Form Of Gastroesophageal Reflux Disease Research Articles

Efficacy of adding sodium alginate to omeprazole in patients with nonerosive reflux disease: a randomized clinical trial

Nonerosive reflux disease (NERD) is the most common form of gastroesophageal reflux disease. Patients with NERD have a lower response rate to proton pump inhibitors (PPIs) than patients with erosive esophagitis when gauged from relief of heartburn. Sodium alginate decreases the acidity of refluxate and protects the esophageal mucosa. However, whether the addition of sodium alginate to PPI therapy can improve NERD symptoms remains unknown. Accordingly, the aim of this study was to evaluate the efficacy of adding sodium alginate to basal PPI therapy for NERD. Patients who had experienced heartburn on at least 2 days per week during the 1-month period before entering the study and had no endoscopic mucosal breaks (grade M or N according to Hoshihara's modification of the Los Angeles classification) were randomized to one of two treatments for 4 weeks: omeprazole (20 mg once daily) plus sodium alginate (30 mL four times a day) (group A) or omeprazole (20 mg once daily) alone (group B). Eighty-seven patients were enrolled, and 76 patients were randomly assigned to group A (n = 36) or group B (n = 40). Complete resolution of heartburn for at least 7 consecutive days by the end of treatment was significantly more common in group A (56.7%) than in group B (25.7%). One patient from group A had mild drug-related diarrhea that was not clinically serious. In conclusion, omeprazole combined with sodium alginate was better than omeprazole alone in Japanese patients with NERD.

Nocturnal Gastroesophageal Reflux: Assessment and Clinical Implications

Nocturnal Gastroesophageal Reflux: Assessment and Clinical Implications

Laryngopharyngeal Reflux as a Major Cause of Chronic Respiratory Symptoms and Asthma Mimic among Community Health Center Patients

RATIONALE: Laryngopharyngeal reflux (LPR) is a clinically distinct form of gastroesophageal reflux disease (GERD). Commonly described symptoms of LPR include: dysphonia, globus pharyngeus, non-productive throat clearing, cough, dysphagia, and recurrent sore throats. LPR has not been yet described as a frequent source of recurrent dyspnea, respiratory distress and a common asthma mimic in the community.

The Role of Nonacid Reflux in NERD: Lessons Learned From Impedance-pH Monitoring in 150 Patients off Therapy

Nonerosive reflux disease (NERD) is the most common form of gastroesophageal reflux disease. While the role of acid reflux has been established, the relevance of nonacid reflux in generating symptoms in NERD is unknown. To evaluate the diagnostic utility of impedance-pH monitoring in NERD patients. Patients with typical reflux symptoms (heartburn and/or regurgitation) and normal endoscopy (NERD) underwent a combined impedance-pH monitoring off proton pump inhibitor (PPI) therapy. Previously investigated 48 healthy volunteers served as controls. Distal esophageal acid exposure (% time pH < 4), number of acid and nonacid reflux episodes, 2-min window symptom index (SI; positive if > or = 50%), and symptom association probability (SAP; positive if > or = 95%) were calculated. Between June 2004 and June 2007, 150 NERD patients (82 women, mean age 48 yr, range 18-78 yr) reported symptoms during the impedance-pH monitoring. NERD patients had more reflux episodes (median [25th-75th percentile]) compared with healthy volunteers (total: 46 [26-65] vs 32 [18-43], P < 0.05; acid: 29 [14-43] vs 17 [8.5-31.0], P < 0.05; and nonacid: 20 [15-27] vs 18 [13.5-26.0], P = NS). Sixty-three (42%) patients had abnormal % time pH < 4. Among 87 patients with normal % time pH < 4., 22 (15%) had a positive SAP for acid, 19 (12%) for nonacid reflux, and 7 (5%) for both. Classifying patients with symptomatic nonacid reflux as having a hypersensitive esophagus reduced the number of patients with functional heartburn from 65 (43%) to 39 (26%). Monitoring for nonacid reflux in NERD patients reduces the proportion of patients classified as having "functional heartburn." Studies assessing the clinical implications of these findings are warranted.

Serum gastrin and pepsinogens do not correlate with the different grades of severity of gastro‐oesophageal reflux disease: a matched case–control study

Gastrin and pepsinogens reflect the functional state of the gastric mucosa. To evaluate whether serum gastrin and pepsinogens correlate with the different grades of severity of gastro-oesophageal reflux disease (GERD). In all, 388 patients with heartburn not taking any form of acid suppressive therapy were matched-controlled for age and gender and sub-classified into four groups: group 1 non-erosive reflux disease (NERD); group 2, erosive reflux disease (ERD) Los Angeles (LA) A and B, group 3, ERD LA C and D; group 4 Barrett's oesophagus (BO). Fasting serum was analysed for gastrin 17, pepsinogen I, pepsinogen II und Helicobacter pylori using specific EIA tests (GastroPanel; Biohit, Plc). Kruskal-Wallis test and analysis of variance. There was a significant difference among the four groups with respect for pepsinogen I, but not for pepsinogen II, the pepsinogen I pepsinogen II ratio, H. pylori serology and gastrin levels. Pepsinogen I was the lowest in NERD and the highest in BO (median 91.6, mean +/- standard deviation 106.2 +/- 51.6 vs. median 114.7, mean +/- standard deviation 130.4 +/- 70.6; P = 0.046). Pepsinogen I levels were higher in H. pylori positive subjects. After adjusting for H. pylori status, the differences in pepsinogen I across patient groups were no longer statistically significant (P = 0.298). Serum gastrin and pepsinogen I and II do not correlate with the different grades of severity of GERD. The non-invasive GastroPanel is not useful for the differentiation of the various forms of GERD.

Modern attitude towards management of laryngopharyngeal form of gastroesophageal reflux disease. Lithuanian clinical practice guidelines for adults

The aim of this article is to introduce Lithuanian clinical practice guidelines for the management of laryngopharyngeal form of gastroesophageal reflux disease for standardization of the diagnosis and treatment of the disease and prevention of its complications. Composed guidelines provide recommendations for primary care physicians as well as otorhinolaryngologists and gastroenterologists for the management of adults with uncomplicated laryngopharyngeal form of gastroesophageal reflux disease. Committee composed of experts from Lithuanian Otorhinolaryngological and Gastroenterological Societies developed guidelines based on a comprehensive review of the evidence-based literature related to laryngopharyngeal form of gastroesophageal reflux disease and guidelines of other countries. The guidelines provide description of each medicine groups with emphasis on proton pump inhibitors as the most effective drugs for the treatment of laryngopharyngeal form of gastroesophageal reflux disease. Indications for empirical treatment with proton pump inhibitors are described, as well as duration of treatment, doses, optimal regimen of use, and assessment of treatment efficacy. The therapy should begin with the application of proton pump inhibitors twice daily, before meal for three months. Combined therapy for nonresponders is described. Algorithm for stopping the medication is recommended. These recommendations may provide an efficient and economical approach to the management of this problem.

COX-2 CA-Haplotype Is a Risk Factor for the Development of Esophageal Adenocarcinoma

Neoplastic progression of BE towards EAC is associated with increased expression of COX-2. Increased COX-2 expression and enzyme activity is linked to the COX-2 CA haplotype, which consists of two gene polymorphisms in the COX-2 promoter. To study the impact of COX-2 haplotypes on the risk of developing EAC in patients with different forms of gastroesophageal reflux disease including BE. DNA was obtained from a total of 635 Dutch white patients comprised of 140 patients with EAC, 255 with BE, and 240 with reflux esophagitis. COX-2 haplotypes were based on the gene polymorphisms at -765C/G and -1195A/G, as determined by PCR-RFLP. The tested population contained 170 (14%) CA- (-765C and -1195A) haplotypes, 829 (65%) GA and 271 (21%) GG-haplotypes, and no GC-haplotypes. The haplotype distribution in patients with reflux esophagitis and BE was similar (CA 12%, GA 68%, GG 21%), but differed significantly from that in patients with EAC (CA 21%, GA 58%, GG 20%). Particularly, the CA-haplotype was more common (P < 0.001) in EAC patients. CA-carriership was associated with EAC (OR 2.8, 95% CI 1.3-6.2, P= 0.008), with homozygosity for the CA-allele being statistically most significantly associated (OR 6.1, 95% CI 1.6-24.2, P= 0.01). The COX-2 CA-haplotype is more frequently observed in patients with EAC than in patients with BE and reflux esophagitis. These data suggest a direct link between COX-2 activity and neoplastic progression in patients with BE and reflux esophagitis.

Diagnostics of laryngopharyngeal form of gastroesophageal reflux disease for adults (Lithuanian clinical practice guidelines)

The laryngopharyngeal form of gastroesophageal disease represents one of the atypical manifestations of supraesophageal gastroesophageal reflux disease characterized by morphologic and functional changes in the larynx and pharynx with the associated clinical symptoms. The article presents diagnostic algorithm (guidelines) for laryngopharyngeal form of gastroesophageal disease, elaborated by the group of Lithuanian experts in otorhinolaryngology and gastroenterology. The guidelines are based on the data of evidence-based medicine and results of the scientific studies in Lithuania. Diagnostics of laryngopharyngeal form of gastroesophageal disease has to be based on: (1) patient’s complaints (permanent hoarseness, throat itching and clearing, cough, heartburn, “globus” sensation) for more than 3 months; (2) typical laryngoscopic findings (edema, erythema, roughness, hypertrophy of mucosa of the posterior glottis); (3) detection of reflux esophagitis as a subsequence of pathological gastroesophageal reflux; (4) assessment of relationship between reflux and morphological/functional changes. The guidelines are designed for the otorhinolaryngologists, gastroenterologists, and general practitioners.

Gastroesophageal reflux disease is a progressive disease

It is controversial whether gastrooesophageal reflux disease represents a spectrum disease from a nonerosive to a complicated one, or whether it is a categorial disease, i.e. it can be divided into three categories, such as nonerosive gastrooesophageal reflux disease, erosive gastrooesophageal reflux disease and Barrett's esophagus (BE) with little or no transition from one category to the other. This controversy might be of general interest, because it has some implications in the management of the patient. However, literature data concerning the natural history of gastrooesophageal reflux disease are very limited, and in particular very few papers have dealt with the issue of describing the natural history of patients with nonerosive gastrooesophageal reflux disease. Aim of the present review is to reassess these scanty data, and to try to demonstrate that progression from milder to more severe forms of gastrooesophageal reflux disease is possible and documented.

“On‐demand” therapy for gastroesophageal reflux disease: Are current proton pump inhibitors good candidates?

AbstractIn the long term management of gastroesophageal reflux disease, an “on‐demand” therapy is a sensible and effective treatment strategy. Patients do not comply with continuous maintenance medications and will usually take medications only when symptoms occur. An “on‐demand” therapy is particularly useful in patients with nonerosive reflux disease or mild forms of gastroesophageal reflux disease. Currently available proton pump inhibitors provide potent acid suppression and are suitable for an on‐demand therapy. Special features required of an on‐demand therapeutic agent would include a rapid onset of action. Owing to its special characteristics, with rapid binding to the proton‐pumps, rabeprazole provides the fastest symptom relief compared to other agents. Formal trials of on‐demand therapy show that patients take medications only once in every 3 or 4 days and the majority of patients are satisfied with this treatment approach.

Systematic review: does gastro‐oesophageal reflux disease progress?

Gastro-oesophageal reflux disease affects approximately 20% of western populations. Barrett's oesophagus, associated with severe gastro-oesophageal reflux disease, is premalignant and regular endoscopic surveillance is generally performed. In contrast, mild gastro-oesophageal reflux disease is thought not to progress and is not generally subjected to endoscopic follow-up. Aim To investigate whether gastro-oesophageal reflux disease progresses endoscopically. Systematic review of the literature. Well-designed prospective studies are few, diagnostic criteria were not always standardized, management strategies varied and various sources of bias could not be excluded. Whilst most patients do not progress to more severe forms of gastro-oesophageal reflux disease, and some cases actually regress, progression is seen in a small proportion of patients. Annual progression rates for non-erosive gastro-oesophageal reflux disease developing erosive oesophagitis ranged from 0% to 30%. About 1-22% of patients with mild erosive oesophagitis developed more severe inflammation annually, while 1-13% of patients with erosive oesophagitis developed Barrett's oesophagus each year. Although most patients with gastro-oesophageal reflux disease do not progress, and some actually regress, progression does occur in a minority. Better data are required to determine whether patients with mild gastro-oesophageal reflux disease would benefit from increased surveillance with the aim of detecting more advanced disease.

Pathophysiological characteristics of the various forms of gastro-oesophageal reflux disease: Spectrum disease or distinct phenotypic presentations?

Background The traditional approach to gastro-oesophageal reflux disease as a spectrum disease has recently been criticised and the distinct phenotypic presentations model has been proposed. Aim To evaluate the main pathophysiological characteristics of various gastro-oesophageal reflux disease presentations. Methods Oesophageal manometry and 24-h pH-monitoring were performed in a gastro-oesophageal reflux disease series collected in a 7-year period. Results Four hundred and twenty-one subjects were studied. Mean total percentage acid reflux time was significantly higher in long-segment Barrett's oesophagus and in ulcerative oesophagitis than in all the other gastro-oesophageal reflux disease groups, whilst in short-segment Barrett's oesophagus results were quite similar to those found in non-erosive reflux disease and in erosive reflux disease. Patients with ulcerative oesophagitis and long-segment Barrett's oesophagus were older than all the other gastro-oesophageal reflux disease groups. The mean lower oesophageal sphincter pressure was significantly reduced in non-erosive reflux disease, erosive reflux disease, ulcerative oesophagitis, short-segment Barrett's oesophagus and long-segment Barrett's oesophagus as compared with functional heartburn and hypersensitive oesophagus and with controls. Conclusions In keeping with the spectrum model of gastro-oesophageal reflux disease, severity of acid reflux increases from non-erosive reflux disease through erosive reflux disease up to ulcerative oesophagitis and long-segment Barrett's oesophagus. Ulcerative oesophagitis and long-segment Barrett's oesophagus could represent an advanced step in the natural history of gastro-oesophageal reflux disease. Our results do not confirm the distinct phenotypic presentations hypothesis.

Laryngeal examination is superior to endoscopy in the diagnosis of the laryngopharyngeal form of gastroesophageal reflux disease

Objective. The laryngopharyngeal form of gastroesophageal reflux disease (LF GERD) is a frequent manifestation of supraesophageal GERD. Diagnosis of LF GERD is difficult: most of the common diagnostic methods of GERD have insufficient accuracy in establishing LF GERD. The purpose of this study was to evaluate the role of endoscopic and laryngologic examination in the diagnosis of LF GERD and to create a laryngoscopic reflux index (LRI). Material and methods. A total of 108 LF GERD patients and 90 controls were investigated. The criteria for LF GERD were: complaints, reflux-laryngitis, and esophagitis (endoscopically or histologically proven). Lesions in four laryngeal regions were evaluated: arytenoids (A), intraarytenoid notch (IAN), vestibular folds (VF), and vocal cords (VC). Three types of mucosal lesions were evaluated on a points basis: alterations of the epithelium, erythema, and edema. Total LRI was calculated by summing-up the indices in the separate laryngeal areas. Results. The LRI mean value (11.48±3.78 points) of LF GERD patients was statistically significantly greater than that (1.64±1.93 points) of the controls. The most significant laryngoscopic changes of LF GERD were: mucosal lesions of IAN, mucosal lesions of VC, and edema of VC. A combination of these three findings reliably distinguishes the LF GERD patients from controls in 95.9% of cases. The mucosal lesions of IAN have the greatest importance in diagnosing LF GERD: the odds ratio to LF GERD – 21.32, p<0.001. Endoscopic esophagitis was established in 36 (33.3%) cases. The severity of esophagitis did not correlate with the severity of the laryngeal findings. Conclusions. Laryngoscopy is superior to endoscopy in diagnosing LF GERD. Endoscopy has limited value in the diagnosis of LF GERD. Establishing the LRI could be helpful in the differential diagnosis of the disease in the everyday clinical practice.

Predictors of Heartburn During Sleep in a Large Prospective Cohort Study

Nocturnal gastroesophageal reflux, which may result in nocturnal heartburn, has been demonstrated to be associated with a more severe form of gastroesophageal reflux disease (GERD). The aim of this study was to determine the clinical predictors of heartburn during sleep in a large prospective cohort study. Study subjects were members of the parent cohorts from which the Sleep Heart Health Study (SHHS) recruited participants. SHHS is a multicenter, longitudinal, cohort study of the cardiovascular consequences of sleep-disordered breathing. As part of the recruitment process, parent cohort members completed a questionnaire that permitted an assessment of the relationships between heartburn during sleep, and patient demographics, sleep abnormalities, medical history, and social habits in nine community-based parent cohorts across the United States. All variables, significant at the p < 0.05 level, were included as independent variables in multivariate logistic regression models with heartburn during sleep status included as the dependent variable A total of 15,314 subjects completed the questions about heartburn during sleep, and of these, 3,806 subjects (24.9%) reported having this symptom. In four increasingly comprehensive multivariate models, increased body mass index (BMI), carbonated soft drink consumption, snoring and daytime sleepiness (Epworth sleepiness scale score), insomnia, hypertension, asthma, and usage of benzodiazepines were strong predictors of heartburn during sleep. In contrast, college education decreased the risk of reporting heartburn during sleep. Heartburn during sleep is very common in the general population. Reports of this type of symptom of GERD are strongly associated with increased BMI, carbonated soft drink consumption, snoring and daytime sleepiness, insomnia, hypertension, asthma, and usage of benzodiazepines. Overall, heartburn during sleep may be associated with sleep complaints and excessive daytime sleepiness.

Pathophysiology of GERD in China: The Same Factors at a Lower Scale

Most of the factors involved in the pathogenesis of gastroesophageal reflux disease (GERD), previously described in European, Australian, and American studies, are present in Chinese patients with GERD, but at a lower scale. The acidity of gastric contents is reduced either spontaneously or by Helicobater pylori infection. A low-fat diet probably contributes to a more favorable gastric distribution of the meals, reduced obesity, and lowers the number of TLESRs. The prevalence of hiatal hernia is low and esophageal motility disorders are moderate. Like in Western countries, the pathophysiology of GERD in China is multifactorial, with variable combination of moderate abnormalities in individual patients, leading to milder forms of GERD.

Laparoscopic treatment of Barrett’s esophagus*

arrett’s esophagus is an acquired abnormality that is characterized rossly by an upward displacement of the squamo-columnar junction, ith replacement of the typical whitish smooth esophageal mucosa by a elvety reddish mucosa. Microscopically, Barrett’s esophagus is characerized by the presence of specialized intestinal metaplasia. It is associted with gastroesophageal reflux disease (GERD), and it is found in 15% o 20% of patients with GERD. The incidence of Barrett’s appears to ave increased dramatically in the last 20 years, a fact that has been inked to the 10-fold increase in the incidence of adenocarcinoma of the sophagus observed during the last decade. The goals of surgical therapy, or of any therapy, for patients with arrett’s esophagus are to provide long-term control of reflux sympoms; provide a durable gastroesophageal barrier to acid and bile; and ffect the elimination of Barrett’s, or at least decrease the risk of eveloping adenocarcinoma. Currently, there is considerable controversy s to whether an operation can achieve these goals. First, these patients ave a much more defective LES and a more virulent form of GERD that eads to greater esophageal damage than is seen in patients with GERD ut no Barrett’s. The operation is therefore more complex, the number f complications greater, and the chances of a successful long-term utcome in terms of competency of the cardia decreased. Second, here is a generalized belief that once Barrett’s develops, correction of eflux does not alter its natural history, although this concept has been ecently challenged. We review the evidence that laparoscopic surgery an achieve each of these goals.

Diagnostik der Refluxkrankheit

The diagnosis of gastro-esophageal reflux disease (GERD) predominantly relies on the patient's history and endoscopically visible alterations of the esophageal mucosa. Heartburn as the dominating symptom is highly suggestive of GERD though not specific whereas heartburn as one complaint among others is of limited value. Endoscopy enables the definite diagnosis of reflux esophagitis; however, the majority of patients (approximately 60%) does not exhibit erosions (non-erosive form of GERD). In these patients a short course of empiric PPI therapy gives valuable information about the presence or absence of GERD. Only those patients non-responsive to adequate PPI doses should undergo pH-metry. Other diagnostic investigation (e.g. manometry) should be restricted to selected cases.

The relationship between gastroesophageal reflux disease and obstructive sleep apnea

There has been an accumulating body of research concerning the extraesophageal complications of gastroesophageal reflux disease over the past decade. Given the cardiological, pulmonological, laryngeal, and dental aspects of such complications, an interdisciplinary approach is required. The most recognized manifestations are noncardiac chest pain, bronchial asthma, chronic bronchitis, chronic cough, and posterior laryngitis, as well as the acidic damage of dental enamel. This article focuses on the potential relationship between reflux disease and obstructive sleep apnea, which has been raised only more recently. Because of the decrease of primary peristalsis and the reduced production of saliva, as well as the diminished acid and volume clearance of the esophagus, sleeping can be considered as a risk factor of the reflux event by itself. Moreover, it should also be taken into account that the transdiphragmatic pressure increases in parallel with the growing intrathoracic pressure generated during obstructive apnea episodes. This has a non-negligible effect on the phrenoesophageal ligament, which is connected to the lower esophageal sphincter. Repetition of the pressure changes results in insufficiency of the cardia. While this pressure change produces a considerable suction effect, further reducing the clearing mechanism of the gastric volume, lower esophageal sphincter insufficiency can directly lead to reflux disease. The challenge for gastroenterologists is to gain further insight into this relationship and to play a more active role in the complex therapy of the disease, as well as to develop a new diagnostic approach towards the severe forms of gastroesophageal reflux disease.

The role of cagA Helicobacter pylori strains in gastro-oesophageal reflux disease.

The role of Helicobacter pylori infection in gastro-oesophageal reflux disease is controversial. The aim of this study was to evaluate the prevalence of colonization by cagA-positive and cagA-negative H. pylori strains in the spectrum of gastro-oesophageal reflux disease. A total of 108 patients (50 male/58 female; mean age, 50.3 years) with dyspepsia and peptic ulcer or erosive gastritis/duodenitis were categorized into patients without reflux and patients with reflux oesophagitis graded from I to IV. All patients underwent upper endoscopy with biopsies of the antrum. H. pylori was detected by histology, urease test and polymerase chain reaction. The cagA status was diagnosed in the gastric biopsy by polymerase chain reaction. The overall prevalence of H. pylori colonization in patients with reflux was 68.6% and was 70.2% in those without oesophageal disease (P = 0.862). Colonization by cagA-positive strains was also not statistically different between the two groups (31.4% versus 40.4%, P = 0.332). However, patients with grades II-IV reflux oesophagitis were less colonized by the bacterium (36.4%) than patients with grade I oesophagitis (77.5%) (P = 0.009). H. pylori cagA-positive strains were also less likely to colonize the stomach of patients with grades II-IV oesophagitis (0%), than grade I reflux oesophagitis (40%) patients and controls (40.4%). Infection of the stomach by H. pylori and especially by H. pylori cagA strains may play a protective role against the development of the most severe forms of gastro-oesophageal reflux disease.

Gastroesophageal reflux disease and Barrett's esophagus.

Gastroesophageal reflux disease (GERD) is a very common disorder, mainly occurring in Western countries. The nonerosive form of GERD, which occurs in more than half of the patients affected, deserves particular attention. Administering symptomatic therapy without a prior endoscopic examination has become an attractive option, since it also provides diagnostic information. Proton-pump inhibitors (PPIs) have become established as the standard therapy, but new insights into the pathophysiology of the condition may lead to new treatment options using gamma-aminobutyric acid (GABA) agonists. Endoscopic therapy is still at the experimental stage and has yet to prove its value as an alternative to PPI and surgery. However, it is questionable whether antireflux surgery is more cost-effective in the longer term.[nl]Gastroenterologists are now much more aware of Barrett's esophagus than was the case a few years ago. Barrett's esophagus is a frequent finding in patients with reflux symptoms, but is a rare cause of death in affected patients. For several reasons, there is a large gap between recommendations regarding surveillance, on the one hand, and everyday practice on the other. New diagnostic procedures such as chromoendoscopy may allow better detection of premalignant and malignant alterations in metaplastic mucosa, but the safety of such techniques has been questioned. Prophylactic ablation is a debatable approach, whereas endoscopic interventions in patients with high-grade dysplasia and early adenocarcinoma are continuing to develop as attractive alternatives to esophagectomy in selected patients. It remains to be seen whether chemoprevention using cyclooxygenase-2 (COX-2) inhibitors should be carried out in high-risk patients with Barrett's esophagus, in order to prevent malignant transformation to esophageal cancer.