Gastroesophageal Reflux Symptoms Research Articles

Peroral endoscopic myotomy: is it better to perform it in naive patients or as second-line therapy? Results of an open-label-controlled study in 105 patients

BackgroundWhether Peroral Endoscopic Myotomy (POEM) can be proposed as a second-line treatment in patients with achalasia remains to be confirmed in real-life series.ObjectiveThis study aimed to compare the efficacy, feasibility and safety of POEM between treatment-naïve patients and patients who had prior endoscopic or surgical therapies for achalasia.MethodsAll consecutive patients who underwent a POEM procedure for achalasia in our centre from June 2015 to September 2018 were included in this retrospective study. They were classified into treatment-naïve patients (POEM1) and patients who had at least one previous endoscopic and/or surgical treatment for achalasia (POEM2).ResultsA total of 105 patients were included, 52 in the POEM1 group and 53 in the POEM2 group. Clinical success (defined as an Eckardt score ≤ 3) at 6 months was observed in 93% of POEM1 patients and 84% of POEM2 patients (p = 0.18). Technical success rate was not significantly different between the two groups (100% vs 96%, respectively; p = 0.50). No significant difference was noted in terms of adverse event rate (19% vs 19%, respectively; p = 1.00). Post-procedure pain occurred in 12% of treatment-naive and 9% of non-naïve patients (p = 0.76). The median length of hospital stay was 3 days in both groups (p = 0.17). Symptomatic gastroesophageal reflux occurred in 25% of POEM1 patients and 16% of POEM2 patients (p = 0.24).ConclusionEfficacy, feasibility and safety of POEM are not different between treatment-naïve and non-naïve patients. POEM is a valuable second-line approach in patients with persistent symptoms of achalasia after surgical or endoscopic treatments.

First Robotic Roux-en-Y Gastric Bypass for the Treatment of Refractory Gastroesophageal Reflux Disease in a Patient With Systemic Sclerosis.

Systemic sclerosis (SSc) is an immune-mediated disease that results in fibrosis of the skin and internal organs. Refractory gastroesophageal reflux disease (GERD) associated with severe esophageal dysmotility is common in SSc patients, and surgical treatment with usual anti-reflux procedures such as fundoplications is associated with dismal symptomatic relief and postoperative dysphagia. We report the first robotic short-limb Roux-en-Y gastric bypass (RYGB) with a short Roux limb for the treatment of GERD in a patient with SSc with intense esophageal dysmotility.The operativetime was two hours. The procedure and postoperative course were uneventful. The patient presented complete relief of gastroesophageal reflux symptoms and no postoperative dysphagia in a two-year follow-up.Therefore, short-limb RYGB is a safe and very effective alternative for the treatment of severe GERD in patients with SSc. The robotic surgical platform may have some advantages compared to conventional laparoscopy.

Clinical Indication of Upper Gastrointestinal Endoscopy and its outcome

Introduction: Upper gastrointestinal (GI) symptoms are the commonest complaints among the patients for which they seek medical attention. Diseases associated with these symptoms are leading causes of morbidity and mortality worldwide. Objective: To assess the clinical indication of upper gastrointestinal endoscopy and its outcome. Materials and Methods: This was a retrospective study was conducted at Department of Gastroenterology,Abdul Malek Ukil Medical College Hospital, Noakhali, Bangladesh from January 2020 to December 2020. Six hundred two (602) patients were included. All patients who had come with anemia, dyspepsia, suspected gastrointestinal bleed, dysphagia, malena were included in this study. The data was collected using Microsoft excel software and was classified into indications for performing the endoscopy and their obtained results .The results were further classified into age and sex. Results: Total 602 patients who underwent UGIE during the one year study period were analyzed. Among them 326 were males (54.2%) and 276were females (45.8%). None of the patients were on aspirin or proton pump inhibitors. The maximum number of people who underwent the procedure were within 20 – 60 year age group and there was decreasing trends before and after this age group. The patients underwent esophagogastroduodenoscopy mainly because of dyspepsia 226 37.5%) and pain abdomen 163(27.07%), followed by gastroesophageal reflux symptoms 92(15.2%), dysphagia 48(7.9%), suspected varices 30 (4.9%), gastrointestinal bleeding 23(3.8%), anemia had the least of all indication 20(3.3%). Among the indication for upper gastrointestinal endoscopy was considered appropriate according to ASGE criteria, endoscopy was normal in 268(44.5%) patients. Erosive gastritis is the most frequent diagnosis 78(12.9%), followed by non-erosive gastritis 42(6.9%), followed by esophagitis 40 (6.6%), duodenal erosions 38(6.3%) duodenal ulcer 36(5.9%), gastric ulcer 30(4.9%), esophageal varices 21(3.4%), carcinoma of esophagus 16 (2.6%), carcinoma of stomach 12 (1.9%), hiatus hernia 11(1.82%) others 10(1.8%) Conclusion: In conclusion, uppers gastro-intestinal endoscopy is a simple, safe, more reliable and valuable tool with easy learning curve, it enables direct visualization of the upper GI tract and when combined with histopathological examination helps in diagnosing as well as therapeutic interventions for patients with various pathologies. Compared to previous decade there has been gradual rise in GERD which can be attributed to changes in lifestyle and/or a high fat diet with lack of exercise, leading to obesity.

Frequency of GERD in women of childbearing age in Malatya region

Gastroesophageal reflux disease (GERD) is frequently seen not only in our country but also all over the world. GERD not only impairs health and quality of life, but also causes serious financial losses in the working population. In this study, our aim is to determine the frequency of gastroesophageal reflux disease among female healthcare professionals of childbearing age in our region. Questions were asked about demographic data such as weight, age, height, BMI, medical history, and gastroesophageal reflux of female healthcare workers, whose data were generated by us. The answers to the questionnaires were collected and evaluated retrospective. All participants in the study were women. This study was carried out on 1224 female healthcare workers of reproductive age working in Malatya Turgut Özal University training and research hospital. Approximately 1150 of the employees who were distributed questionnaires filled out the questionnaires. The mean age of the female healthcare workers of childbearing age was 30.01±5.38 years, between 19-50. The mean height of the healthcare workers was 1.64±7.8 meters, the average weight was 68.05±13.2 kg, and their body mass index (BMI) was 27.4±3.6 kg/m². The frequency of GERD in the study group was found to be positive in 24%. 38.5% of the healthcare workers had previously gone to the doctor with complaints of pyrosis and/or regurgitation. A significant relationship was found between GERD and stress, fizzy drinks, lying down after meals, and family history of GERD. There was no significant relationship between the smoking and coffee use and age of the participants in the study in terms of the presence of GERD.We think that gastroesophageal reflux symptoms are common due to stress, unbalanced diet, irregular sleep and lifestyle habits due to the COVID pandemic in the last two years due to the fact that the participants in the study were healthcare professionals. Among our healthcare professionals, both pyrosis and other GERD symptoms were found to be higher than some of the previous studies, similar to those in our country. We think that the reason for this is that the extremely stressful work of health workers in the last 2 years has contributed to this. As it is known, health workers have worked very hard in the last 2 years, they did not even use their annual leaves, even those who wanted to retire could not retire. We think that this stress environment may also contribute to GERD symptoms.

Omeprazole vs. Poliprotect®

A randomised, controlled, multicentre, double-blind and double-masked study confirmed the efficacy of Poliprotect®, a molecular complex of natural ingredients designed for the protection of the gastroesophageal mucosa, contained in the medicinal product NeoBianacid®. Poliprotect was non-inferior to the standard dose of omeprazole (20 mg/day) in the treatment of symptoms of non-erosive gastroesophageal reflux and painful functional dyspepsia.

A Systematic Review on the Efficacy and Safety of Alginate-based Liquid Formulations in Reducing Gastroesophageal Reflux in Neonates and Infants.

Neonates and infants experience gastroesophageal reflux as manifested through vomiting, reflux, and coughing. The complaint from many caregivers begins around the 2nd or 3rd month of life and subside around the 6th month of infancy. The standard of care has not been established and treatment options are limited owing to the pharmacological interventions that are deemed safe and effective. Alginate-based formulations, a widely used product in adults such as Gaviscon™, have been explored as another option to treat gastroesophageal reflux. To determine the safety and efficacy of alginate-based formulations in reducing symptoms of gastroesophageal reflux in neonates and infants. An electronic search was conducted for randomized control trials in MEDLINE via PubMed, Herdin Plus, Cochrane Central Register of Controlled Trials, SCOPUS, and Clinical Trials Registry. The search terms were "gastroesophageal reflux," "acid reflux," "neonates," "newborn," "infants," "baby," "babies,", and "alginate." Two review authors independently assessed the available full text articles and a third author intervened to settle the discussion. Two studies were identified and included in this study. Due to the difference in the period of measurement of the trials, a meta-analysis was not pursued. However, a systematic review was still conducted. The two studies suggest a significant improvement of symptoms with alginate-based liquid formulations as intervention. No significant adverse events have been noted making this treatment option generally safe for use in infants. There is insufficient evidence to conclude that alginate-based formulations ultimately help decrease gastroesophageal reflux in neonates and infants, but initial trials show promising results. There is also insufficient data to conclude the safety profile of this treatment option given the small sample.

Sleeve Gastrectomy Associated with Antral Lesion Resection and Roux-en-Y Antrojejunal Reconstruction

Obesity has been growing worldwide, reaching epidemic proportions. Bariatric surgery is the most effective and durable treatment for severe obesity and related diseases. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are the most frequently performed bariatric operations, with long-term good results, in terms of weight loss and comorbidities control. Gastroesophageal Reflux Disease (GERD) is commonly associated with obesity. In general, it precludes the indication of sleeve gastrectomy, since this technique has a refluxogenic potential, as shown in many studies. In such cases, RYGB is considered the best surgery, reaching good weight loss and gastroesophageal reflux disease control. The drawback of this technique is that it leaves the remnant stomach, the duodenum, and the proximal part of the jejunum inaccessible. Besides, RYGB makes transoral endoscopic access to the biliary tree impossible. For all these reasons, this bariatric technique is not indicated in cases of gastric polyposis, gastric dysplasia, or strong family history of cancer, among others. We report a case of a morbidly obese patient with intense GERD, for whom a RYGB was precluded due to her strong family history of cancer, even knowing that it would be the best choice for reflux disease control. Instead, SG was chosen, even knowing it could worsen the gastroesophageal reflux disease. The patient signed an informed consent, after being fully enlightened about the risks. During the surgery, a small subserosal whitish lesion was detected, near the pylorus, on the anterior wall of the antrum. Thinking in a Gastrointestinal Stromal Tumor (GIST), it was resected, with a 2 cm safety margin, leaving a 4 to 5 cm hole on the gastric wall. The decision to maintain the proposed sleeve gastrectomy was made, to avoid leaving a remnant stomach, in a patient with such a strong family history of cancer. In the area of the resected lesion, an intraoperative decision was made not to just close the big gastric hole, being afraid of causing some anatomic or functional disturbance in gastric emptying. Instead, we decided to use the gastric opening to construct a Roux-en-Y antrotrojejunal anastomosis, with a 50 cm alimentary limb and a 200 cm biliopancreatic limb. Accordingly, it was performed a sleeve gastrectomy, associated with an antrojejunostomy in a Roux-en-Y fashion. The patient had an uneventful postoperative course. In the second year, she achieved normal weight and good nutritional status, without gastroesophageal reflux symptoms complaints. Seriography study shows that most of the contrast material passes through the antrojejunal anastomosis, instead of the pylorus, while the duodenum is endoscopically patent. This case report shows an unexpected surgical finding that led to a tactic of adding a Roux-en-Y gastric bypass in the antrum, associated with a sleeve gastrectomy, a strategy that may be adopted in cases of morbidly obese patients with important GERD, for whom gastrointestinal exclusions are contraindicated. To confirm this hypothesis, controlled studies are needed.

NON-INVASIVE METHODS OF DIAGNOSTICS OF GASTRO-ESOPHAGEAL REFLUX DISEASE IN PATIENTS WITH ISCHEMIC HEART DISEASE.

The aim: To determine the diagnostic value of non-invasive methods of GERD diagnosis based on questionnaire data and a diagnostic test with a proton pump inhibitor (PPI) with Rabeprazole in patients with coronary heart disease (CHD). Materials and methods: 90 patients were under observation, namely, 68 patients with coronary heart disease with concomitant essential arterial hyperten¬sion (EAH), 6 patients with coronary artery disease + arrhythmias, and 18 - others diseases. All patients were surveyed according to the GerdQ questionnaire, followed by PPI testing with Rabeprazole, and body mass index (BMI) was calculated for all the patients. A BMI of 18.5-24.9 kg/m2 was considered as normal body weight, and a BMI > 24.9 kg/m2 was considered overweight. Results: Based on the results of the questionnaire, it was established that the most common complaints typical for GERD were noted by patients with CHD in combination with EAH. There were 48 of such patients and, depending on BMI, they were divided into 2 groups: 1st group (n=14) - patients with CHD+EAH+GERD with normal body weight and 2nd group (n=34) - overweight patients with CHD+EAH+GERD. In patients of group 1, typical symptoms of GERD prevailed (in 71.4% of patients), and in patients group 2, the distribution of typical and extra-esophageal symptoms did not differ significantly (52.9% vs. 47.1%). Among the extraesophageal manifestations, pain behind the sternum (in the projection of the esophagus) was significantly more often recorded in patients of group 1, and rhythm disturbances in patients of group 2 (43.8% and 75.0% of patients, respectively, p<0.05). The results of the GerdQ questionnaire showed a direct relationship between GERD, body weight and symptom score. Patients with GERD+normal body weight had a mean score of 6 for classic gastroesophageal reflux symptoms, while patients with GERD+increased body weight had a mean score of 7. The sensitivity of the questionnaire was 78.7%, and the specificity - 92.9%. According to the PPI test, in the 1st and 2nd groups, already in the first three days, 28.5% and 23.5% of patients noted the disappearance of heartburn and after 10 days - 85.7% and 64.7%, respectively. Over the entire period, that is, after 14 days of observation, 85.7% of patients in the 1st group and 73.5% in the 2nd group noted improvement. Conclusions: It has been established that questionnaires based on the GerdQ questionnaire followed by a PPI test with Rabeprazole in patients with coronary heart disease combined with essential arterial hypertension have a high diagnostic value and can be used for early diagnosis and effective treatment of GERD.

Investigation of the potential relationship between gastroesophageal reflux disease and laryngopharyngeal reflux disease in symptomatology – a prospective study based on a multidisciplinary outpatient

Objective To investigate the relationship between laryngopharyngeal reflux disease (LPRD) and gastroesophageal reflux disease (GERD). Methods Gastroesophageal Reflux Disease Questionnaire (GERD-Q) and Reflux Symptom Index (RSI) scale were administered to patients attending the gastroenterology outpatient clinic at the Sixth Medical Center of the PLA General Hospital from 7 April 2021 to 10 June 2021. Patients with GERD-Q score >7 were indicated GERD, and patients with RSI >13 were indicated LPRD. The analysis of patients with pure GERD (independent GERD, iG), patients with LPRD and GERD (LPRD & GERD, L&G), patients with simple LPRD (independent LPRD, iL) and the percentage of normal group (GERDQ-negative and RSI-negative, N). Results 3060 GERD-Q and RSI questionnaires were distributed, and 2974 complete questionnaires were returned. Among them, 274 (9.20%) iL, 334 (11.23%) iG and 151 (5.10%) L&G patients and 2215 (74.48%) N patients. The positive rate of GERD in this sample was 16.31%, of which 31.13% had coexisting LPRD, and the positive rate of LPRD was 14.29%, of which 35.53% had coexisting GERD. Among patients with LPRD, the positive rate of concomitant GERD (χ 2 = 4.157, p = 0.041) and RSI score (Z = −6.823, p = 0.000) was significantly higher in patients with the presence of respiratory symptoms than in those without respiratory symptoms. Conclusion LPRD can exist alone or in conjunction with GERD. Patients with both LPRD and GERD had the most severe reflux symptoms. The need to focus on the risk of those initially screened only with GERD developing LPRD. Respiratory symptoms play an important role in reflux disease.

Fundoplication in laparoscopic Heller's cardiomyotomy for achalasia.

Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose. To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia. We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication. We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication. Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software. We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux. When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.

Autologous Stem Cell Transplantation (ASCT) for Refractory Juvenile-Onset Systemic Sclerosis (jSSc) Is Safe and Well Tolerated and Improves Clinical and Patient-Reported Outcomes

Introduction: jSSc is a rare autoimmune disease that leads to inflammation, fibrosis, and dysfunction of multiple organ systems which can cause skin sclerosis, interstitial lung disease (ILD), myositis, fasciitis, gastrointestinal and vascular disease. Severe SSc is often refractory to immunomodulatory medications including newer targeted agents. ASCT has demonstrated success in adults with SSc, but experience and data in pediatric patients is limited. Methods: We report our first four consecutive adolescent and young adult ASCT patients. All patients were referred to our scleroderma center at UPMC Children's Hospital of Pittsburgh where they were evaluated by our multidisciplinary team. Baseline patient characteristics are summarized in Table 1. Patients met criteria for ASCT by severity of lung or skin disease, or both. The first 3 patients had severe ILD or musculoskeletal chest wall weakness resulting in pulmonary function tests (PFTs) below traditional cut offs for adult SSc ASCT trials. All four patients had refractory disease and had previously received 3-8 immunomodulatory medications. Autologous stem cells were mobilized with cyclophosphamide and filgrastim and collected via pheresis. Following this, conditioning chemoradiation was administered per an IRB-approved individual treatment plan (Patients 1-3) or on our clinical trial NCT03630211 (Patient 4) with rituximab, anti-thymocyte globulin (ATG), TBI 600 cGy with lung and kidney shielding, and cyclophosphamide or thiotepa +/- alemtuzumab. A CD34+ selected cryopreserved autologous peripheral blood stem cell graft was infused on day 0. Antimicrobial prophylaxis was given per institutional standard and PCRs for EBV, CMV and adenovirus were closely monitored. Steroids were weaned off by 5 weeks post-ASCT. Results: The median cell dose was 5.9 e6 CD34/kg. All patients engrafted, with median neutrophil engraftment on day 11 (range 11-15), and median platelet engraftment (>50K) on day 18.5 (range 16-20). There were infusion-related side effects with equine ATG, but none with rabbit ATG. There were no cases of sinusoidal obstructive syndrome, thrombotic microangiopathy or clinically significant bleeding. No patients required a PCA for pain and received minimal (median=3) doses of narcotics. Patients were discharged from the hospital a median of 19 days after transplant (range 17-21). Only one patient was readmitted, and had a negative 48 hour infectious rule out. Two patients acquired COVID-19 infections at 5 and 19.5 months post-ASCT; both remained outpatient with quick improvement after treatment with best available therapy. There were no viral reactivations, bacterial or fungal infections. There has been no evidence of organ toxicity and there are objective improvements in clinical parameters as well as patient reported outcomes (PROs) over the follow-up visits (Table 2). All patients demonstrated an improvement in their skin involvement, as measured by the modified Rodnan Skin Score (mRSS). There was an improvement in clinical symptoms and exam findings of Raynaud's. The lower esophageal sphincter became less hypotensive; objective measures and symptoms of gastroesophageal reflux were much improved. Despite severely reduced values of forced vital capacity (FVC) and diffusing capacity of the lungs for carbon monoxide (DLCO) prior to ASCT, all subjects regained pre-ASCT values. All patients demonstrated an improvement in their PROs and report improvement in fatigue, pain, and the ability to participate in activities of daily living. All patients are off immunomodulatory medications. Tandem serial skin biopsies of the forearm support decreased collagen burden and disappearance of a myofibroblasts population with single cell RNA sequencing (n=3, timepoints 0, 6, 12 mos; data not shown), which correlates with an improvement in the skin score. Conclusions: In refractory jSSc patients, ASCT is well tolerated, even in patients with severe disease who would otherwise not be eligible for clinical trials based on exclusion criteria that were developed for adults with SSc. ASCT can serve as a hard reset to the immune system for patients with this refractory autoimmune disease, with improvements in clinical parameters that reflect disease modification involving the skin, musculoskeletal, vascular, and gastrointestinal systems. Further clinical research treating patients with this rare disease is of great need. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Clinical Implications of the Gastroesophageal Reflux Disease Questionnaire and Reflux Symptom Index in Patients With Suspected Laryngopharyngeal Reflux Symptoms.

Background/AimsTo evaluate the usefulness of gastroesophageal reflux disease questionnaire (GerdQ) and reflux symptom index (RSI) for diagnosis of gastroesophageal reflux disease (GERD) in patients with suspected laryngopharyngeal reflux (LPR) symptoms (cough, hoarseness, globus, and throat pain).MethodsA total of 98 patients with LPR symptoms were incorporated from either gastroenterology or otorhinolaryngology clinic. Patient’s laryngoscopic findings were graded by reflux finding score (RFS), and RFS ≥ 7 was considered as positive LPR. Erosive esophagitis on endoscopy or abnormal results on ambulatory impedance-pH monitoring were used as diagnostic criteria for GERD. Esophageal motor function was evaluated using high-resolution esophageal manometry.ResultsNinety-three (94.9%) of the 98 subjects were diagnosed as LPR by RFS, but only 15 (15.3%) had GERD. For GerdQ, the cutoff value of 9 showed the highest area under curve (AUC) to diagnose GERD by receiver operating curve analysis (AUC = 0.565); the sensitivity, specificity, positive predictive value, and negative predictive value were unsatisfactory (50.0%, 70.7%, 22.6%, and 89.2%, respectively.) RSI also showed poor performance in diagnosing GERD; the cutoff value of 25 showed the highest yield (AUC = 0.581); the sensitivity, specificity, positive predictive value, and negative predictive value were 42.9%, 79.3%, 26.1%, and 89.0%, respectively. Ineffective esophageal motility was frequently observed (69 of 98, 70.4%), but there was no difference in esophageal motility parameters between GERD and non-GERD patients.ConclusionsIn patients with LPR symptoms, significant discrepancies are observed between laryngoscopic diagnosis and GERD. In this population, neither GerdQ nor RSI is useful in diagnosing GERD.

Laryngopharyngeal symptoms and oesophageal disorder: The role of heterotopic gastric mucosa in upper oesophagus.

Heterotopic gastric mucosa in the upper oesophagus (HGMUE) was considered as geneogenous manifestation. However, its clinical characteristics may be beyond our knowledge if we focus on its extra-oesophageal presentation. So the aim of this study was to investigate the relationship between HGMUE and laryngopharyngeal symptoms. Eight hundred and eleven patients who had gastric endoscopy examination were enrolled in this study and the cervical oesophagus was examined for the patch during withdrawal of the endoscope. Questionnaire for gastroesophageal reflux disease (GERD-Q) and Reflux Symptom Index (RSI) were completed by all the patients. Pathology feature and therapeutic effect of HGMUE patients were evaluated. About 34.53% of the patients undergoing the gastroduodenoscopy had laryngopharyngeal (LP) symptoms. The relevance rate of HGMUE in LP(+) group (10.69%) was higher than that in LP(-) group (2%). The LP symptoms were related to the histological type and expression of H+-K+-ATPase in the histological sample of HGMUE patients. The positive rate of H+-K+-ATPase was 100% in LP(+) group, and that in LP(-) group was 28.6%. PPI therapy was effective for improving the LP symptoms in HGMUE patients. The RSI score in LP(+) patients decreased from 8.12 ± 1.46 at baseline to 4± 0.74 at the end of 8 weeks after treatment of PPI. HGMUE was an important cause of LP symptoms in patients, especially in those who had no evidence of GERD. The mechanism of HGMUE-induced LP symptoms was due to its location and the function of acid secretion according to the endoscopic finding and histologic characteristics.

Feeding at 6-12 months in infants with CHD.

Feeding difficulty is common in infants with CHD. The purpose of this study was to describe the feeding skills and behaviours of infants with CHD at 6-12 months of age and explore relationships between feeding, gastrointestinal distress, and gastroesophageal reflux. Parents of 30 infants with CHD completed online surveys when their infant was 6, 8, 10, and 12 months old. Surveys included parent-report measures of feeding skills (Child Oral and Motor Proficiency Scale), feeding behaviours (Pediatric Eating Assessment Tool), symptoms of gastrointestinal distress (Infant Gastrointestinal Symptoms Questionnaire), and gastroesophageal reflux (Infant Gastroesophageal Reflux Questionnaire-Revised). We found that 95, 32, 67, and 30% of infants were delayed in their feeding skill development at 6, 8, 10, and 12 months, respectively. Symptoms of problematic feeding behaviours were similarly high, with 90, 62, 29, and 38% of infants meeting criteria for problematic feeding at 6, 8, 10, and 12 months, respectively. Feeding skills and behaviours were related but unique contributors. Feeding behaviours were related to both gastrointestinal distress and gastroesophageal reflux, but feeding skills were rarely related to either. Delayed acquisition of feeding skills and problematic feeding were common in infants with CHD. Infants with more gastrointestinal and gastroesophageal reflux symptoms had more symptoms of problematic feeding behaviours. Comprehensive assessment, targeted interventions, and early involvement of feeding specialists are important to support feeding in infants with CHD through at least the first year of life.

A comparison of efficacy and safety of potassium-competitive acid blocker and proton pump inhibitor in gastric acid-related diseases: A systematic review and meta-analysis.

Potassium-competitive acid blocker (PCAB) is a recent alternative to proton pump inhibitor (PPI) for potent acid suppression. The current systematic review and meta-analysis aimed to compare the efficacy and safety of PCAB versus PPI in treating gastric acid-related diseases. We searched up to June 5, 2022, for randomized controlled trials of gastric acid-related diseases that included erosive esophagitis, symptomatic gastroesophageal reflux disease (GERD), peptic ulcers, and Helicobacter pylori infection. The pooled risk ratio (RR) was evaluated for the efficacy outcome and treatment-emergent adverse events (TEAEs) as the safety outcome. Sensitivity analyses were performed to test the robustness of the study findings. Of the 710 screened studies, 19 studies including 7023 participants were analyzed. The RRs for the healing of erosive esophagitis with Vonoprazan versus PPI were 1.09 (95% confidence interval [CI] 1.03-1.14), 1.03 (95% CI 1.00-1.07), and 1.02 (95% CI 1.00-1.05) in Weeks 2, 4, and 8, respectively. There were no differences in the improvement of GERD symptoms and healing of gastric and duodenal ulcers between PCAB and PPI. The pooled eradication rates of H.pylori were significantly higher in Vonoprazan versus PPI first-line treatment (RR 1.13; 95% CI 1.04-1.22). The overall RR of TEAEs with Vonoprazan versus PPI was 1.08 (95% CI 0.89-1.31). Overall, the risk of bias was low to some concerns. Furthermore, sensitivity analyses confirmed the robustness of the study's conclusion. Vonoprazan is superior to PPI in first-line H.pylori eradication and erosive esophagitis but non-inferior in other gastric acid-related diseases. Likewise, short-term safety is comparable in both treatment groups.

Association of anxiety and depression among health specialties students with GERD in Makkah city, kingdom of Saudi Arabia (KSA). Cross-sectional study

Introduction: The correlation between psychological factors and digestive abnormalities is significant yet, the full mechanism still undetermined. Objectives: Our study aimed to study the correlation between anxiety, depression, and GERD among health specialties students in Makkah city, Saudi Arabia (KSA). Methods: a survey-based study was demonstrated among health-related students in different medical colleges at Umm Al-Qura University in the period time between December 2020 until January 2021. GERD symptom frequency was evaluated using a previously validated gastroesophageal reflux symptom questionnaire GERD-Q; however, depressive and anxious symptoms were assessed using a Hospital Anxiety/Depression Scale (HADS). Result: A total of 353 students participated in the current study. The mean age of participants in the present study was 22.69 ± 2.27. 215 (60.9%) participants were male, and 138 (39.1%) were female. The majority of respondents were 2nd-year students. There is a significant correlation between anxiety and depression among students with GERD (P-value, 0.001), (P-value, 0.017), respectively. Conclusions: Depression and anxiety represent a significant factor in correlation with students with GERD.

It takes a village to manage eosinophilic esophagitis

Patients with eosinophilic esophagitis (EoE) present with gastroesophageal reflux, feeding difficulties, and occasional growth concerns in infants and toddlers, abdominal pain and gastroesophageal reflux symptoms in school-aged children, and food impaction and dysphagia in adolescents and adults.1 Most of the subjects with EoE have an atopic comorbidity.1 Diagnosis is made by an esophageal biopsy, obtained through an esophagogastroduodenoscopy (EGD), which reveals eosinophilic inflammation above 15 eosinophils per high-power field localized to the esophagus.

Traditional Chinese medicine based on Tongjiang methodology combined with proton pump inhibitor (PPI) step-down in treating non-erosive reflux disease: a study protocol for a multicentered, randomized controlled clinical trial

BackgroundNon-erosive reflux disease (NERD) is characterized by typical gastroesophageal reflux symptoms, such as heartburn and regurgitation but an absence of esophageal mucosal damage during upper gastrointestinal endoscopy. Although proton pump inhibitors (PPIs) are the first line therapy, almost 50% of patients with NERD fail to respond to this treatment. Traditional Chinese medicine (TCM) can better relieve the symptoms of NERD. Therefore, a randomized controlled trial (RCT) was designed to investigate the efficiency of TCM granules based on Tongjiang (TJ) methodology combined with PPI step-down therapy for NERD patients who did not respond to PPIs alone.MethodThis multicentered, double-blinded, RCT with two parallel groups will recruit 174 participants who will be randomized into the TCM granules combined with PPI step-down group (n = 87) and the TCM granules placebo combined with PPI step-down group (n = 87). Both groups of participants will receive 6 weeks of treatment and 4 weeks of follow-up, and all participants will be assessed for related symptoms, mental health status, and quality of life at each visit. The primary outcome measurements include visual analog scale (VAS) for heartburn and regurgitation and the major symptoms scale. The secondary outcome measurements include PPI withdrawal rate, symptom recurrence rate, minor symptoms scale, SF-36, PRO, SAS, SDS, GERD–HRQL, and TCM syndromes scales.DiscussionPrevious research has shown that TCM is capable to alleviate NERD symptoms. This trial will help to provide a better understanding of the synergistic efficiency of the combination of TCM and PPIs, to explore whether the dosage of PPIs can be reduced after the supplement of TCM granules and to provide a feasible plan to reduce dependencies or withdraw NERD patients from PPIs. The outcome of this trial is expected to reduce the symptom recurrence rates, lessen patients’ physical and psychological burdens, and achieve good social benefits.Trial registrationClinicaltrials.gov NCT04340297. Registered on April 9, 2020

S2274 Bravo Capsule Aspiration

Introduction: Bravo wireless capsule is a catheter-free pH monitoring system used to diagnose GERD in patients who fail anti-secretory therapy. Several adverse events have been reported in the literature; these include nose or throat discomfort and dislocation from positioned sites. Case Description/Methods: A 72-year-old man with a history of GERD, prostate cancer, hypothyroidism, obstructive sleep apnea, presented for esophagogastroduodenoscopy (EGD) with Bravo™ placement due to persistent esophageal reflux symptoms despite appropriate therapy. The Bravo™ capsule (Medtronic, Minneapolis, MN) with a delivery system was introduced through the mouth and advanced into the esophagus. The device was placed with visual confirmation; however, the patient had severe a coughing fit. Suction was applied and the delivery system was then withdrawn. Repeat EGD was performed and no Bravo™ was seen in esophagus, stomach, or duodenum. Due to suspicion of dislodgement, a chest x-ray was performed and Bravo™ was seen in the left lung (figure 1, panel A). The patient was admitted to the hospital, and the pulmonology service was consulted for device removal. Bronchoscopy was performed successfully with the extraction of a capsule from the left main bronchus (Figure 1, panel B). After 24 hours observation, the patient did not have any symptoms or signs of aspiration pneumonitis and was discharged home. Discussion: We present a case of an adult patient with aspiration of the capsule into the lungs. This is an unusual complication with pH monitoring techniques(3). Given the limited number of cases of Bravo™ aspiration, there are no definite guidelines or gold-standard treatment up to date. A patent airway and good oxygenation must be maintained. The initial diagnostic evaluation includes chest radiographs, since the Bravo™ capsule is radiopaque(4).Once located, bronchoscopic tools can usually reveal the capsule, as was done with our patient.Figure 1.: Panel A, left: X-ray showing bravo capsule in left lung panel B, right: bronchoscopy showing reveals bravo capsule in left main bronchus.

Comparison of acid-lowering drugs for endoscopy negative reflux disease: Systematic review and network Meta-Analysis.

The comparative efficacy and safety of medical therapies for gastro-esophageal reflux symptoms in endoscopy-negative reflux disease is unclear. We conducted a network meta-analysis to evaluate efficacy and safety of proton pump inhibitors (PPIs), histamine-2-receptor antagonists, potassium-competitive acid blockers (PCABs), and alginates in patients with endoscopy-negative reflux disease. We searched MEDLINE, EMBASE, EMBASE Classic, and the Cochrane central register of controlled trials from inception to February 1, 2022. We included randomized controlled trials (RCTs) comparing efficacy of all drugs versus each other, or versus a placebo, in adults with endoscopy-negative reflux disease. Results were reported as pooled relative risks with 95% confidence intervals to summarize effect of each comparison tested, with treatments ranked according to P-score. We identified 23 RCTs containing 10,735 subjects with endoscopy-negative reflux disease. Based on failure to achieve complete relief of symptoms between ≥2 and <4 weeks, omeprazole 20 mg o.d. (P-score 0.94) ranked first, with esomeprazole 20 mg o.d. or 40 mg o.d. ranked second and third. In achieving adequate relief, only rabeprazole 10mg o.d. was significantly more efficacious than placebo. For failure to achieve complete relief at ≥4 weeks, dexlansoprazole 30 mg o.d. (P-score 0.95) ranked first, with 30 ml alginate q.i.d. combined with omeprazole 20 mg o.d., and 30 ml alginate t.i.d. second and third. In terms of failure to achieve adequate relief at ≥4 weeks, dexlansoprazole 60 mg o.d. ranked first (P-score 0.90), with dexlansoprazole 30 mg o.d. and rabeprazole 20 mg o.d. second and third. All drugs were safe and well-tolerated. Our results confirm superiority of PPIs compared with most other drugs in treating endoscopy-negative reflux disease. Future RCTs should aim to better classify patients with endoscopy-negative reflux disease, and to establish the role of alginates and PCABs in achieving symptom relief in both the short- and long-term.