Esophageal Acid Exposure Research Articles

Clinical Characteristics of Patients With Ineffective Esophageal Motility by Chicago Classification Version 4.0 Compared to Chicago Classification Version 3.0

Chicago classification version 4.0 (CCv4.0) of esophageal motility disorders developed a more stringent diagnostic criteria for ineffective esophageal motility (IEM) than version 3.0. We studied the implications of the new diagnostic criteria on the prevalence of IEM, and clinically characterized and compared the population of patients who no longer meet diagnostic criteria for IEM to those who retain the diagnosis. We included all consecutively performed high-resolution esophageal impedance manometries from 2014 to 2021. Three cohorts of patients with IEM were created: Patients with IEM by Chicago classification version 3.0 (CCv3.0; CC3 group), by CCv4.0 only (CC4 group), and by CCv3.0 who are now considered normal (Normal group). Demographics, manometric and reflux parameters, and clinical outcomes were compared. A total of 594 manometries were analyzed. Of those, 66 (11.1%) met criteria for IEM by CCv3.0 (CC3), 41 (62.0%) retained an IEM diagnosis using CCv4.0 criteria (CC4), while 25 (38.0%) patients no longer met criteria for IEM (Normal). The CC4 group had higher esophageal acid exposure, especially supine (% time - 18.9% vs 2.2%; P = 0.005), less adequate peristaltic reserve (22.0% vs 88.0%; P = 0.003), and higher Demeester score (49.0 vs 21.2; P = 0.017) compared to the Normal group. There was no difference in bolus clearance between the groups. IEM under CCv4.0 has a stronger association with pathologic reflux, especially supine reflux, and inadequate peristaltic reserve, but impairment in bolus clearance is unchanged when compared with IEM diagnosed based on CCv3.0. Further studies are required to determine the implications of these findings on management strategies.

Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review

Summary Background The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force. Methods An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence. Results Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia. Conclusion A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.

Long-term clinical and functional results of magnetic sphincter augmentation.

Magnetic sphincter augmentation (MSA) was introduced in 2007 as an alternative surgical procedure for patients with gastroesophageal reflux disease (GERD). The majority of data since MSA's introduction has focused on short and intermediate-term results, demonstrating safety and high efficacy in terms of reflux symptom control, freedom from proton pump inhibitor use and normalization of distal esophageal acid exposure. However, GERD is a chronic condition that demands a long-term solution. Limited available data from studies reporting outcomes at 5years or later following MSA demonstrate that the promising short- and mid-term efficacy and safety profile of MSA remains relatively constant in the long term. Compared with Nissen fundoplication, MSA has a much lower rate of gas-bloat and inability to belch at a short-term follow-up, a difference that persists in the long-term. The most common complaint after MSA at a short-term follow-up is dysphagia. However, limited data suggest dysphagia rates largely decrease by 5years. Dysphagia is the most common indication for dilation and device removal in both early- and long-term studies. However, the overall rates of dilation and removal are similar in short- and long-term reports, suggesting the majority of these procedures are performed in the short-term period after device implantation. The indications and standard practices of MSA have evolved over time. Long-term outcome data currently available are all from patient cohorts who were selected for MSA under early restricted indications and outdated regimens. Therefore, further long-term studies are needed to corroborate the preliminary, yet encouraging long-term results.

The influence of supragastric belching severity on esophageal acid exposure and motility.

Supragastric belching (SGB) is a phenomenon where air is rapidly sucked from the pharynx into the esophagus and immediately expelled through abdominal straining. It is considered a behavior disorder and is increasingly recognized not only in patients with excessive belching, but also in those with reflux-like symptoms. Increased prevalence of esophageal hypomotility and increased acid exposure were previously reported in small cohorts of SGB patients. We aimed to clarify the impact of SGB on motility, reflux, and acid exposure in a large cohort of SGB patients. In a single-center database study, we searched for patients with pathological SGB. MII-pH and Manometry tracings were manually re-evaluated in all patients. Demographic, clinical, motility, reflux, and SGB-related data were gathered. Three hundred and forty-eight patients were included. Heartburn, belching, and regurgitation were the most common symptoms. Ineffective esophageal motility (IEM) was found in 27% of patients. SGB related to 47% of all reflux and to 53.6% of acid reflux events, and accounted for 27.3% of acid exposure time (AET). In those with severe SGB, 62% of acid reflux events and 46% of AET were SGB-related. Supragastric belching is common, associated with higher incidence of IEM and is responsible for almost a third of esophageal acid burden. The impact of SGB is proportional to its severity. Diagnosis of SGB should be sought in patients with excessive belching and in patients with refractory reflux symptoms. Recognizing SGB and treating patients with behavioral therapy may alleviate acid exposure and improve quality of life.

The outcome of primary per oral endoscopic myotomy (POEM) for treatment of achalasia: Norwegian single-center experience with long-term follow-up.

Per oral endoscopic myotomy (POEM) has become an established treatment for achalasia, but no Scandinavian studies with long-term follow-up exist. This study from a tertiary referral center in Norway investigates the short-, mid-, and long-term feasibility, safety, efficacy, and complications of POEM. Prospective data from the first 84 patients who underwent POEM from 2014 to 2019 were analyzed. The median follow-up time was 44 months. Clinical success was defined as the Eckardt score (ES) ⩽3, and reflux as pathological if the acid exposure time (pH < 4) was more than 6%. ES was used for symptom evaluation before, and at 6, 12, and up to 64 months after POEM. A total of 50 males and 34 females were included. A total of 43 (51%) were treatment naïve, 24 (28.6%) had been previously treated with botulinum toxin, pneumatic balloon dilatation, or both, and 17 (20.2%) were previously treated with Heller's myotomy. The median post-POEM ES at 12 months was 1 (0-9), compared to pre-POEM 7 (4-12) (p < 0.01). At 12 months after POEM, clinical success persisted in 74 patients (88.1%). Clinical success was the highest for patients who were naïve to treatment, 41/43 (95%), and lower for those previously treated with Heller's myotomy 12/17 (70.6%). Long-term follow-up at 5-6 years of 42 patients showed a clinical success rate of 94%. We experienced adverse events in five patients (6%). Post-POEM pathological reflux was found in 46% (28/61). After 3-4 years, the median ES was 1, and after 5-6 years, it was 2. POEM was safe and relieved the symptoms of achalasia significantly and persistently. The procedure had a better outcome in treatment naïve than previously treated patients. However, POEM is associated with significantly increased esophageal acid exposure. Norwegian single-center study: POEM had a clinical success rate of 94% after 5-6 years since its introduction at the center in 2014, providing a safe and effective treatment for achalasia.

Feasibility and Efficacy of Magnetic Sphincter Augmentation for the Management of Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy for Obesity

BackgroundPatients with medically intractable GERD after laparoscopic sleeve gastrectomy (LSG) have limited surgical options. Fundoplication is difficult post-LSG. Roux-en-Y gastric bypass may be used as a conversion procedure but is more invasive with potential for serious complications. Magnetic sphincter augmentation (MSA) is a less invasive GERD treatment alternative. The objective of this study was to assess safety and efficacy outcomes of MSA after LSG.MethodsThe primary outcome of this observational, multicenter, single-arm prospective study was the rate of serious device and/or procedure-related adverse events (AEs). The efficacy of the LINX device was measured comparing baseline to 12-month post-implant reductions in distal acid exposure, GERD-HRQL score, and average daily PPI usage.ResultsThirty subjects who underwent MSA implantation were followed 12 months post-implant. No unanticipated adverse device effects were observed. There were two adverse events deemed serious (dysphagia, pain, 6.7%) which resolved without sequelae. GERD-HRQL scores showed significant improvement (80.8%, P < 0.001), and reduction in daily PPI usage was seen (95.8%, P < 0.001). Forty-four percent of subjects demonstrated normalization or > = 50% reduction of total distal acid exposure time (baseline 16.2%, 12 months 11%; P = 0.038).ConclusionsPost-LSG, MSA showed an overall improvement of GERD symptoms, and reduction in PPI use with explants within anticipated range along with improvement in distal esophageal acid exposure time.Graphical

Novel histologic score predicts recurrent intestinal metaplasia after successful endoscopic eradication therapy.

Endoscopic eradication therapy (EET) is an effective treatment for Barrett's esophagus (BE); however, disease recurrence remains problematic requiring surveillance post-treatment. While data regarding predictors of recurrence are limited, uncontrolled reflux may play a significant role. Our aim was to develop a scoring system based on histopathologic reflux in surveillance biopsies following EET to identify patients at high risk for recurrence of BE. Patients were identified from two centers in the treatment with resection and endoscopic ablation techniques for BE consortium. Hematoxylin and eosin-stained slides of surveillance biopsies post-EET were assessed for histologic changes associated with reflux from a cohort of patients who also underwent pH-metry (derivation cohort). We developed a novel scoring system (Recurrent Epithelial Changes from Uncontrolled Reflux [RECUR]) composed of dilated intercellular spaces, epithelial ballooning, basal cell hyperplasia, and parakeratosis, to identify patients with abnormal esophageal acid exposure. This scoring system was then used to grade surveillance biopsies from patients with or without recurrence of BE following EET (validation cohort). Of 41 patients in the derivation cohort, 19.5% had abnormal acid exposure times (AET) while on proton pump inhibitor therapy. The mean (SD) RECUR score for patients with AET <4% was 4.0 (1.6), compared with 5.5 (0.9) for AET ≥4% (P = 0.015). In the validation cohort consisting of 72 patients without recurrence and 64 patients with recurrence following EET, the RECUR score was the only significant predictor of recurrence (odds ratio: 1.36, 95% confidence interval: 1.10-1.69, P = 0.005). Histologic grading of surveillance biopsies using the RECUR scoring system correlates with BE recurrence following EET.

Improving the Diagnostic Yield of High-Resolution Esophageal Manometry for GERD: The “Straight Leg-Raise” International Study

The straight leg raise (SLR) maneuver during high-resolution manometry (HRM) can assess esophagogastric junction (EGJ) barrier function by measuring changes in intraesophageal pressure (IEP) when intra-abdominal pressure is increased. We aimed to determine whether increased esophageal pressure during SLR predicts pathologic esophageal acid exposure time (AET). Adult patients with persistent gastroesophageal reflux disease (GERD) symptoms undergoing HRM and pH-impedance or wireless pH study off proton pump inhibitor were prospectively studied between July 2021 and March 2022. After the HRM Chicago 4.0 protocol, patients were requested to elevate 1 leg at 45º for 5 seconds while supine. The SLR maneuver was considered effective when intra-abdominal pressure increased by 50%. IEPs were recorded 5 cm above the lower esophageal sphincter at baseline and during SLR. GERD was defined as AET greater than 6%. The SLR was effective in 295 patients (81%), 115 (39%) of whom had an AET greater than 6%. Hiatal hernia (EGJ type 2 or 3) was seen in 135 (46%) patients. Compared with patients with an AET less than 6%, peak IEP during SLR was significantly higher in the GERD group (29.7 vs 13.9 mm Hg; P < .001). Using receiver operating characteristic analysis, an increase of 11 mm Hg of peak IEP from baseline during SLR was the optimal cut-off value to predict an AET greater than 6% (area under the receiver operating characteristic curve, 0.84; sensitivity, 79%; and specificity, 85%), regardless of the presence of hiatal hernia. On multivariable analysis, an IEP pressure increase during the SLR maneuver, EGJ contractile integral, EGJ subtype 2, and EGJ subtype 3, were found to be significant predictors of AET greater than 6% CONCLUSIONS: The SLR maneuver can predict abnormal an AET, thereby increasing the diagnostic value of HRM when GERD is suspected. gov ID: NCT04813029.

S414 POEM Is Associated with Increased Reflux in All Positions Compared to Heller Myotomy

Introduction: Achalasia is an esophageal motility disorder that results from a disruption of the neuromodulatory responses of the esophagus and lower esophageal sphincter (LES). A common consequence of treating the hypercontractile LES is worsened gastroesophageal reflux (GER). It is well-established that peroral endoscopic myotomy (POEM) leads to a higher absolute rate of GER than Laparoscopic Heller Myotomy with Dor fundoplication (LHM); however, the exact patterns of reflux have not been well-described. Methods: The charts of patients who underwent LHM or POEM between 2017 and 2019 at our institution were reviewed, and patients who had completed a 2-month post-treatment esophageal pH study off acid-lower agents were included. We also included patients who underwent EGD but did not undergo pH monitoring due to finding erosive esophagitis. Patients with a history of prior myotomy or who underwent Heller without Dor fundoplication were excluded. Results: Of the 236 patients included, 85 (36%) had undergone POEM while 151 (64%) had undergone LHM. Overall, 45% of POEM patients experienced more than 30 reflux episodes per day compared to 12% for LHM, p< 0.001. POEM patients had more GER in all positions compared to LHM, identified by a mean total % time spent in reflux of 9.3% vs 3.2%, upright 7.8% vs 2.6%, and supine 10.1% vs 3.5%, p< 0.001 for all. POEM patients also developed significantly more long refluxes (episodes > 5 minutes) per day (4.0 vs 1.7, p< 0.001). 47% of POEM patients experienced at least one reflux episode longer than 30 minutes, compared to 19% of LHM patients (p< 0.001). POEM patients who developed relatively more reflux in the supine position than upright comprised 41.1% compared to 21.7% of LHM, p=0.007. Conclusion: This study sheds light on the pattern of reflux in POEM as compared to LHM. POEM patients had evidence of significantly more esophageal acid exposure across all indices. POEM patients on average spent 9.3% of their day in reflux as compared to 3.2% for LHM. POEM patients had higher supine to upright ratios of reflux exposure. The finding of abnormal reflux in both the upright and supine position, with relative skew towards supine reflux after POEM may help to better tailor anti-reflux therapies in this population (Table). Table 1. - Reflux pattern differences between POEM and LHM. p-value significant if p<0.05 Characteristic POEM LHM p-value TOTAL Number of refluxes /24h 40.0 15.4 < 0.001 Percent time in reflux 9.3% 3.2% < 0.001 Number of long refluxes /24h 4.0 1.7 < 0.001 Average of longest reflux (mins) 45.7 19.0 < 0.001 UPRIGHT Number of refluxes /1h 1.8 0.6 < 0.001 Percent time in reflux 7.8% 2.6% < 0.001 Number of long refluxes /1h 0.18 0.06 < 0.001 Average of longest reflux (minutes) 19.0 9.9 < 0.001 SUPINE Number of refluxes /24h 1.4 0.5 0.003 Percent time in reflux 10.1% 3.5% < 0.001 Number of long refluxes /1h 0.2 0.1 0.001 Average of longest reflux (minutes) 35.8 12.4 < 0.001 OVERALL DeMeester Score 37.2 13.2 < 0.001 % Time reflux in supine/upright >1 41.1% 21.7% 0.007

S471 Does Lower Esophageal Sphincter Distensibility Measured by the Functional Lumen Imaging Probe Relate to Total Esophageal Acid Exposure Time?

S471 Does Lower Esophageal Sphincter Distensibility Measured by the Functional Lumen Imaging Probe Relate to Total Esophageal Acid Exposure Time?

S423 Association Between Defective Secondary Peristalsis Detected by Functional Lumen Imaging Probe Topography (FLIP) and GERD

Introduction: Esophageal secondary peristalsis is a defense mechanism against GERD by clearance of refluxate. When absent or defective, it may lead to increased esophageal acid exposure time (AET). Functional lumen imaging probe topography (FLIP) allows assessment of secondary peristalsis induced by volumetric distension. Aim: evaluate the association between secondary peristalsis and GERD. Methods: We included patients with esophageal symptoms who underwent FLIP topography and reflux monitoring (wireless pH or catheter-based pH-impedance) while off PPI ≥7 days, high-resolution esophageal manometry (HRM) findings (LES pressure, ineffective esophageal motility , absent contractility) were added for secondary analysis when available. Exclusion criteria: achalasia, prior gastroesophageal surgery, Botox injection within 6 months of FLIP and reflux study. Abnormal AET on reflux monitoring was defined as % time pH< 4 greater than 4%. FLIP was performed with a 16 cm balloon during propofol-sedated endoscopy; peristaltic response was assessed at 30-40-50-60 ml and classified as repetitive antegrade contractions (RACs), borderline contractile response, repetitive retrograde contractions (RRCs), impaired, absent, and spastic reactive. EGJ distensibility index (DI) was calculated at 60ml. Secondary peristalsis was considered intact if RACs seen at any volume, impaired otherwise. Those with borderline contractility but no RACs were excluded from analysis.. We assessed the association between FLIP and HRM findings and GERD by t test and chi square. Results: 37 patients included (23, 62% female), mean age 58.45 years, mean BMI 25.7. GERD present in 15 (40.5%). Mean esophageal AET was lower in patients with versus without intact peristalsis but significance not reached (5.8% vs 3.0%, p=0.058). The proportion of patients with GERD was lower in patients with peristalsis versus without intact peristalsis but significance not reached (25% vs 40%, p=0.18). There was no association between GERD and DI or any HRM measures. Conclusion: Our data suggests that defective secondary peristalsis is more frequent in GERD patients and is thus and important contributing factor to reflux. Lack of significance may be due to small sample size and type II error, but a larger number of patients is needed to clarify this and data collection is ongoing.

149. LOCAL INFLAMMATORY RESPONSE TO GASTROESOPHAGEAL REFLUX: ASSOCIATION OF GENE EXPRESSION OF INFLAMMATORY CYTOKINES WITH MULTICHANNEL INTRALUMINAL PH-IMPEDANCE DATA

Abstract Expression of inflammatory cytokines’ genes may take part in pathophysiology of different forms of gastroesophageal reflux disease (GERD). Aim: to explore the expression of inflammatory cytokines’ genes in esophageal mucosa in patients with erosive esophagitis and non-erosive forms of gastroesophageal reflux disease and its association with data of esophageal multichannel intraluminal pH-impedance measurements. This was a single-center prospective study. Esophageal mucosa samples were taken from lower part of the esophagus during endoscopy. Expression of IL-1β, IL-10, IL-18, TNFA, TLR4, GATA3, CD68, beta-2 macroglobulin genes in esophageal mucosa was assessed with ImmunoQuantex assays. Multichannel intraluminal esophageal pH-impedance (MII-pH) studies performed to all the participants. Diagnosis of GERD was confirmed by the results of MII-pH data. Patients were allocated to erosive esophagitis (EE) or non-erosive GERD groups (NERD). Non-symptomatic subjects with normal endoscopy and MII-pH results served as a control. Spearman rank correlation was used to asses association of genes expression and results of MII-pH. Data of 60 patients with GERD and 10 subjects of the control group were available for the analysis. Higher expression of IL-18 (5.89 ± 0.4 vs 5.28 ± 1.1, p = 0.04) and GATA3 (2.92 ± 0.86 vs 2.23 ± 0.96, p = 0.03) genes was found in EE group compared to NERD. Expression of IL-1β, IL-18, TNFA, and TLR4 genes was lower (P &amp;lt; 0.05) in the control group compared to EE and NERD. Esophageal acid exposure correlated with the expression of IL-1β (R = 0.29), IL-18 (R = 0.31), TNFA (R = 0.35), GATA3 (R = 0.34), TLR4 (R = 0.29), CD68 (R = 0.37) genes. Mean esophageal рН correlated inversely with the expressions of IL-18, TNFA, GATA3, TLR4, CD68 genes. In patients with erosive esophagitis, local expression of interleukin 18 and GATA3 transcription factor genes was higher compared to subjects with non-erosive form of gastroesophageal reflux disease. Esophageal acid exposure correlated directly with expression of IL-1β, IL-18, TNFA, TLR4, CD68 and B2M genes. Inverse correlation revealed between expression of IL-18, TNFA, GATA3, TLR4 CD68 genes and mean esophageal pH.

Local inflammatory response to gastroesophageal reflux: Association of gene expression of inflammatory cytokines with esophageal multichannel intraluminal impedance-pH data.

BACKGROUNDGene expression of inflammatory cytokines may take part in the pathophysiology of different forms of gastroesophageal reflux disease (GERD).AIMTo explore gene expression of inflammatory cytokines in esophageal mucosa in patients with erosive esophagitis (EE) and non-erosive forms of GERD (NERD) and its association with data of esophageal multichannel intraluminal impedance-pH (MII-pH) measurements.METHODSThis was a single-center prospective study. Esophageal mucosa samples were taken from the lower part of the esophagus during endoscopy. Expression of interleukin (IL)-1β, IL-10, IL-18, tumor necrosis factor α (TNFA), toll-like receptor 4 (TLR4), GATA binding protein 3 (GATA3), differentiation cluster 68 (CD68) and β-2 microglobulin genes in esophageal mucosa was assessed with ImmunoQuantex assays. MII-pH measurements were performed on all the participants. Diagnosis of GERD was confirmed by the results of the MII-pH data. Based on the endoscopy, patients were allocated to the groups of EE and NERD. The control group consisted of non-symptomatic subjects with normal endoscopy and MII-pH results. We used nonparametric statistics to compare the differences between the groups. Association of expression of the mentioned genes with the results of the MII-pH data was assessed with Spearman’s rank method.RESULTSData from 60 patients with GERD and 10 subjects of the control group were available for the analysis. Higher expression of IL-18 (5.89 ± 0.4 vs 5.28 ± 1.1, P = 0.04) and GATA3 (2.92 ± 0.86 vs 2.23 ± 0.96, P = 0.03) was found in the EE group compared to NERD. Expression of IL-1β, IL-18, TNFA, and TLR4 was lower (P < 0.05) in the control group compared to EE and NERD. Esophageal acid exposure correlated with the expression of IL-1β (Spearman’s rank r = 0.29), IL-18 (r = 0.31), TNFA (r = 0.35), GATA3 (r = 0.34), TLR4 (r = 0.29), and CD68 (r = 0.37). Mean esophageal рН correlated inversely with the expression of IL-18, TNFA, GATA3, TLR4, and CD68. No association of gene expression with the number of gastroesophageal refluxes was found.CONCLUSIONIn patients with EE, local expression of IL-18 and GATA3 was higher compared to subjects with NERD. Esophageal acid exposure correlated directly with expression of IL-1β, IL-18, TNFA, TLR4, CD68, and β-2 microglobulin genes. Inverse correlation was revealed between expression of IL-18, TNFA, GATA3, TLR4, and CD68 and mean esophageal pH.

Positive and negative impact of anti-reflux mucosal intervention on gastroesophageal reflux disease.

Anti-reflux mucosal intervention (ARMI), including anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA), is a promising endoscopic treatment for gastroesophageal reflux disease (GERD). Few studies reported a detailed analysis of the objective reflux parameters. Patients with chronic PPI-dependent GERD and receiving ARMI were prospectively enrolled. Comprehensive clinical symptom profiles, endoscopy results, and 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring were collected and analyzed before and 3months after ARMI. Twenty-three patients undergoing ARMI (11 ARMS and 12 ARMA) were enrolled. The median (IQR) operative time and post-procedure stays were 50 (46-56) min and 2 (2-2) days without major complications. 73.9% of patients reported subjective global improvement. A significant decrease in the total reflux symptom index score was noted from 12 (5-19) to 8 (4-12) (P = 0.010). The esophageal acid exposure time (AET) significantly decreased from 4.6 (2.8-6.9) to 2.1 (1.1-5.6) (P = 0.013), and the number of acid refluxes and DeMeester score were significantly reduced. Three patients (13%) had increased AET (3.4% to 6.1%, 6.3% to 15.4%, and 3.2% to 5.6%); however, all reported global improvement and two patients could discontinue PPI subjectively. One patient (4.3%) had worsened erosive esophagitis and reflux symptoms. 56.5% of patients stopped PPI. ARMI is generally effective and safe in PPI-dependent patients. However, possible negative effects of ARMI exist in some patients; further application of MII-pH is necessitated to evaluate the treatment response after ARMI and avoid the detrimental effect of PPI discontinuation. Graph.

The relationship between esophageal acidity and symptom frequency in symptomatic nonerosive gastroesophageal reflux disease.

The present paper examines the extent to which novel measures of esophageal acid exposure can elucidate possible relationships between symptom perception and esophageal acidity in subjects with nonerosive gastroesophageal reflux disease. Recordings of esophageal pH and symptom occurrence from 20 subjects with nonerosive gastroesophageal reflux disease were analyzed. Interval esophageal acid exposure was calculated in two different ways for the interval that preceded each symptom in each subject. Interval esophageal acidity was calculated as the time‐weighted acid concentration for the interval. Interval esophageal acid exposure time was calculated as the percentage of the total recording time that esophageal pH was less than pH 4 for the interval. There was a negative relationship between the probability of a symptom and interval esophageal acid exposure indicating the paradoxical finding that the lower the value of esophageal acid exposure, the higher the probability of a symptom. The time courses of symptoms and cumulative esophageal acidity resolved this paradox by indicating that esophageal acid exposure oscillates between longer periods of low esophageal acid exposure with a high number of symptoms reflecting high esophageal acid sensitivity, and shorter periods of high esophageal acid exposure with fewer symptoms reflecting low esophageal acid sensitivity. Thus, the present analyses show how novel measures of acidity can identify and also resolve a previously unrecognized paradoxical relationship between esophageal acid exposure and symptom frequency in subjects with nonerosive gastroesophageal reflux disease.

Objective Outcomes of an Extended Anti-reflux Mucosectomy in the Treatment of PPI-Dependent Gastroesophageal Reflux Disease (with Video)

BackgroundAnti-reflux mucosectomy (ARMS) is a choice for proton pump inhibitor (PPI)-dependent patients with gastroesophageal reflux disease (GERD). We present an extended anti-reflux mucosectomy, named ligation-assisted anti-reflux mucosectomy (L-ARMS). The aim of this study was to assess the feasibility of the procedure and short-term outcomes on PPI use and symptom resolution. MethodsInstitutional review board approval was obtained for retrospective review of a prospectively collected database including patients who underwent L-ARMS. L-ARMS includes mucosa ligation and endoscopic mucosectomy without submucosal injection around the squamocolumnar junction. The GERD symptoms, endoscopy, 24-h pH monitoring results, and manometry were collected by chart review. Voluntary validated surveys assessed symptomatic improvement over time. ResultsThere were 69 patients available for review. The procedure was technically completed in all cases with no severe complications, and the average operation time was 33 min. At 6 months after L-ARMS, treatment with PPIs had been halted in 55.1% of the patients, 30.4% of the enrolled patients used PPIs occasionally, and the lower esophageal sphincter (LES) pressure, DeMeester scores, and GERD-health-related quality of life questionnaire (GERD-HRQL) scores showed a significant improvement compared with the baseline measurements (P < 0.001). Forty-five patients complained of mild dysphagia and were relieved in 4 weeks with no specific treatment. Compared to patients without dysphagia, patients complained of dysphagia after surgery had better clinical benefits indicated by GERD-HRQL and DeMeester score. ConclusionsAs a modified ARMS, L-ARMS is an effective procedure for controlling GERD symptoms, esophageal acid exposure, and LES pressure, which can be safely performed endoscopically in a time-saving and simple manner.

Impact of gastroesophageal reflux disease on idiopathic pulmonary fibrosis and lung transplant recipients.

Idiopathic pulmonary fibrosis (IPF) is a prevalent subset of interstitial lung disease (ILD) that often progresses to require lung transplantation. Gastroesophageal reflux disease (GERD) is common in the IPF population, and GER-related micro-aspiration appears to be an important risk factor for IPF pathogenesis and for the deterioration of transplanted lung function. Many patients with IPF have elevated esophageal acid exposure on reflux testing despite having no or minimal symptoms. Studies on the effects of medical GERD therapy on IPF-related outcomes have had mixed results. Antireflux surgery is safe in appropriately selected IPF patients, and appears to have potential for slowing the decline of lung function. GERD can persist, improve or develop after lung transplantation, and the presence of GERD is associated with allograft injury and pulmonary function decline in lung transplant recipients. Clinicians should have a low threshold to assess for objective evidence of GERD in IPF patients. Antireflux surgery in IPF patients with GERD appears to improve lung function, but further studies are needed before surgical treatment can be recommended routinely in this setting. In lung transplant recipients, reflux testing after transplant is the most accurate way to guide GERD treatment decisions.

Nocturnal acid breakthrough and esophageal acidification during treatment with dexlansoprazole as compared to omeprazole in patients with gastroesophageal reflux disease.

Nocturnal acid breakthrough (NAB) may differ based on duration of proton pump inhibitor (PPI) action and Helicobacter pylori (H. pylori) infection; NAB may influence esophageal acidification (EA) and mucosal damage. Dexlansoprazole, a long-acting PPI, was not compared with omeprazole for NAB, gastric acid suppression, and EA in relation to H. pylori infection. In this prospective open-label comparative observational study, gastroesophageal reflux disease (GERD) patients were evaluated using 24-h dual-channel pH-impedance monitoring while on dexlansoprazole (60 mg, n = 39) and omeprazole (20 mg, n = 41) to study the degree of gastric acid suppression, esophageal acid exposure, and NAB (primary outcome measures). H. pylori was detected by rapid urease test and histology. NAB tended to be frequent with omeprazole than dexlansoprazole (33/41 [80.5%] vs. 23/39 [59%]; p = 0.06). Though nocturnal mean esophageal pH was comparable between the dexlansoprazole and omeprazole groups, its duration was less with the former (181.5 [15.2-334.2] vs. 283 [158-366] min, p = 0.03). NAB was as frequent in the H. pylori-infected than the non-infected group (11/19 [57.9%] vs. 45/61 [73.8%]; p = 0.1). The nocturnal gastric and esophageal pH in the H. pylori-infected group was higher than in the non-infected group (4.6 ± 1.7 vs. 4 ± 1.6, p = 0.157; 6.1 ± 0.6 vs. 5.8 ± 0.6, p = 0.128). Dexlansoprazole tended to increase 24-h and nocturnal mean gastric pH among H. pylori-infected more than omeprazole (5.9 ± 1.1 vs. 4.2 ± 1.7, p = 0.023; 5.7 ± 1.2 vs. 3.8 ± 1.5, p = 0.006). Dexlansoprazole is more effective than omeprazole in suppressing gastric acid secretion, resulting in lesser EA and NAB, particularly in the presence of H. pylori.

Recent insights on functional heartburn and reflux hypersensitivity.

Rome IV experts have proposed that gastroesophageal reflux disease (GERD) should be diagnosed only in patients with abnormal esophageal acid exposure, and that reflux hypersensitivity (RH) and functional heartburn (FH) both should be considered functional conditions separate from GERD. Although past and recent evidence support that FH can be completely distinguished from GERD, the concept that RH is not GERD is highly questionable. This review attempts to provide current data on these issues. Many recent investigations have provided new data on the different pathophysiological features characterizing RH and FH. Major differences have emerged from analyses of impedance-pH monitoring studies using the novel impedance metrics of baseline impedance (an index of mucosal integrity) and the rate of postreflux swallow-induced peristaltic waves (a reflection of the integrity of esophageal chemical clearance). The better ability to interpret impedance-pH tracings together with earlier data on the different prevalence of microscopic esophagitis in RH and FH patients, and recent studies documenting poor therapeutic efficacy of pain modulators and good results of antireflux surgery for RH support recategorization of RH within the GERD world. Further research is needed to correctly phenotype patients who have heartburn without mucosal breaks, and to guide their effective management.

The Effects of Modifying Amount and Type of Dietary Carbohydrate on Esophageal Acid Exposure Time and Esophageal Reflux Symptoms: A Randomized Controlled Trial.

INTRODUCTION:This is the first randomized controlled diet intervention trial to investigate both the amount and type of carbohydrate on symptomatic gastroesophageal reflux disease (GERD).METHODS:Ninety-eight veterans with symptomatic GERD were randomly assigned to high total/high simple, high total/low simple, low total/high simple, or low total/low simple carbohydrate diet for 9 weeks. The primary outcomes were esophageal acid exposure time (AET) and total number of reflux episodes derived from 24-hour ambulatory pH monitoring. Secondary outcomes were esophageal reflux symptoms rated using the Gastroesophageal Reflux Disease Questionnaire (GERDQ) and GERD Symptom Assessment Scale (GSAS).RESULTS:Half of the subjects were White and half African American (mean age, 60.0 ± 12.5 years; mean body mass index, 32.7 ± 5.4 kg/m2). There was a significant main effect of diet treatment on AET (P = 0.001) and on the total number of reflux episodes (P = 0.003). The change in AET in the high total/low simple group (−4.3% ± 3.8%) differed significantly from the high total/high simple control group (+3.1% ± 3.7%), (P = 0.04). The reduction in simple sugar intake averaged 62 g less per day. Subjects' ratings of symptoms improved in all carbohydrate modification groups, including significant reductions in heartburn frequency, heartburn severity, acid taste in the mouth, lump/pain in the throat or chest, and sleep disturbance.DISCUSSION:A modification of dietary carbohydrate intake that targeted a substantial reduction in the intakes of simple sugars improved pH monitoring outcomes and symptoms of GERD that profoundly affect daily life. These findings provide a feasible and clinically applicable contribution to the limited objective data existing for efficacious dietary recommendations in the routine treatment and management of GERD.