Evidence Of Gastroesophageal Reflux Disease Research Articles

Randomized Placebo-Controlled Double-Blind Crossover Trial of Buspirone in Functional Dysphagia and Ineffective Esophageal Motility

Introduction: Functional Dysphagia (FD) is a syndrome in which patients report dysphagia without evidence of Gastroesophageal Reflux Disease (GERD) or a histopathology-based esophageal motility disorder. There are data that argue that Ineffective Esophageal Motility (IEM) is the manometric correlate of FD. IEM is defined as a High Resolution Esophageal Manometry (HREM) with 50% or more of the swallows having a Distal Contractile Index (DCI) of. Methods: We performed a prospective, double-blind, placebo-controlled, cross-over trial of 10 patients with both FD and IEM. Patients were randomized to one of two groups for a period of six total weeks. Group A patients were treated with buspirone for two weeks followed by a two-week washout period and subsequently treated with placebo. Patients in Group B were treated with placebo for the first two weeks and buspirone the last two weeks. Outcomes measured at baseline, end of week 2, and week 6 include the Mayo Dysphagia Questionnaire-14 (MDQ-14), the GERD-HRQL, and HREM. A sample size of 10 patients was found to have 80% power to detect a difference of 25% in the number of failed or weak swallows. Results: The mean age of our 10 patients was 53 +/- 9 years and 70% were female. While 70% of the patients treated with placebo had IEM, only 50% of those treated with buspirone had IEM. However, this difference was not statistically significant. Furthermore, when comparing those treated with placebo with those treated with buspirone, there was no statistically significant difference in resting lower esophageal sphincter pressure, median integrated residual pressure, mean DCI, or percentage of swallows weak, failed, or normal (Table 1). There was also no statistically significant difference in any of the questions in the MDQ-14 or the GERD-HRQL (Table and Figure 1). Of note, patients had a statistically significant decrease in the total GERD-HRQL total score when treated with placebo compared to baseline levels.Figure: Percentage of Patients with Dysphagia at Baseline, With Placebo, and After Buspirone.Table: Table. Buspirone versus Placebo in Functional Dysphagia and Ineffective Esophageal MotilityConclusion: Despite previous data showing improved motility in healthy volunteers, our study shows no difference in terms of HREM parameters or symptom scores in FD and IEM patients treated with buspirone compared to placebo. Further research is necessary to identify novel agents.

Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea.

Background/AimsSeveral specific foods are known to precipitate gastroesophageal reflux disease (GERD) symptoms and GERD patients are usually advised to avoid such foods. However, foods consumed daily are quite variable according to regions, cultures, etc. This study was done to elucidate the food items which induce typical GERD symptoms in Korean patients.MethodsOne hundred and twenty-six Korean patients with weekly typical GERD symptoms were asked to mark all food items that induced typical GERD symptoms from a list containing 152 typical foods consumed daily in Korea. All patients underwent upper gastrointestinal endoscopy followed by 24-hour ambulatory esophageal pH monitoring. The definition of “GERD” was if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.ResultsOne hundred and twenty-six cases (51 GERD and 75 possible GERD) were enrolled. In 19 (37.3%) of 51 GERD cases and in 17 (22.7%) of 75 possible GERD cases, foods inducing typical GERD symptoms were identified. In the GERD group (n = 19), frequent symptom-inducers were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki. In the possible GERD group (n = 17), frequent symptom-inducers were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizza, topokki, rice cakes, champon noodles, and hotdogs.ConclusionsIn one-third of GERD patients, foods inducing typical symptoms were identified. Hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki were the foods frequently inducing typical symptoms in Korea. The list of foods frequently inducing typical GERD symptoms needs to be modified based on their own local experiences.

Role of PH Monitoring in Laryngopharyngeal Reflux Patients with Voice Disorders.

Laryngopharyngeal reflux (LPR) is considered an important cause of voice disorder. We aimed to determine the frequency of LPR in patients with voice disorder and the association between Koufman Reflux Symptom Index (RSI), Reflux Finding Score (RFS), gastroesophageal reflux disease (GERD), and proximal acid reflux in these patients. We performed a prospective study in patients aged more than 18 years presenting at the ear, nose, and throat (ENT) clinic with a change in voice lasting more than 3 weeks. All patients underwent nasopharyngolaryngoscopy and a dual-probe esophageal pH study. LPR was diagnosed by a Koufman RSI of >13 and/or RFS of >7. GERD was diagnosed according to a DeMeester Johnson score of >14.7. Proximal acid reflux was diagnosed if acid exposure time was >0.02% in a proximal pH probe. The study included 30 patients with a voice disorder. The mean age of participants was 38.5 years and 40% of patients were female. Using either of the two criteria, LPR was present in 46.7% of patients, half of whom had GERD. Among the remaining 53.3% patients with a voice disorder and no evidence of LPR, GERD was present in 25%. There was no significant association between the presence of LPR based on RSI (P=1) and GERD or RFS and GERD (P=0.06). Proximal acid reflux was present in only 10% patients with a voice disorder, and there was no significant association of this test with RFS (P=1) or RSI (P=1). Approximately half of the patients with a voice disorder have LPR, and only a subset of these patients have evidence of GERD. Fiberoptic laryngoscopic findings (RFS) complementing RSI appears to be important in diagnosing possible reflux etiology in voice disorders and can be an indicator for instituting anti-reflux therapy. However, there is no significant association between RSI, RFS, and GERD suggesting that these tests evaluate different features of the disease. Proximal acid reflux is uncommon in patients with voice disorder based on current measurement criteria. Acid exposure time as measured in the proximal probe of a 24-hour dual pH probe may need to be re-evaluated as one of the diagnostic criteria for LPR.

Reply

We thank Dr Furnari and colleagues for their interest in our paper.1Cheng F.K.F. et al.Clin Gastroenterol Hepatol. 2015; 13: 867-873Google Scholar They raise 2 excellent points for discussion. The first is in regards to categorizing nonerosive reflux disease based on normal endoscopic findings of esophageal mucosa and number of reflux episodes on 24-hour pH and impedance monitoring without taking into account symptom association analysis. We agree that the number of reflux episodes alone may be less than ideal to assess for nonerosive reflux disease. In fact, this is what prompted Johnson and DeMeester2Johnson L.F. et al.Am J Gastroenterol. 1974; 63: 325-332Google Scholar to develop a score that incorporates other parameters besides reflux episodes. Our study classification differs from Savarino et al3Savarino E. et al.Am J Gastroenterol. 2008; 103: 2685-2693Google Scholar in that we used the results of impedance testing early in the categorization of patients with reflux who had a normal 24-hour pH score and a normal endoscopy. This method focuses on the objective role of testing rather than reliance on patient symptoms, in which limitations exist in the accuracy of patient reporting. One study showed that patients do not report most of their symptoms during the 24-hour testing period.4Kavitt R.T. et al.Am J Gastroenterol. 2012; 107: 1826-1832Google Scholar Furthermore, both symptom index and symptom association probability may be overinterpreted in patients with gastroesophageal reflux disease with day to day variability.5Slaughter J.C. et al.Clin Gastroenterol Hepatol. 2011; 9: 868-874Google Scholar, 6Vela M.F. et al.Am J Gastroenol. 2013; 108: 1658-1659Google Scholar These indices are also primarily used to assess patients with gastroesophageal reflux disease, but not in those who fail to respond to proton pump inhibitors7Wiener G.J. et al.Am J Gastroenterol. 1988; 83: 358-361Google Scholar, 8Weusten V.L. et al.Gastroenterology. 1994; 107: 1741-1745Google Scholar and are suboptimal in predicting response to therapy as outcome.9Taghavi S.A. et al.Gut. 2005; 54: 1067-1071Google Scholar Finally, the only data evaluating response to surgery in proton pump inhibitor–nonresponders are uncontrolled,10Frazzoni M. et al.Surg Endosc. 2013; 27: 2940-2946Google Scholar and more high-quality outcome studies are needed. The second point is that an impedance cutoff value of 73 reflux episodes may overestimate the number of patients classified as hypersensitive esophagus or with functional symptoms. The 73 episodes as the cutoff value for reflux episodes is in accordance with the American College of Gastroenterology guidelines.11Hirano I. et al.Am J Gastroenterol. 2007; 102: 668-685Google Scholar In a Belgian-French study, the 95% of reflux episodes is 75, nearly identical to US studies.12Shay S. et al.Am J Gastroenterol. 2004; 99: 1037-1043Google Scholar, 13Tutuian R. et al.Gastroenterology. 2006; 130: A171Google Scholar, 14Moawad F.J. et al.Aliment Pharmacol Ther. 2013; 37: 1011-1018Google Scholar Furnari et al refer to an Italian study that demonstrated the 95% value as 54 reflux episodes in a cohort that may have been influenced by consuming a Mediterranean diet.15Zentilin P. et al.Dig Liver Dis. 2006; 38: 226-232Google Scholar Although we agree that a lower cutoff value may reduce the number of false-positive episodes during testing, further high-quality studies on normal impedance values need to be performed before uniformly standardizing a lower cutoff value. The other implication is patients without acid reflux may be referred for antireflux surgery rather than be treated with a pain modulator. However, data for fundoplication in non–acid reflux, particularly in the absence of reduced lower esophageal sphincter pressure, are scarce and generally we do not advocate this as an initial approach to the management of non–acid reflux. Caution About Overinterpretation of Number of Reflux Episodes in Reflux Monitoring for Refractory Gastroesophageal Reflux DiseaseClinical Gastroenterology and HepatologyVol. 14Issue 7PreviewWe read with great interest the study by Cheng et al,1 who investigated patients with gastroesophageal reflux disease (GERD) refractory to antisecretory therapy by means of endoscopy and impedance-pH monitoring off-therapy and concluded that roughly half of these patients referred for testing actually underwent investigations and received medications with no evidence of GERD; they were affected by functional heartburn, functional disorders other than heartburn, or by undetermined disorders. These data confirm previous studies2,3 on the importance of investigating refractory patients and also emphasize the need of stopping antisecretory therapy to reduce overuse of proton pump inhibitors. Full-Text PDF

Association between follicular tracheitis and gastroesophageal reflux

ObjectiveFollicular tracheitis (also known as tracheal cobblestoning) is an entity that is poorly described and of unclear significance. The objective of this study was to better define follicular tracheitis and determine the association between the clinical finding of follicular tracheitis on bronchoscopy and objective evidence of gastroesophageal reflux disease. MethodsRetrospective chart review of children with recurrent croup having undergone a rigid bronchoscopy and an investigation for gastroesophageal reflux between 2001 and 2013. Results117 children with recurrent croup children age 6–144 months were included in the study. Follicular tracheitis was noted on 41% of all bronchoscopies. Fifty-nine percent of all children who underwent bronchoscopy were diagnosed with gastroesophageal reflux on at least one investigation. Forty-nine of 117 children underwent a pH probe study, and 51% were found to have evidence of reflux on this study. Nine children were diagnosed with eosinophilic esophagitis. Three patients underwent a biopsy of the follicular tracheitis lesions, which revealed chronic inflammation. There was no evidence of an association between findings of follicular tracheitis and a positive test for gastroesophageal reflux (p=0.52) or a positive pH probe study (p=0.64). There was no association between follicular tracheitis and subglottic stenosis (p=0.33) or an history of asthma and/or atopy (p=0.19). ConclusionIn children with recurrent croup, follicular tracheitis remains an unspecific finding associated with an inflammatory disorder of unknown etiology.

Esophagogastric junction contractility for clinical assessment in patients with GERD: a real added value?

The role of esophagogastric junction contractile integral (EGJ-CI) as assessed by high-resolution manometry (HRM) is unclear. We aimed to correlate the EGJ-CI with impedance-pH findings in gastro-esophageal reflux disease (GERD) patients. Consecutive patients with GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ-CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. A value below 13 was considered as a defective EGJ-CI. We also assessed EGJ morphology, esophageal acid exposure time (AET), number of reflux episodes (NRE), and symptom association analysis (SAA). A positive impedance-pH monitoring was considered in case of abnormal AET and/or NRE and/or positive SAA. Among 130 patients we enrolled, 91 had GERD (abnormal AET and/or elevated NRE and/or positive SAA) and 39 had functional heartburn (FH) (negative endoscopy, normal AET, normal NRE, and negative SAA). The GERD patients had a lower median value of EGJ-CI (11 [3.1-20.7] vs 22 [9.9-41], p<0.02) compared to FH patients. Patients with a defective EGJ-CI had, more frequently, a positive impedance-pH monitoring or esophageal mucosal lesions at endoscopy (p<0.05 and p<0.05, respectively) than patients with a normal EGJ-CI. An EGJ-CI cut-off value of 5mmHgcm yielded the optimal performance in identifying GERD at impedance-pH (sensitivity 89%-specificity 63%). A defective EGJ-CI at HRM is clearly associated with evidence of GERD at impedance-pH monitoring. Evaluating EGJ-CI may be useful to predict an abnormal impedance-pH testing.

PWE-158 Magnetic sphincter augmentation broadens the appeal of surgical intervention in chronic reflux sufferers

Introduction Magnetic bead oesophageal sphincter augmentation device (MSAD) offers an alternative to tissue fundoplication (TF) in the management of gastro oesophageal reflux disease (GORD). This study evaluates patient decision pathways in selecting one of these surgical options and quality of life based outcomes. Method Consecutive patients with chronic GORD who underwent surgical intervention for definitive treatment were enrolled in the study. The selection criteria for MSAD procedure included objective evidence of GORD, good oesophageal motility, absence of a large hiatus hernia and long segment Barrett’s oesophagus. Pre-operative symptoms, oesophageal physiology, pre-operative and one year post-operative reflux related quality of life scores (HRQL) and the reason for selection of a surgical technique were obtained from a prospective database. Comparative analysis between the MSAD and the TF group was performed. Results A total of 80 patients were included in the study. Forty six patients were suitable for MSAD, of which 44 (96%) elected to undergo the procedure. Thirty four patients failed to meet the inclusion criteria for MSAD and underwent TF, along with 2 patients who preferred to be treated with TF despite suitability for MSAD. Distal oesophageal acid exposure was significantly higher in the TF group (DeMeester score median 52.6 [22–74]) than in the MSAD group (DeMeester score median 34.4 [16–55] (p = 0.011). The HRQL score however were similar for both groups (TF 23.9; MSAD 25.8; p = 0.55). MSAD patients felt the main reason for choosing the procedure was becasue it was less invasive,(30/44, 71%) and secondarily because they perceived it to be associated with less side effects (5/44, 11%). In the TF group 24 patients (64%) felt that the surgeon had influenced their choice of procedure, of which 22 (94%) would have chosen MSAD had they been suitable. Four patients however (11%) chose TF because it was an established procedure with extensive experience. Conclusion Suitability for MSAD was found in 57.5% of patients with objective evidence of GORD. The perception that it represents a less invasive, less problematic but definitive procedure, is an attractive option for patients who may not otherwise have considered more radical surgery. There was no clear correlation with the extent of distal oesophageal acid exposure and the impact of this on patient health related quality of life, suggesting that debilitating symptoms can still occur with relatively modest degrees of reflux. The option of MSAD as a sphincter augmentation rather than a gastric reconstruction procedure may broaden the spectrum of patients willing to undergo surgical rather than medical therapy. Disclosure of interest None Declared.

Proton Pump Inhibitor Therapy in Eosinophilic Esophagitis: Current Role and Future Perspectives

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms related to esophageal dysfunction, eosinophil-predominant inflammation, and lack of response to high-dose proton pump inhibitor (PPI) therapy. Responsiveness to PPI therapy in patients with suspected EoE has been historically assumed as evidence of gastroesophageal reflux disease (GERD), but this concept has rapidly changed over the past few years. A novel phenotype, termed PPI-responsive esophageal eosinophilia (PPI-REE), was described in 2011. PPI-REE refers to patients who appear to have EoE, but who achieve complete remission after PPI therapy. Currently, a PPI trial is mandatory before diagnosing EoE since 30–40 % of EoE patients will be eventually diagnosed with PPI-REE. Evolving evidence on PPI-REE suggests it is not simply GERD but actually a subphenotype of EoE, given the fact PPI-REE and EoE remain genetically and phenotypically indistinguishable. Instead of PPI-REE, the term PPI-responsive EoE might be more accurate to name this entity. PPI-REE might occur with either normal or pathological esophageal pH monitoring. PPI therapy can partially restore epithelial integrity and reverse allergic inflammation gene expression in PPI-REE. Whether esophageal barrier impairment is the cause of the effect of esophageal eosinophilia and whether PPI therapy primarily targets barrier or inflammation healing in PPI-REE have not been yet elucidated. The natural history of the disease, long-term doses, and duration of PPI therapy, as well as factors influencing symptom and/or inflammation relapse remain yet unknown. The mechanism as to why among identical patients, some respond to PPI therapy (PPI-REE) while others do not (EoE), warrants further research.

Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation.

To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) in morbidly obese patients. Symptomatic GERD is considered by many a contraindication to LSG. However, studies evaluating the relationship between LSG and GERD by 24-hour pH monitoring are lacking. Consecutive morbidly obese patients selected for LSG were included in a prospective clinical study. Gastroesophageal function was evaluated using a clinical validated questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring before and 24 months after LSG. This trial is registered with ClinicalTrials.gov (no. NCT02012894). From June 2009 to September 2011, a total of 71 patients were enrolled into the study; 65 (91.5%) completed the 2-year protocol. On the basis of preoperative 24-hour pH monitoring, patients were divided into group A (pathologic, n=28) and group B (normal, n=37). Symptoms improved in group A, with the Gastroesophageal Reflux Disease Symptom Assessment Scale score decreasing from 53.1±10.5 to 13.1±3.5 (P<0.001). The DeMeester score and total acid exposure (% pH<4) decreased in group A patients (DeMeester score from 39.5±16.5 to 10.6±5.8, P<0.001; % pH<4 from 10.2±3.7 to 4.2±2.6, P<0.001). Real "de novo" GERD occurred in 5.4% group B patients. No significant changes in lower esophageal sphincter pressure and esophageal peristalsis amplitude were found in both groups. LSG improves symptoms and controls reflux in most morbidly obese patients with preoperative GERD. In obese patients without preoperative evidence of GERD, the occurrence of "de novo" reflux is uncommon. Therefore, LSG should be considered an effective option for the surgical treatment of obese patients with GERD.

Categorization of Patients With Reflux Symptoms Referred for pH and Impedance Testing While Off Therapy

Patients with suspected gastroesophageal reflux disease (GERD) often are treated empirically with proton pump inhibitors (PPIs). Patients whose symptoms are not reduced during the PPI trial are referred for further tests. We investigated whether patients referred for the evaluation of reflux symptoms had GERD. We also aimed to categorize patients with a poor response to PPIs into groups with hypersensitive esophagus or functional heartburn. We performed a retrospective study, searching a clinical database of patients referred for GERD testing from 2006 through 2011. We collected data on all patients who underwent upper endoscopy, esophageal manometry, and 24-hour pH-impedance monitoring, and were off PPIs for at least 1 week. Evidence of GERD was determined by an abnormal upper endoscopy or 24-hour pH-impedance monitoring. Further categorization was determined by impedance results and the symptom association probability index. We identified 221 patients (mean age, 47.6 ± 13.3 y; 56% male; 61% Caucasians); 97% previously had been prescribed PPIs, before they were tested. The patients had erosive esophagitis (n = 21; 10%), nonerosive reflux disease with increased pH (n = 61; 27%), nonerosive reflux disease with abnormal impedance (n = 18; 8%), hypersensitive esophagus (n = 30; 14%), functional heartburn (n = 18; 8%), functional disorders other than heartburn (n = 30; 14%), and undetermined disorders (n = 43; 19%). In a retrospective analysis of 221 patients, roughly half of the patients referred for testing did not have evidence of GERD. Further categorization of patients can help guide diagnosis and management.

Gastroesophageal and extraesophageal reflux symptoms: similarities and differences.

The association between extraesophageal reflux (EER) and symptoms of gastroesophageal reflux disease (GERD) is inadequately understood. We used the Comprehensive Reflux Symptom Scale (CReSS) to evaluate EER and reflux-symptom prevalence in gastroenterology and otolaryngology outpatients and symptom awareness among UK gastroenterologists. Cross-sectional cohort survey. Six hundred thirty-nine participants were surveyed: 103 controls, 359 patients undergoing esophagogastroduodenoscopy (EGD), and 177 otolaryngology clinic patients with throat symptoms. Participants completed the CReSS questionnaire. The study was undertaken in the Endoscopy Unit and the Department of Otolaryngology-Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle-upon-Tyne, United Kingdom. Registered members of the British Gastroenterology Society were asked to rate how frequently reflux patients might complain of each CReSS item. The median CReSS total in volunteers (4) was significantly lower (P < .002) than in ear, nose, and throat (ENT) patients (26) or EGD patients with (42) or without (32) esophageal inflammation. All items were scored as ≥1 by >15% of ENT patients and 28% of EGD patients. Three major, robust CReSS factors: esophageal, pharyngeal, and upper airway emerged. Of 259 gastroenterologists, >20% scored 8 of the 34 symptoms as never being reported by reflux patients. Endorsement of each EER CReSS item by 28% to 58% of patients with endoscopic evidence of GERD supports the Montreal consensus on an EER-GERD continuum. Gastroenterologists vary considerably in their appreciation of EER symptom relevance. The advantages of CReSS include standardized, comprehensive capture of patient experience; discriminant validity of ENT and GERD patients from volunteers; and discrete esophageal, pharyngeal, and upper airway subscales. 4.

PTU-050 The Value Of Gastroscopy In The Investigation Of Non Cardiac Chest Pain

IntroductionNon-cardiac chest pain (NCCP) is a common cause for referral to gastroenterology. Following the exclusion of a cardiac cause, NCCP is attributed to a variety of disorders, including gastroesophageal reflux...

To Wrap or Not

McAteer and colleagues1 use the Pediatric Health Information System database to evaluate factors associated with progression to antireflux procedures (ARPs) in children hospitalized for gastroesophageal reflux disease (GERD). Theydemonstrated that children younger than 2 months are more likely to undergo ARPs compared with older children. Furthermore, childrenwith additional comorbidites are more likely to undergo ARPs. These findings are not new and are expected within the pediatric surgical community. Buriedwithin this report is the true controversy regarding the management of GERD in children. Physiologic reflux/ regurgitation iscommonin infantsand,giventime,asignificant proportion of childrenwill simply outgrow their reflux symptoms. The authors point out that no uniformworkupwas performedbefore theoperative intervention.Furthermore, the indicationsforARPsvaried.Thus,theauthors logicallymakeaplea for standardization of theworkup and indications for ARPs in children todeterminewhich children reallyneedoperative interventionvs time tooutgrow their symptoms.Unfortunately, thisstudydoesnothingtoaddressthosepleasforstandardmedicalmanagement andworkup before proceedingwith ARPs. Given that an ARP remains one of the most common operationsperformedbypediatric surgeons, I amperplexed that a standard workup and clear indications for such procedures in childrendonot exist as theydo inadults.One reason for this difference is that children with GERD typically present with feeding problems and have additional comorbidities that influence the need for an ARP. It is common to see a newborn with severe cardiac disease and minimal physiologic reserve who cannot tolerate oral feedings. Should only a gastrostomy tube be inserted, with the risk of aspiration and even death given the patient’s fragile state, or should an ARP be performed (despite no clinical evidence of GERD) in addition to the gastrostomy tube? Another common scenario is a newbornwithneurologic compromisewhoonly tolerates continuous feedings via a postpyloric feeding tube.Oral/gavage feedings result inemesiswithoccasional apneaandcyanotic spells. How long should this patient remain in the hospital and be treated medically to determine whether he or she will outgrowthesesymptoms?Should thesurgeonrecommendanARP to facilitate discharge from the hospital and to prevent future complications (eg, aspirationpneumonia)?Areadditional studies required in either patient to make these decisions? As demonstrated above, care of children with GERD is complex and involves many different factors. Although the authors recognize the ongoing controversy in the management of GERD in infants and children, the data reported in this study are derived from an administrative database that simply does not provide enough details to make any significant conclusions.

Relationship Between Radiotherapy and Gastroesophageal Reflux Disease in Causing Tracheoesophageal Voice Rehabilitation Failure

The objective was to analyze the association of radiotherapy with gastroesophageal reflux as determinant of fistula related pathology, in voice prosthesis patients. Retrospective study. Sixty-one laryngectomy patients were enrolled between 2005 and 2012. All patients underwent phonatory rehabilitation with voice prosthesis, along with evidence of gastroesophageal reflux disease, for which proton pump inhibitors (PPIs) were prescribed. We analyzed the occurrence of fistula-related problems among patients who received postoperative radiotherapy and those patients who did not. We observed a higher rate of failure of speech rehabilitation in laryngectomy patients with gastroesphageal reflux: this occurred when they had a history of postoperative radiotherapy (45%) compared with patients who did not (17%) (P<0.05), although all patients were treated with PPIs. Our results seem to confirm the importance of postoperative radiotherapy with gastroesophageal reflux for the determinism of fistula-related problems.

Proton pump inhibitor responders who are not confirmed as GERD patients with impedance and pH monitoring: who are they?

A short-course of proton pump inhibitors (PPIs) is often used to confirm gastroesophageal reflux disease (GERD). However, some patients with PPI responsive heartburn do not seem to have evidence of GERD on impedance-pH monitoring (MII-pH). The aim of the study was to evaluate patients with reflux symptoms and a negative endoscopy, who well respond to PPIs with MII-pH. We enrolled 312 patients with GERD symptoms and negative endoscopy: 144 reported well-controlled symptoms after 8-week PPIs and 155 were non-responders. Symptom relief was evaluated with GERD Impact Scale and visual analog scale score. All patients underwent MII-pH off-therapy. Thirteen patients were excluded from analysis. Patients were grouped as follows: non-erosive reflux disease (NERD; increased acid exposure time, AET); hypersensitive esophagus (HE; normal AET, positive symptom association, SI/SAP); MII-pH-/PPI+ (normal AET, negative SI/SAP) in the responder group; MII-pH-/PPI- in non-responders. MII-pH in PPI responders (symptom relief during PPI therapy > 75%) showed: 79/144 NERD (54.9%); 37/144 HE (25.7%); 28/144 MII-pH-/PPI+ (19.4%). MII-pH-/PPI+ patients reported the same symptom relief when compared with NERD and HE. In non-responder (symptom relief during PPI therapy < 50%) group, 27/155 patients were NERD (17.4%); 53/155 were HE (34.2%); 75/155 were MII-pH-/PPI- (48.4%). NERD diagnosis was significantly higher in responder group (p<0.01). In a substantial subgroup of patients responding to PPI with typical reflux symptoms, the diagnosis of GERD cannot be confirmed with pH-impedance monitoring. Proton pump inhibitor response and presence of typical symptoms are thus not reliable predictors of the diagnosis and antireflux surgery should always be preceded by reflux monitoring.

Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: Review of the Bariatric Outcomes Longitudinal Database

BackgroundThe prevalence of gastroesophageal reflux disease (GERD) in the morbidly obese population is as high as 45%. The objective of this study was to compare the efficacy of various bariatric procedures in the improvement of GERD. MethodsThe Bariatric Outcomes Longitudinal Database is a prospective database of patients who undergo bariatric surgery by a participant in the American Society of Metabolic and Bariatric Surgery Center of Excellence program. GERD is graded on a 6-point scale, from 0 (no history of GERD) to 5 (prior surgery for GERD). Patients with GERD severe enough to require medications (grades 2, 3, and 4) from June 2007 to December 2009 are identified; the resolution of GERD is noted based on 6-month follow-up. ResultsOf a total of 116,136 patients, 36,938 patients had evidence of GERD preoperatively. After excluding patients undergoing concomitant hiatal hernia repair or fundoplication, there were 22,870 patients with 6-month follow-up. Mean age was 47.6±11.1 years, with an 82% female population. Mean BMI was 46.3±8.0 kg/m2. Mean preoperative GERD score for patients with Roux-en-Y gastric bypass (RYGB) was 2.80±.56, and mean postoperative score was 1.33±1.41 (P<.0001). Similarly, adjustable gastric banding (AGB, 2.77±.57 to 1.63±1.37, P<.0001) and sleeve gastrectomy (SG, 2.82±.57 to 1.85±1.40, P<.0001) had significant improvement in GERD score. GERD score improvement was best in RYGB patients (56.5%; 7955 of 14,078) followed by AGB (46%; 3773 of 8207) and SG patients (41%; 240 of 585). ConclusionAll common bariatric procedures improve GERD. Roux-en-Y gastric bypass is superior to adjustable gastric banding and sleeve gastrectomy in improving GERD. Also, the greater the loss in excess weight, the greater the improvement in GERD score.

Histologic definition of gastro-esophageal reflux disease

To review recent data supporting the development of new histology-based definitions of gastro-esophageal reflux disease (GERD). Three precisely definable columnar epithelial types--cardiac, oxyntocardiac and intestinal--may be interposed between esophageal squamous epithelium and gastric oxyntic (acid secreting) mucosa. This enables definition of a new histologic concept: the squamo-oxyntic gap. The squamo-oxyntic gap is zero or very small in autopsies performed on patients without evidence of GERD. The gap progressively increases in length with the severity of GERD, indicating that the squamo-oxyntic gap is a marker for chronic GERD. The distal part of the gap lines gastric-type rugal folds and, therefore, is distal to the present endoscopic definition of the gastro-esophageal junction. I contend that this distal gap segment (which has esophageal submucosal glands) is actually the dilated distal esophagus; this is the pathologic correlate of destruction of the abdominal segment of the lower esophageal sphincter. The dilated distal esophagus is mistaken for 'gastric cardia' by present endoscopic definitions. I believe that these data support the adoption of novel histologic definitions of GERD as follows: the presence of any squamo-oxyntic gap defines GERD; the length of the gap is a measure of severity of chronic GERD; and the presence of intestinal metaplasia in the gap defines Barrett esophagus and cancer risk.

Response of Chronic Cough to Acid-Suppressive Therapy in Patients With Gastroesophageal Reflux Disease

Epidemiologic and physiologic studies suggest an association between gastroesophageal reflux disease (GERD) and chronic cough. However, the benefit of antireflux therapy for chronic cough remains unclear, with most relevant trials reporting negative findings. This systematic review aimed to reevaluate the response of chronic cough to antireflux therapy in trials that allowed us to distinguish patients with or without objective evidence of GERD. PubMed and Embase systematic searches identified clinical trials reporting cough response to antireflux therapy. Datasets were derived from trials that used pH-metry to characterize patients with chronic cough. Nine randomized controlled trials of varied design that treated patients with acid suppression were identified (eight used proton pump inhibitors [PPIs], one used ranitidine). Datasets from two crossover studies showed that PPIs significantly improved cough relative to placebo, albeit only in the arm receiving placebo fi rst. Therapeutic gain in seven datasets was greater in patients with pathologic esophageal acid exposure (range, 12.5%-35.8%) than in those without (range, 0.0%-8.6%), with no overlap between groups. A therapeutic benefit for acid-suppressive therapy in patients with chronic cough cannot be dismissed. However, evidence suggests that rigorous patient selection is necessary to identify patient populations likely to be responsive, using physiologically timed cough events during reflux testing, minimal patient exclusion because of presumptive alternative diagnoses, and appropriate power to detect a modest therapeutic gain. Only then can we hope to resolve this vexing clinical management problem.

Early referral for 24-h esophageal pH monitoring may prevent unnecessary treatment with acid-reducing medications

Gastroesophageal reflux disease (GERD) affects nearly 25 % of adults; however, an objective diagnosis is rarely established. We hypothesized that patients' symptoms and response to acid-reducing therapy are poor predictors of the outcome of 24-h esophageal pH monitoring. A review of 24-h esophageal pH monitoring studies performed at an ambulatory tertiary care center between 2004 and 2011 was performed. Demographics, type of GERD symptoms, and duration and response to acid-reducing medications before referral for pH monitoring were collected. DeMeester score, symptom sensitivity index (SSI), and symptom index (SI) were tabulated and compared with the patients' symptoms and response to medical therapy. One hundred patients were included. Of all reported symptoms, only heartburn was more common in patients with positive DeMeester scores, but there were no correlations between any symptoms and SSI or SI scores. Sixty-nine percent of patients with esophageal symptoms had a positive DeMeester score compared with only 29 % of patients with extraesophageal symptoms (P < 0.01). Esophageal symptoms and endoscopic evidence of GERD significantly increased the likelihood of having a positive DeMeester score, but they had no influence on SSI or SI scores. There was no correlation between response to acid-reducing medications and DeMeester, SSI, or SI scores. A total of 536 person-years of acid-reducing medications were prescribed to the study population, of which 151 (28 %) were prescribed to patients who had a negative pH study. Extraesophageal symptoms and response to empiric trials of acid-reducing medications are poor predictors of the presence of GERD and the DeMeester score is more likely to identify GERD in patients who met other empiric diagnostic criteria than SSI or SI. Early referral for 24-h esophageal pH monitoring may avoid lengthy periods of unnecessary medical therapy.

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