Esophageal Acid Exposure Research Articles

S590 Examining the Correlation Between Gastroesophageal Sphincter Distensibility Measured by EndoFLIP and Esophageal Acid Exposure

S590 Examining the Correlation Between Gastroesophageal Sphincter Distensibility Measured by EndoFLIP and Esophageal Acid Exposure

The Association Between Acidification Time on Wireless Motility Capsule and Gastroesophageal Reflux Disease.

Gastric physiological characteristics such as fundus accommodation, gastric distention, emptying/transit time, and basal acid output may contribute to the pathogenesis of gastroesophageal reflux disease (GERD). Wireless motility capsule (WMC) uses pH data to determine gastric transit time but has not been used in the evaluation of GERD. Certain metrics such as acidification time, nadir pH, and gastric transit time may provide insight into the mechanisms of GERD related to gastric physiology, allowing WMC to be a complementary tool in the diagnosis of GERD. We aimed to determine whether pH data and transit time on WMC tests correlated with the presence of GERD on ambulatory reflux testing. This was a retrospective study of 28 patients who had undergone both WMC and reflux testing via wireless pH or pH/impedance. Acidification time (time from capsule ingestion to pH<2), nadir postprandial pH, and gastric transit time were manually determined from the WMC capsule proprietary software. Spearman correlation was used to compare these metrics with gastric transit time, percent esophageal acid exposure, and DeMeester score. Acidification time moderately correlated with gastric transit time, R: 0.44, P=0.02, but not nadir pH, percent esophageal acid exposure, or DeMeester score. Patients with an abnormal reflux test had a significantly longer median acidification time (135.5 vs. 78.5min, P=0.021). After stratifying by patients with normal versus prolonged gastric transit time, there was a trend toward longer acidification time in patients with positive reflux testing in both groups, but this was not statistically significant. Patients with prolonged gastric transit time >300 minutes were not more likely to have a positive reflux test (38% vs. 35%, P=1). The acidification time on WMC was significantly longer in patients with proven GERD and acidification time positively correlated with gastric transit time. Larger studies are needed to determine whether WMC could be used as a complementary tool in investigating patients with GERD symptoms.

Esophageal pH-monitoring in nonbrachycephalic dogs; a reference.

To establish parameters that describe acidic gastroesophageal reflux (GER) events in nonbrachycephalic, hospitalized dogs without gastrointestinal disease following short total intravenous anesthesia, to establish upper reference limits for parameters that describe GER. Clinical prospective study. Healthy, client-owned dogs presenting for elective orthopedic surgery. Dogs were sedated with IM methadone (0.2 mg/kg) and medetomidine (5 ug/kg), followed by alfaxalone total intravenous anesthesia. The Digitrapper esophageal dual pH monitoring probe was placed transnasally into the esophagus. Dogs were unsedated during the subsequent recording period. A GER event was defined as esophageal pH less than 4.0. Parameters that described GER were: (1) number of GER events per hour, and (2) cumulative esophageal acid exposure (percentage of recording duration) at each sensor. Upper reference limits were calculated for each parameter. Thirty-five dogs were included (median age 7 years, range 1-12). The median recording duration was 21.1 h (range 13.6-29.3). Productive regurgitation was not noted in any dog. The median number of distal and proximal GER events per hour was 0.3 (range 0-4.3) and 0 (range 0-1), respectively. The median cumulative distal and proximal esophageal acid exposure was 0.2% (range 0.3-9%) and 0% (range 0%-1%), respectively. Upper reference limits for distal and proximal GER per hour was 2.4 and 0.4, respectively, and, for cumulative distal and proximal esophageal acid exposure, 2.3% and 0%, respectively. Dogs undergoing esophageal pH monitoring in a similar hospital setting with parameters above these upper reference limits have excessive GER.

Antireflux Surgery Versus Antireflux Medication and Risk of Esophageal Adenocarcinoma in Patients With Barrett’s Esophagus

Background and aimsAntireflux treatment is recommended to reduce esophageal adenocarcinoma in patients with Barrett’s esophagus. Antireflux surgery (fundoplication) counteracts gastroesophageal reflux of all types of carcinogenic gastric content, and reduces esophageal acid exposure to a greater extent than antireflux medication (proton pump inhibitors). We examined the hypothesis that antireflux surgery prevents esophageal adenocarcinoma to a larger degree than antireflux medication in patients with Barrett’s esophagus. MethodsThis multi-national and population-based cohort study included all patients with a diagnosis of Barrett’s esophagus in any of the national patient registries in Denmark (2012-2020), Finland (1987-1996 and 2010-2020), Norway (2008-2020), or Sweden (2006-2020). Patients who underwent antireflux surgery were compared with non-operated patients using antireflux medication. The risk of esophageal adenocarcinoma was calculated using multivariable Cox regression, providing hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, sex, country, calendar year, and comorbidity. ResultsThe cohort consisted of 33,939 patients with Barrett’s esophagus. Of these, 542 (1.6%) had undergone antireflux surgery. During up to 32 years of follow-up, the overall HR was not decreased in patients having undergone antireflux surgery compared to non-operated patients using antireflux medication but rather increased (adjusted HR 1.9, 95% CI 1.1-3.5). Additionally, HRs did not decrease with longer follow-up, but instead increased for each follow-up category, from 1.8 (95% CI 0.6-5.0) within 1-4 years of follow-up to 4.4 (95% CI 1.4-13.5) after 10-32 years of follow-up. ConclusionPatients with Barrett’s esophagus who undergo antireflux surgery do not seem to have a lower risk of esophageal adenocarcinoma than those using antireflux medication.

480. ANTIREFLUX SURGERY’S LIFESPAN: 20 YEARS AFTER LAPAROSCOPIC FUNDOPLICATION

Abstract Background Laparoscopic Fundoplication (LF) is the surgical technique of choice for treating GERD, but only few studies report a follow-up beyond 15 years. The aim was to evaluate the results at least 20 years after laparoscopic fundoplication at a single national referral center for esophageal diseases. Methods We prospectively collected data on a cohort of consecutive patients who underwent LF between 1992–2001. Patients were divided into two groups: a GERD group (patients with pathological esophageal acid exposure and hiatal hernias &amp;lt;3 cm) and a large hiatal hernia (HH) group (patients having type I &amp;gt; 3 cm and types II-IV hiatal hernias). Patients were followed up for at least 20 years using endoscopy, barium-swallow, esophageal manometry, and pH monitoring. LF was defined failed in case of: GERD symptom recurrence (SS &amp;gt; 10); recurrence of esophagitis; HH recurrence or slipped-fundoplication; pathological pH-monitoring; BE progression or adenocarcinoma onset. Results The study population consisted of 142 patients: 112 in the GERD group and 30 in the HH group. The characteristics of patients are shown on Figure 1. Conversion to open surgery proved necessary in 8 patients (5.6%). At a median follow-up of 22 years, 80.4% of the GERD patients and 63.3% of the HH patients were failure-free. Revisional surgery was necessary in 14 (9.8%) patients (9 GERD and 5 HH patients); indications were dysphagia (5 cases), slipped fundoplication or hernia recurrence (6 cases), abnormal pH-monitoring or esophagitis resistant to medical therapy (2 cases), and telescoping (one case). Two decades after LARS, 87.6% of GERD patients and 76.7% of HH patients were satisfied with the procedure. Conclusions The present study concerns one of the largest populations of patients who had undergone LF to have been followed up for more than 20 years at a single center. The findings showed that laparoscopic antireflux surgery is effective and durable (for &amp;gt;20 years) in patients with uncomplicated GERD and, to a lesser extent, in those with a large hiatal hernia. The satisfaction rate more than 20 years after surgery almost reached 90% in the GERD group.

HIATAL HERNIA, PANORAMIC REVIEW OF DIAGNOSIS AND MANAGEMENT

Introduction: Hiatal hernia (HH) occurs frequently in the population, characterized by various non-specific symptoms, however most of these symptoms are found to be related to gastroesophageal reflux disease. A hiatal hernia is said to be a medical condition in which the upper portion of the stomach or other internal organ protrudes through an opening in the diaphragm. Objective: to detail current information related to hiatal hernia, description, etiology, classification, diagnosis, differential, prognosis, management and complications. Methodology: a total of 38 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 27 bibliographies were used because the other articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: hiatal hernia, hiatal repair, diagnosis, management. Results: The incidence of symptomatic cases of hiatal hernia is related to the diagnosis of gastroesophageal reflux disease (GERD). The incidence of hiatal hernias increases with age. About 55%-60% of individuals over 50 years of age have a hiatal hernia. However, approximately 9% have symptoms and it depends on the type and competence of the lower esophageal sphincter (LES). The largest percentage of these hernias are type I sliding hiatal hernias. Type II, paraesophageal hernias, represent approximately 5% of hiatal hernias in which the LES remains stationary, with the stomach protruding superiorly to the diaphragm. There is also a high prevalence in women, attributable to increased intra-abdominal pressure during pregnancy. The estimated overall 30-day mortality rate in relation to antireflux surgery is approximately 0.19%. Conclusions: Hiatal hernia (HH) is relatively common in the general population. It is caused by increased intra-abdominal pressure, leading to protrusion of the stomach and other abdominal viscera into the mediastinum. Hiatal hernias can be congenital or acquired. The current anatomical classification of hiatal hernias consists of four types or categories, each with its different characteristics. Diagnosis of hiatal hernia can be challenging because of the change in the anatomy of the esophagogastric junction on swallowing, breathing and movement. The pre-surgical study of the individual supports the diagnosis and the exclusion of other pathologic entities to properly direct the surgical intervention. The success of hiatal hernia surgery can be measured by the improvement of symptoms, such as esophageal acid exposure, complications and the requirement for reoperation. Complications of surgery are usually mild and are not directly linked to the surgery itself. KEY WORDS: surgery, hernia, hiatus, diagnosis, management.

Conventional versus oblique fiber-sparing endoscopic myotomy for achalasia cardia: a randomized controlled trial (with videos)

GERD is common after peroral endoscopic myotomy (POEM). Selective sparing of oblique fibers may reduce the incidence of reflux esophagitis after POEM. In this study, we compared the incidence of GERD between conventional myotomy (CM) versus oblique fiber-sparing (OFS) myotomy in patients with achalasia. Eligible patients with type I and II achalasia who underwent POEM from January 2020 to October 2020 were randomized into 2 groups (CM and OFS myotomy). Exclusion criteria were type III achalasia, sigmoid esophagus, and history of Heller's myotomy. The primary study outcome was incidence of reflux esophagitis (at least grade B) in the 2 groups. Secondary outcomes were reflux symptoms, esophageal acid exposure, clinical success, and adverse events. One hundred fifteen patients were randomized into CM (n= 58) and OFS myotomy (n= 57) groups. POEM was technically successful in all patients. Overall, reflux esophagitis was found in 56 patients (48.7%). The incidence of at least grade B esophagitis was similar in both groups (CM vs OFS myotomy: 25.9% vs 31.6%, P= .541). The mean number of reflux episodes (48.2 ± 36.6 vs 48.9 ± 40.3, P= .933), increased esophageal acid exposure >6% (45.5% vs 31.7%, P= .266), and high DeMeester scores (38.6% vs 41.5%, P= .827) were similar in both groups. There was no difference in the rate of symptomatic reflux (GERD questionnaire score >7) or use of proton pump inhibitors at 1 year. Sparing of sling fibers has no significant impact on the incidence of significant reflux esophagitis after POEM. Novel strategies need to be explored to prevent reflux after POEM. (Clinical trial registration number: NCT04229342.).

Functional Food in Relation to Gastroesophageal Reflux Disease (GERD).

Gastroesophageal reflux disease (GERD) is a common esophageal disorder characterized by troublesome symptoms associated with increased esophageal acid exposure. The cornerstones of therapy in this regard include treatment with acid-suppressive agents, lifestyle modifications, and dietary therapy, although the latter has not been well defined. As concerns regarding long-term proton pump inhibitor (PPI) use continue to be explored, patients and healthcare providers are becoming increasingly interested in the role of diet in disease management. However, dietary interventions lack evidence of the synthesis effect of functional foods. The following is a review of dietary therapy for GERD, emphasizing food components' impact on GERD pathophysiology and management. Although the sequential dietary elimination of food groups is a common practice, the literature supports broader intervention, including reduced overall sugar intake, increased dietary fiber, and changes in overall eating practices. While the primary concern of food companies is to provide safe products, the caloric, nutritional, and functional composition of foods is also generating interest in the food industry due to consumers' concerns.

Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5years.

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM. Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES)≤3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM. Seventy-two cases (45.9±13.4years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7±3.3cm, and mean procedure duration was 59.2±25.9min. There was significant improvement in ES (pre-POEM 6.5±1.8 vs post-POEM 0.7±0.7), lower esophageal sphincter pressure pressures (31.7±12.5 vs 13.3±5.7mmHg) and barium emptying (14.2±4.2 vs 2.4±3.1cm) after POEM. At a median follow-up of 63months (IQR 40-95), clinical success (ES≤3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively. POEM is a durable treatment modality in cases with relapse of symptoms after HM.

The Value of Fundoplication in the Treatment of Type I Achalasia

BackgroundType I achalasia comprises 20% of achalasia and has nearly absent esophageal motor activity. Concerns that fundoplication decreases the effectiveness of Heller myotomy in these patients has increased adoption of peroral endoscopic myotomy (POEM). Hence, we compared outcomes after Heller myotomy with Dor fundoplication vs POEM. MethodsFrom 2005 to 2020, 150 patients with type I achalasia underwent primary surgical myotomy (117 Heller myotomy, 33 POEM). Patient demographics, prior treatments, timed barium esophagrams, Eckardt scores, and reinterventions were assessed between the 2 groups. Median follow-up was 5 years for Heller myotomy and 2.5 years for POEM. ResultsThe Heller myotomy group was younger, had fewer comorbidities, and lower body mass index vs POEM. Risk-adjusted models demonstrated clinical success (Eckardt ≤3) in 83% of Heller myotomies and 87% of POEMs at 3 years; longitudinal complete timed barium esophagram emptying and reintervention were also similar. An abnormal pH test result was documented in 10% (6 of 60) after Heller myotomy and in 45% (10 of 22) after POEM (P < .001). ConclusionsDespite nearly absent esophageal contractility, Heller myotomy with Dor fundoplication and POEM result in similar long-term symptom relief, esophageal emptying, and occurrence of reintervention in patients with type I achalasia. There is decreased esophageal acid exposure with the addition of a fundoplication, without compromised esophageal drainage, allaying fears of a detrimental effect of a fundoplication. Hence, choice of procedure may be personalized based on patient characteristics and esophageal morphology and not solely on manometric subtype.

The Utility of Symptom Association Probability (SAP) in Predicting Outcome After Laparoscopic Fundoplication in Patients with Abnormal Esophageal Acid Exposure

IntroductionAbnormal DeMeester score on pH monitoring is a well-established predictor of favorable outcome after antireflux surgery (ARS). Esophageal pH monitoring also facilitates analysis of the temporal association between symptoms and reflux episodes. This association can be expressed with several symptom–reflux association indices with symptom association probability (SAP) being the most reliable. SAP is often used as an adjunct to DeMeester score during preoperative assessment of patients seeking ARS. However, data on the utility of SAP in predicting ARS outcome is limited. The aim of this study was to determine the utility of SAP as an adjunct to DeMeester score in predicting outcomes after fundoplication. MethodsRecords of patients who underwent primary fundoplication from 2015 to 2021 were reviewed. Patients with a preoperative DeMeester score >14.7 on Bravo pH monitoring were included. A SAP >95% was considered SAP-positive. Favorable outcome was defined as freedom from proton pump inhibitors (PPIs) and patient satisfaction at 1 year postoperatively. Outcomes were compared based on the presence and number of SAP-positive symptoms, individual typical and atypical SAP-positive symptoms, and within demographic, clinical, and reflux severity subgroups. ResultsThe final study population consisted of 597 patients (71.4% female) with a median (IQR) age of 59.0 (49–67). At a mean (SD) follow-up of 10.5 (8) months, 82.0% patients achieved favorable outcome (satisfaction and freedom from PPI), freedom from PPI was 91.7%, and satisfaction was 87.4%. SAP was positive in 430 (72.0%) patients, of which 221 (37.0%) had one SAP-positive symptom, 164 (27.5%) had two SAP-positive symptoms, and 45 (7.5%) had all three SAP-positive symptoms. There was no association between having at least one SAP-positive symptom and favorable outcome (p=0.767). There was no difference in favorable outcome between patients with one, two, or all SAP-positive symptoms (0.785). Outcomes were comparable for SAP-positive typical (p=0.873) and atypical symptoms (p=1.000) and all individual symptoms (p>0.05). Outcomes were also comparable within all subgroups (p>0.05). ConclusionSymptom association probability with an abnormal DeMeester score did not enhance the prediction of antireflux surgery outcome. These findings suggest that SAP should not be used in surgical decision-making in patients with objective evidence of reflux. Graphical Abstract [Display omitted]

Prospective clinical cohort study: low incidence of Barrett esophagus but high rate of reflux disease at 5-year follow-up after sleeve gastrectomy versus Roux-en-Y gastric bypass.

Gastroesophageal reflux disease seems more frequent after laparoscopic sleeve gastrectomy (LSG) than Roux-en-Y gastric bypass (LRYGB). Retrospective case series have raised concerns about a high incidence of Barrett esophagus (BE) after LSG. This prospective clinical cohort study compared the incidence of BE ≥5 years after LSG and LRYGB. St. Clara Hospital, Basel, and University Hospital, Zürich, Switzerland. Patients were recruited from 2 bariatric centers where preoperative gastroscopy is standard practice and LRYGB is preferred for patients with preexisting gastroesophageal reflux disease. At follow-up ≥5 years after surgery, patients underwent gastroscopy with quadrantic biopsies from the squamocolumnar junction and metaplastic segment. Symptoms were assessed using validated questionnaires. Wireless pH measurement assessed esophageal acid exposure. A total of 169 patients were included, with a median 7.0 ± 1.5 years after surgery. In the LSG group (n = 83), 3 patients had endoscopically and histologically confirmed de novo BE; in the LRYGB group (n = 86), there were 2 patients with BE, 1 de novo and 1 preexisting (de novo BE, 3.6% versus 1.2%; P = .362). At follow-up, reflux symptoms were reported more frequently by the LSG group than by the LRYGB group (51.9% versus 10.5%). Similarly, moderate-to-severe reflux esophagitis (Los Angeles grade B-D) was more common (27.7% versus 5.8%) despite greater use of proton pump inhibitors (49.4% versus 19.7%), and pathologic acid exposure was more frequent in patients who underwent LSG than in patients who underwent LRYGB. After at least 5 years of follow-up, a higher incidence of reflux symptoms, reflux esophagitis, and pathologic esophageal acid exposure was found in patients who underwent LSG compared with patients who underwent LRYGB. However, the incidence of BE after LSG was low and not significantly different between the 2 groups.

Effect of Proton Pump Inhibitors on the Management of GERD in the Department of Gastroenterology HMC Peshawar

Background: In this trial, patients treated at the Department of Gastroenterology, Hayatabad Medical Complex in Peshawar, would have their gastroesophageal reflux disease (GERD) managed with proton pump inhibitor (PPI) medication. The treatment of omeprazole (40 mg once daily) or famotidine (40 mg O.D. daily) for 12 months was randomly allocated to 100 patients with GERD. The primary outcome measure was the mean change in oesophageal acid exposure time from baseline to twelve months. The frequency of GERD-related symptoms and general health-related quality of life over time were considered secondary objectives. Endoscopic results were also documented at the beginning and after a year. The study's adverse occurrences were kept under observation. The findings demonstrated that from baseline to twelve months, the mean oesophageal acid exposure duration significantly decreased in both PPI groups (mean S.E., 18.9 1.7 minutes for omeprazole group against 16.4 2.1 minutes for famotidine group, p0.001). Additionally, the treatment groups substantially outperformed the control groups at twelve months compared to baseline regarding the mean Frequency of GERD-related symptoms and overall health-related quality of life (p 0.001). There were no documented severe adverse events. GERD may be effectively and safely treated with PPI medication, and there are no clinically significant differences between omeprazole and famotidine.

RefluxStop – A Novel Device to Address Gastroesophageal Reflux Disease in the Context of Esophageal Hypomotility

Abstract Background RefluxStop is a non-active, implantable medical device intended to reduce esophageal acid exposure in patients with gastroesophageal reflux disease (GERD). RefluxStop does not affect the esophageal lumen and thus might also be suited for patients with esophageal hypomotility. Aims To report short-/midterm functional outcomes after implantation of RefluxStop. Methods All patients who received laparoscopic implantation of the RefluxStop device from 09/2018-12/2022 in a university hospital were included for retrospective analysis. Subjective (GERD-HRQL-questionnaires; after six weeks and every six-month thereof) and objective data (24h-pH-manometry, barium swallows and upper endoscopies) are reported as functional outcome parameters. Results Forty-five patients were included. Median age was 49.3y (min 28.1– max 76.8), median Body Mass Index 28kg/m2 (19-34), and 21 patients were female (46.7%). Nine patients (20%) had esophagitis Los Angeles grade C or more, 3 had non-acidic reflux (7%), and 32 (71%) had esophageal motility disorders. Primary presenting symptoms were typical in 31(69%), pain or dysphagia in 5(11%), respiratory in 8(18%) and nausea in 1 patient (2%). GERD-HRQL score was significantly reduced from baseline to 6 weeks postop (23.9 and 4.3 (p &amp;lt; 0.001)) and to last follow-up (6.8, p = 0.021). In the last follow-up, after a median of 3.2y, primary presenting symptoms were gone in 31(69%), improved in 6(13%), and stayed the same in 2(4%). Typical symptoms were gone or improved in 34 of 37 patients (92%), dysphagia and pain in 12 of 15 patients (80%), and respiratory symptoms in all of 14 patients. De novo bloating occurred in 1 patient and was improved or gone in 5 patients; no diarrhea was seen. Conclusions RefluxStop shows promising results over four years in a challenging patient population burdened with GERD and esophageal motility disorders.

The effect of sleep positional therapy on nocturnal gastroesophageal reflux measured by esophageal pH-impedance monitoring.

The aim of the study was to evaluate the effect of an electronic positional therapy wearable device on nocturnal gastroesophageal reflux measured by pH-impedance reflux monitoring. We performed a single-center, prospective, interventional study in 30 patients with nocturnal reflux symptoms and a nocturnal esophageal acid exposure time (AET) ≥1.5% measured off acid-suppressive medication by ambulatory pH-impedance reflux monitoring. Patients were treated with an electronic positional therapy wearable device for 2 weeks. The device vibrates in the right lateral decubitus position so it conditions patients to avoid that sleep position. After 2 weeks treatment, the pH-impedance study was repeated. Primary outcome was the change in nocturnal AET. Secondary outcomes include change in number of reflux episodes and reflux symptoms. Complete data were available for 27 patients (13 females, mean age 49.8 years). The median nocturnal AET decreased from 6.0% (IQR, 2.3-15.3) to 3.1% (0.1-10.8) after 2 weeks of treatment (p = 0.079). The number of reflux episodes was significantly reduced after 2 weeks of treatment (baseline: 8.0 (3.0-12.3) vs. end: 3.0 (1.0-8.0); p = 0.041). Treatment led to a statistically significant decrease in time spent in right lateral decubitus position (baseline: mean 36.9% ± 15.2% vs. end: 2.7% ± 8.2%; p = <0.001) and an increase in the left lateral decubitus position (baseline 29.2% ± 14.8% vs. end: 63.3% ± 21.9%; p = <0.001). Symptom improvement was reported by 70.4% of the patients. Sleep positional therapy using an electronic wearable device promotes sleeping in the left lateral decubitus position and improves reflux parameters measured by pH-impedance reflux monitoring.

Optimizing the treatment of patients with gastroesophageal reflux disease: focus on nutritional risk factors and nutritional approaches

Gastroesophageal reflux disease (GERD) is a common upper gastrointestinal disease characterized by occurrence of typical symptoms associated with an increase in esophageal acid exposure. The transient lower esophageal sphincter relaxations (TLESRs) and hypotension is the key pathophysiological mechanisms of the development of reflux disease. For a long time, it was assumed that certain nutritional and lifestyle factors affect the mechanisms of the onset and progress of GERD. However, the accumulated scientific findings show contradicting results regarding contribution of these factors to the development of reflux disease. The treatment of GERD requires lifestyle modifications, diet therapy, pharmacotherapy, and, if necessary, surgery. Proton pump inhibitors (PPIs) form the basis of pharmacotherapy. Lifestyle modifications, including dietary therapy, is also part of the treatment plan for patients with reflux symptoms, however no clear guidelines in this regard are determined due to the lack of good evidence base. Yet, while the problems associated with the long-term use of PPIs are explored, patients and physicians are increasingly interested in the role of diet in the treatment of GERD. The article provides an overview of the dietary aspects in GERD with a focus on nutritional components and their impact on the pathophysiology and treatment of this disease. Although sequential food-group elimination in GERD is common in clinical practice, literature data demonstrate a broader approach, including reduction of sugar intake, increase of dietary fibres in the diet, and changes in patterns of eating habits as a general principle.

Su1282 ELDERLY SUBJECTS WITH HIGHER DISTAL ESOPHAGEAL ACID EXPOSURE HAVE DIAPHRAGM AND RECTUS ABDOMINIS MUSCLES WEAKNESSES

Su1282 ELDERLY SUBJECTS WITH HIGHER DISTAL ESOPHAGEAL ACID EXPOSURE HAVE DIAPHRAGM AND RECTUS ABDOMINIS MUSCLES WEAKNESSES

Novel Diagnostic Techniques in the Evaluation of Gastroesophageal Reflux Disease (GERD).

In our present clinical paradigm, patient symptoms and presentation in the setting of traditional findings from endoscopy (erosive esophagitis, Barrett's esophagus, reflux-mediated stenosis), esophageal high-resolution manometry, and/or ambulatory reflux monitoring (distal esophageal acid exposure time, numbers of reflux events, reflux-symptom association) guide the care of patients with suspected GERD. However, novel metrics and techniques acquired from or performed at endoscopy, manometry, or pH-impedance monitoring, beyond conventional evaluation, are of great interest to the gastroenterology community given the frequent (and sometimes challenging) presentation of suspected GERD. These novel and evolving diagnostic approaches have the potential to enhance the evaluation of these patients and optimize their management. In this invited review, we discuss the present evidence and potential clinical utility of selected GERD metrics and techniques of interest at endoscopy (dilated intercellular spaces, mucosal impedance), manometry (contractile integral, impedance analysis, straight leg raise, multiple rapid swallow maneuvers), and reflux monitoring (mean nocturnal baseline impedance, post-reflux swallow-induced peristaltic wave indices), and how these tools may be most optimally adopted and utilized for clinical care (Fig.1).

Effects of Helicobacter pylori eradication on esophageal motility, esophageal acid exposure, and gastroesophageal reflux disease symptoms.

The effects of Helicobacter pylori (HP) eradication on gastroesophageal reflux disease (GERD) are yet to be fully elucidated. Few studies have investigated the mechanisms underlying the correlations between HP and GERD with prospective methods. The objective of this prospective clinical study was to explore the effects of HP eradication on GERD. Patients diagnosed with both GERD and HP were included. High-resolution esophageal manometry (HRM), 24-h esophageal pH monitoring, and the Gastroesophageal Reflux Disease Questionnaire (GerdQ) were performed before and after the successful eradication of HP, and the data were compared using statistical analysis. Sixty-eight patients diagnosed with both GERD and HP were included. The After HP eradication group showed significantly decreased median distal contractile integral (DCI) [610.40 (847.45) vs. 444.90 (559.60)] and significantly increased median inefficient esophageal motility (IEM) [36.00 (50.00) vs. 60.00 (57.00)] in the HRM compared with those of the Before HP eradication group, indicating that HP eradication reduced esophageal peristalsis. The 24-h esophageal pH monitoring showed that the longest reflux event, the percentage of time that the pH was <4, the number of reflux episodes, and the DeMeester score were all significantly different between the Before and After HP eradication groups (P < 0.05), suggesting that HP eradication increased esophageal acid exposure. The After HP eradication group also had a significantly higher GerdQ score than that of the Before HP eradication group (P < 0.05). HP eradication reduced esophageal peristalsis, enhanced esophageal acid exposure, and aggravated GERD symptoms, suggesting that HP infection may be a protective factor for GERD.

Long-term Outcome of Peroral Endoscopic Myotomy in Esophageal Motility Disorders: A Systematic Review and Meta-analysis.

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia. In this systematic review and meta-analysis, we aimed to analyze the mid and long-term outcomes of POEM in esophageal motility disorders. Literature search was performed in databases including PubMed, Embase, Cochrane databases, and Google scholar from January 2010 to May 2021. The primary objective of the study was the clinical success (Eckardt score ≤3 or <4) at mid-term (30 to 60 mo) and long-term (>60 mo) follow-up after POEM. Secondary objectives included post-POEM gastroesophageal reflux (GER) as evaluated by symptoms, increased esophageal acid exposure, and reflux esophagitis. Seventeen studies with 3591 patients were included in the review. Subtypes of motility disorders were type I (27%), type II (54.5%), type III (10.7%), distal esophageal spasm/Jackhammer esophagus (2%), and esophagogastric junction outflow obstruction (17.5%). Pooled mean follow-up duration was 48.9 months (95% CI, 40.02-57.75). Pooled rate of clinical success at mid-term follow-up was 87% (95% CI, 81-91; I2 , 86%) and long-term was 84% (95% CI, 76-89; I2 , 47%). In nonachalasia motility disorders (esophagogastric junction outflow obstruction, distal esophageal spasm, and Jackhammer esophagus), pooled rate of clinical success was 77% (95% CI, 65-85; I2 , 0%). GER as estimated by symptoms was 23% (95% CI, 19-27; I2 , 74%), erosive esophagitis was 27% (95% CI, 18-38%; I2 , 91%), and increased esophageal acid exposure was 41% (95% CI, 30-52; I2 , 88%). POEM is a durable treatment option in cases with achalasia. One-fourth of patients suffer from erosive GER in the long-term and success rates are lower in nonachalasia esophageal motility disorders.