angeles classification. One hundred and five patients were included in the pain-predominant group and 119 in the dysmotility-predominant group. Reflux esophagitis was found in 18.8% (42/224) of all dyspeptic patients. Grade A esophagitis was noted in 27.6% (29/105) of the pain-predominant group and in 7.6% (9/119) of the dysmotility-predominant group. Grade B was noted in two patients in each group. A total of 29.5% (31/105) and 9.3% (11/119) had reflux esophagitis, respectively (P < 0.001). Comparing patients with or without reflux esophagitis, there was no difference in body mass index, smoking habit, alcohol consumption, or Helicobacter pylori infection status. A significant proportion of patients presenting dyspepsia, especially pain-predominant dyspepsia, have endoscopic reflux esophagitis. In view of GERD, pain-predominant dyspepsia should be investigated and managed differently from dysmotility-predominant dyspepsia.

Dysphagia in Adult Japanese Is Not Equivalent to the Grade of Endoscopic Reflux Esophagitis

This study was aimed to evaluate the correlation between dysphagia, detected by nursing staff in a brief interview and endoscopic findings in reflux esophagitis. A total of 8,031 Japanese subjects without medication for gastrointestinal disease were briefly asked about the presence of heartburn, dysphagia, odynophagia, and acid regurgitation by nursing staff before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification. The grade of endoscopic esophagitis was not equivalent to symptoms of dysphagia in 8,031 subjects. We evaluated the characteristics of subjects who complained of only dysphagia. Univariate analysis indicated that non-smoking, and non-drinking females were associated with a higher risk for dysphagia, and multivariate analysis indicated the gender was associated with dysphagia. There was no association of dysphagia with herniation and distribution of age. This study indicated that dysphagia was not equivalent to the endoscopic findings according to a brief interview by nursing staff and that dysphagia might be more common in females and those who do not smoke or drink.

Impact of Helicobacter pylori Eradication Therapy on Histologic Change in the Distal Esophagus

Although cases of reflux esophagitis (RE) developing after treatment to eradicate Helicobacter pylori have been discussed in some detail, no reports are available concerning the histologic examination of RE both before and after eradication therapy. Sixty-one patients and 111 specimens were investigated using endoscopic and histologic techniques. The histologic findings including basal zone height, papillar height, Ki-67 labeling index, and COX-2 expression before and after treatment for H. pylori infection were compared with those in normal controls and patients with endoscopic RE. Twelve months after eradication therapy, the incidence of newly developed endoscopic RE was 20% (5/25). Basal zone height and papillar height had increased at 1 month, but had returned to pretreatment levels after 12 months of eradication therapy. The Ki-67 labeling index was significantly increased 1 and 12 months after eradication therapy compared to values before treatment. COX-2 expression gradually increased after the treatment. The phenomena linked to esophagitis appeared after eradication therapy. However, the severity and extent of these signs were not so high after the treatment of H. pylori than those in patients with overt reflux esophagitis. Focusing on the patients with hiatal hernia, papillar height and Ki-67 labeling index increased significantly after eradication therapy, values being almost the same as those in the patients with endoscopic RE. Hiatal hernia plays an important role in the possible occurrence of hidden RE after treatment for a H. pylori infection.

Abdominal Obesity Is an Independent Risk Factor for Endoscopic Reflux Esophagitis in Korean People

Purpose: The relationship between reflux esophagitis and obesity is controversial in Korea, because morbid obesity (BMI > 30 kg/m2) is less common than Western countries. The aim of this study is to evaluate the relationship between obesity and endoscopic reflux esophagitis in Korean people. Methods: 2457 subjects who visited our health center for a general check-up including EGD during the period from September 2004 to April 2005 were enrolled. All of them were given a questionnaire about physical activity, smoking, consumption of alcohol, consumption of beverage, weekly symptom of heartburn or acid regurgitation, use of drugs, and other medical or surgical history. The subjects were classified into three groups by BMI: nonobese (<25 kg/m2), obese (25–30 kg/m2) and severe obese (>30 kg/m2). And abdominal obesity was defined by waist circumference (≥80 cm in women and ≥90 cm in men). Reflux esophagitis was diagnosed by EGD according to the LA classification (≥LA-A). Univariate analyses of various risk factors for reflux esophagitis was performed by using χ2 test, and then multiple logistic regression analyses was used to examine relationship between reflux esophagitis and obesity. Results: After exclusion of subjects who had gastric surgery, analysis was done on 2310 subjects (mean age was 44 ± 9 years and 31.3% was women). 28.8% was obese, 2.4% was severe obese, and 23.5% had abdominal obesity. The prevalence of endoscopic reflux esophagitis was 6.7% and significantly higher in men than in women (8.7%vs. 2.1%, p < 0.001). There was a dose-response relationship between prevalence of reflux esophagitis and BMI (5.7%, 8.2%, and 15.5% in <25, 25−30, and >30, respectively, p = 0.002). Waist circumference (11.2%vs. 5.2%, p < 0.001), hiatal hernia (42.6%vs. 5.8%, p < 0.001), current smoking (9.5%vs. 5.3%, p < 0.001), physical activity (7.6%vs. 4.2%, p = 0.002), use of hypertensive medications (12.7%vs. 6.1%, p = 0.005), and use of aspirin or NSAIDs (15.2%vs. 6.3%, p = 0.001) were significantly related with reflux esophagitis. After adjustment for sex, hiatal hernia, current smoking, physical activity, use of hypertensive medications, and use of aspirin or NSAIDs, only waist circumference remained as an independent risk factor for reflux esophagitis (adjusted OR 1.9, 95% CI 1.3–2.9, p = 0.002). Conclusions: Abdominal obesity is an independent risk factor for reflux esophagitis in Korean people.

Abnormal gastroesophageal flap valve is highly associated with endoscopic reflux esophagitis after Helicobacter pylori eradication.

Whether or not eradicating Helicobacter pylori worsens reflux esophagitis remains controversial. We investigated the relationship between gastroesophageal flap valve grading and endoscopic reflux esophagitis (in patients with peptic ulcer and gastritis) before and after H. pylori eradication in a case controlled study. Whether endoscopic assessment of the gastroesophageal flap valve allows prediction of endoscopic reflux esophagitis development or exacerbation was also assessed. A total of 220 patients with peptic ulcer or chronic gastritis, who received H. pylori eradication therapy, were followed for at least 6 months (range, 6-34 months) for endoscopic changes. Another 88 age- and disease-matched H. pylori-positive controls, without eradication therapy, were also enrolled. Gastroesophageal flap valve grade (I-IV) was assessed using the Hill classification. Endoscopic reflux esophagitis incidence was significantly (p < .01) higher in abnormal gastroesophageal flap valve (grades III and IV) than in normal gastroesophageal flap valve (grades I and II) cases in both H. pylori eradication and control groups. The rate of new endoscopic reflux esophagitis after eradication was significantly (p < .01) higher in the abnormal than in the normal gastroesophageal flap valve group (54.5% vs. 9.1%). By contrast, the endoscopic reflux esophagitis exacerbation rate in patients with endoscopic reflux esophagitis before eradication was low (4.5%) and endoscopic reflux esophagitis improvement was observed in 40.9% of these patients. These results suggest gastroesophageal flap valve grading by endoscopy to be useful for predicting the risk of newly developing endoscopic reflux esophagitis after H. pylori eradication, in addition to predicting the presence of endoscopic reflux esophagitis.

Clinical symptoms in endoscopic reflux esophagitis: evaluation in 8031 adult subjects.

This study aimed to evaluate the correlation between symptoms and endoscopic findings in reflux esophagitis. Subjects, 8031 persons without medication for gastrointestinal disease, were briefly asked about the presence of heartburn, dysphagia, odynophagia, and acid regurgitation by associated medical staff before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification. Endoscopically, 1199 (14.9%) were classified as positive reflux esophagitis, and 2223 (27.7%) had heartburn, 1522 (19.0%) had dysphagia, 493 (6.1%) had odynophagia, and 1466 (18.3%) had acid regurgitation. Multivariate analysis indicated that the symptom most related to esophagitis was heartburn (odds ratio: 2.46), although approximately 40% of subjects with grade C or D did not complain of heartburn. Regarding the other symptoms, less than 30% subjects with severe esophagitis complained of the symptoms and the odds ratio was approximately 1. These results indicate that endoscopic esophagitis was not equivalent to any reflux symptoms from which subjects suffered in their daily lives.

Pathophysiological studies on the relationship between postgastrectomy syndrome and gastric emptying function at 5 years after pylorus-preserving distal gastrectomy for early gastric cancer.

Pylorus-preserving distal gastrectomy (PPG) has frequently been performed on patients with early gastric cancer in Japan to prevent the postgastrectomy syndrome seen after conventional distal gastrectomy (CDG). The long-term postoperative quality of life (QOL) and gastric emptying function in patients after PPG has not been assessed in detail. To clarify the usefulness of PPG for treating early gastric cancer we investigated the relation between postgastrectomy syndrome and gastric emptying function 5 years after PPG and then compared the results with those 5 years after CDG. Altogether, 32 patients who underwent curative gastrectomy at our clinic for early gastric cancer (submucosal cancer without lymph node metastasis) were studied. Ten subjects who underwent PPG with D2 lymphadenectomy without preserving the hepatic and pyloric branches of the vagal nerve [group A: eight men, two women; age 33-70 years (mean 60.7 years)] were interviewed and asked about appetite, weight loss, epigastric fullness, reflux esophagitis, and early dumping syndrome. They were compared with patients after CDG [group B: 36-72 years (mean 63.6 years)]. Esophagogastric endoscopy, abdominal ultrasonography, and gastric emptying function were also studied. The gastric emptying time of a semisolid diet was measured with a radioisotope method using (99m)Tc-labeled rice gruel; the gastric emptying time of a liquid diet was measured with the acetaminophen method using orange juice. The control subjects (group C) consisted of 18 healthy volunteers (10 men, 8 women) without gastrointestinal symptoms aged 38 to 68 years (mean 60.8 years). The following results were obtained: PPG (group A) alleviated postoperative gastrointestinal symptoms such as appetite loss, reflux esophagitis, early dumping syndrome, lost body weight, endoscopic reflux esophagitis, endoscopic gastritis in the remnant stomach, and postogastrectomy cholecystolithiasis better than did CDG (group B). The only weak point with the PPG procedure was that it produced a feeling of epigastric fullness. The pattern of the gastric emptying curve for the semisolid diet was almost the same among groups A, B, and C, although delayed gastric emptying was clearly more frequent in group A than in group B or C ( p < 0.05). Gastric emptying with the liquid diet in group B was significantly faster than that in groups A and C ( p < 0.01). Gastric emptying in groups A and C was similar. These results showed that PPG improved the postoperative QOL, but the delayed emptying of semisolid diet after PPG led to a feeling of epigastric fullness after meals due to retention of contents in the residual stomach. Epigastric fullness after meals continued in many patients after PPG. Thus the only disadvantage of the PPG procedure is the sensation of epigastric fullness and gastric stasis due to delayed gastric emptying of a semisolid diet.

Prevalence of endoscopic reflux esophagitis among Koreans

Although reflux esophagitis is believed to be common in the Western population, very few epidemiologic data on reflux esophagitis in Koreans are available. The aims of this study were to evaluate the prevalence of endoscopic reflux esophagitis in patients who came for a physical check-up at Korea University Hospital, and to study the relationship between various factors relevant to reflux disease. This study was carried out prospectively on 7,015 patients who received an esophagogastroduodenoscopy from September 1996 to December 1997. Most of the patients were free of symptoms and had come for their self-paid check-up. The overall prevalence of reflux esophagitis was 3.4%, and most of the patients had a mild degree of esophagitis representing grade 1 in 98.3% and grade 2 in 1.7%. The male: female ratio for esophagitis was 7 : 1, and the body mass index (BMI) was significantly higher in patients with reflux esophagitis. A hiatal hernia was found in 166 patients with esophagitis (68.6%), but only in 9.2% patients without esophagitis (P < 0.05). Smoking and alcohol consumption were associated with the development of reflux esophagitis (P < 0.05). The prevalence of endoscopic reflux esophagitis among Koreans is 3.4%, and most of the patients had a mild grade esophagitis. Smoking, alcohol consumption, the presence of a hiatal hernia and a higher BMI are associated with the development of reflux esophagitis.

Reflux esophagitis and its relationship to hiatal hernia.

We performed this study to evaluate the prevalence of reflux esophagitis and/or hiatal hernia in patients referred to a medical center and to examine the relationship between endoscopic reflux esophagitis and hiatal hernia. The study was carried out in 1,010 patients referred to Yong Dong Severance Hospital for upper gastrointestinal endoscopy because of symptoms related to the gastrointestinal tract from September 1994 to March 1996. The presence of hiatal hernia was defined as a circular extension of the gastric mucosa of 2 cm or more above the diaphragmatic hiatus. Reflux esophagitis was found in 5.3% of patients, hiatal hernia in 4.1%, duodenal ulcer in 7.2% and gastric ulcer in 8.2%. The prevalence rates of reflux esophagitis and hiatal hernia in males were significantly higher than those in females. Thirty-two percent of patients with reflux esophagitis had hiatal hernia. In patients without reflux esophagitis, hiatal hernia was found in only 2.5% (p<0.01). There was no significant association between the presence of hiatal hernia and the degree of esophagitis on endoscopy. Duodenal ulcer was the second most common endoscopic abnormality found in patients with reflux esophagitis. The prevalence rate of reflux esophagitis and/or hiatal hernia at a medical center is relatively low compared to peptic ulcer disease and other reports from the Western countries. Our study confirms the close association between reflux esophagitis and hiatal hernia.

Massive hiatus hernia: Evaluation and surgical management

Objective: Paraesophageal hernias represent advanced degrees of sliding hiatus hernia with intrathoracic displacement of the intraesophageal junction. Gastroesophageal reflux disease occurs in most cases, resulting in acquired short esophagus, which should influence the type of repair selected. Methods: Between 1960 and 1996, 94 patients with massive, incarcerated paraesophageal hiatus hernia were operated on at the Toronto General Hospital. The mean age was 64 years (39 to 85 years), with a female to male ratio of 1.8:1. Organoaxial volvulus was present in 50% of cases. Clinical presentation in these patients included postprandial pain in 56%, dysphagia in 48%, chronic iron deficiency anemia in 38%, and aspiration in 29%. Symptomatic reflux, either present or remote, was recorded in 83% of cases. All patients underwent endoscopy by the operating surgeon. In 91 of 94 patients, the esophagogastric junction was found to be above the diaphragmatic hiatus, denoting a sliding type of hiatus hernia. Gross, endoscopic peptic esophagitis was observed in 36% of patients: ulcerative esophagitis in 22% and peptic esophagitis with stricture in 14%. A complete preoperative esophageal motility study was obtained for 41 patients. The lower sphincter was hypotensive in 21 patients (51%), and the amplitude of peristalsis in the distal esophagus was diminished in 24 patients (59%). These abnormalities are both features of significant gastroesophageal reflux disease. In 13 recent, consecutive patients with paraesophageal hernia, the distance between the upper and lower esophageal sphincters was measured during manometry. The average distance was 15.4 ± 2.33 cm (11 to 20 cm), which is consistent with acquired short esophagus. The normal distance is 20.4 cm ± 1.9 ( p < 0.0001). Results: All 94 patients were treated surgically: 97% had a transthoracic repair with fundoplication. A gastroplasty was added in 75 cases (80%) because of clearly defined or presumed short esophagus. There were two operative deaths, and two patients were never followed up. Among the 90 available patients, the mean follow-up was 94 months; median follow-up was 72 months. Seventy-two patients (80%) are free of symptoms (excellent result); 13 (13%) have inconsequential symptoms requiring no therapy (good result); and three patients (4%) are improved but have symptoms requiring medical therapy or interval dilatation (fair result). Two patients had poor results because of recurrent hernia and severe reflux. Both were successfully treated by reoperation with the addition of gastroplasty because of acquired shortening, which was not recognized at the first operation. Conclusions: Most of these 94 patients had symptoms or endoscopic, manometric, and operative findings that were consistent with a sliding hiatus hernia. There was a high incidence of endoscopic reflux esophagitis and of acquired short esophagus. True paraesophageal hernia, with the esophagogastric junction in a normal abdominal location, appears rare. Our observations were supported by measurements obtained at preoperative endoscopy and manometry, and by findings at the time of surgical repair. These observations support the choice of a transthoracic approach for repair in most patients. (J Thorac Cardiovasc Surg 1997;115:53-62)

Enhancement of salivary esophagoprotection: Rationale for a physiological approach to gastroesophageal reflux disease

BACKGROUND & AIMS: Secretion of salivary protective factors in patient s with gastroesophageal reflux disease is impaired. However, the impact of physiological stimulus mastication on salivary protective factors output remains largely unknown. The aim of this study was to measure salivary volume, pH, HCO3-, peptide growth factors, prostaglandin, mucin, protein, and viscosity during mastication. METHODS: In 31 asymptomatic volunteers and 36 patients with endoscopic reflux esophagitis, in basal and parafilm chewing-stimulated saliva, its volume, pH, bicarbonate, epidermal growth factor, transforming growth factor alpha, prostaglandin E2, mucin, protein, and viscosity were investigated. RESULTS: Masticatory stimulation in controls resulted in a significantly increased salivary volume by 205%, pH by 7.6%, bicarbonate by 335%, mucin by 137%, protein by 98%, epidermal growth factor by 123%, and prostaglandin E2 by 132%, accompanied by an increase in transforming growth factor alpha by 80% with 19% decline in viscosity vs. basal values. Mastication in reflux esophagitis significantly increased salivary volume by 215%, pH by 6.8%, bicarbonate by 257%, mucin by 135%, protein by 94%, epidermal growth factor by 207%, and prostaglandin E2 by 240%, whereas transforming growth factor alpha increased by 225% and viscosity by 64% when compared with corresponding basal values. CONCLUSIONS: A profound and significant increase in the secretion rate of inorganic and organic protective components in saliva during masticatory stimulation suggests its potential value as a therapeutic approach to the treatment of patients with gastroesophageal reflux disease. (Gastroenterology 1996 Mar;110(3):675-81)