Management Of Reflux Disease Research Articles

Clinical Characteristics and Management of Gastro Esophageal Reflux Disease (GERD) in Elderly Patients Consulting a General Practitioner

Clinical Characteristics and Management of Gastro Esophageal Reflux Disease (GERD) in Elderly Patients Consulting a General Practitioner

Clinical diagnoses reached in patients undergoing combined ambulatory ph and impedance monitoring for symptoms suspected to be secondary to reflux disease refractory to acid suppression

IntroductionSince August 2007 we have employed combined ambulatory pH and impedance monitoring in the investigation of patients with symptoms thought attributable to gastro-oesophageal reflux refractory to acid suppression. The aim...

A Review of the Diagnosis and Management of Reflux Disease: Toward Creating a Clinical Protocol for the Otolaryngologist

Objectives: Reflux disease, including gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR), is an extremely common condition which is diagnosed and treated routinely in an otolaryngology practice. There is great variability in the methods of both diagnosis and treatment amongst otolaryngologists. Our aim is to review current clinical practice guidelines on reflux disease, to identify areas of agreement and of controversy, and to begin to work toward a clinical protocol for reflux disease for the otolaryngologist. Study Design: Literature review with discussion. Methods: A PubMed search was performed looking for clinical practice guidelines on either GERD or LPR. Five hundred and seventy articles were identified and the most clinically relevant practice guidelines were selected. Results: Thirteen key articles were identified. Eleven of these come from the gastroenterology literature, and none of them come from the otolaryngology literature. There appears to be a consensus on empiric medication trial as first line therapy for presumed uncomplicated GERD and on prioritizing early identification of patients with severe disease complications. Areas of controversy include the definition of GERD and LPR, which diagnostic algorithm to use in which patient, and the long term management of medical therapy. Conclusions: While there are many clinical aspects of reflux disease that still remain a mystery, there is enough literature to support a rudimentary clinical protocol at this time. As further data become available from outcomes measurements, such a protocol may result in improved quality and standardization. A Review of the Diagnosis and Management of Reflux Disease: Toward Creating a Clinical Protocol for the Otolaryngologist

Gastroesophageal reflux disease management according to contemporary international guidelines: A translational study

To test the Genval recommendations and the usefulness of a short trial of proton pump inhibitor (PPI) in the initial management and maintenance treatment of gastroesophageal reflux disease (GERD) patients. Five hundred and seventy seven patients with heartburn were recruited. After completing a psychometric tool to assess quality of life (PGWBI) and a previously validated GERD symptom questionnaire (QUID), patients were grouped into those with esophagitis (EE, n = 306) or without mucosal damage (NERD, n = 271) according to endoscopy results. The study started with a 2-wk period of high dose omeprazole (omeprazole test); patients responding to this PPI test entered an acute phase (3 mo) of treatment with any PPI at the standard dose. Finally, those patients with a favorable response to the standard PPI dose were maintained on a half PPI dose for a further 3-mo period. The test was positive in 519 (89.9%) patients, with a greater response in EE patients (96.4%) compared with NERD patients (82.6%) (P = 0.011). Both the percentage of completely asymptomatic patients, at 3 and 6 mo, and the reduction in heartburn intensity were significantly higher in the EE compared with NERD patients (P < 0.01). Finally, the mean PGWBI score was significantly decreased before and increased after therapy in both subgroups when compared with the mean value in a reference Italian population. Our study confirms the validity of the Genval guidelines in the management of GERD patients. In addition, we observed that the overall response to PPI therapy is lower in NERD compared to EE patients.

Managing upper gastrointestinal disorders in older people

AbstractOur series Prescribing in older people gives practical advice for successful management of the special problems face by this age group. Here, the authors describe the diagnosis and recommended management of gastro esophageal reflux disease and peptic ulcer disease. Copyright © 2010 Wiley Interface Ltd

Efficacy of Three Different Dosages of Esomeprazole in the Long-Term Management of Reflux Disease: A Prospective, Randomized Study, Using the Wireless Bravo pH System

Gastroesophageal reflux disease (GERD) is a chronic condition that usually requires long-term maintenance therapy with proton-pump inhibitors (PPIs). In clinical practice, patients receive PPIs at the lowest dose to control symptoms. However, it is not known whether this approach adequately controls acidic esophageal reflux. We sought to investigate the efficacy of three different dosages of esomeprazole in patients receiving maintenance therapy for GERD, using the Bravo pH system. Patients with a previous history of erosive esophagitis A or B (LA classification) that was healed at the time of enrollment or endoscopy-negative reflux disease (ENRD), documented with an abnormal pH study, were randomized to receive maintenance therapy with esomeprazole 40 mg twice daily (group A), once daily (group B), or every other day (group C). Intraesophageal pH was monitored for two consecutive days using the Bravo wireless system, 30 days after randomization. The parameters subjected to analysis were percent of total time pH<4 and the De Meester score. The pH results from 73 patients (group A=24, group B=24, group C=25 patients) were subjected to final analysis. On the first day of the study, the mean (+/-s.d.) percent of total time pH <4 and the De Meester score were group A: 0.9(1.2) and 4.1(4.0); group B: 1.5(1.6) and 7.0(6.9); group C: 1.3(1.0) and 6.0(3.3), respectively (P=0.262 and 0.134, respectively). On the second day of the study, the corresponding values were group A: 0.7(1.0) and 3.9(5.9); group B: 1.5(1.8) and 6.4(6.6); group C: 7.0(4.4) and 29.4(19.4), respectively. The difference was statistically significant (P<0.0001 and <0.0001, respectively). Further analysis showed that patients not receiving PPI had a significantly higher mean percent of total time pH<4 and De Meester score as compared with patients on PPI once or twice daily (P<0.001 and <0.001 respectively). The administration of esomeprazole 40 mg every other day does not control acidic esophageal reflux on the day off PPI. Esomeprazole 40 mg once daily effectively controls reflux of acid in patients with history of mild esophagitis or ENRD, whereas doubling the dose does not seem to confer any further advantage.

Evolving issues in the management of reflux disease?

Gastroesophageal reflux disease (GERD) is a common chronic disorder often successfully treated, although there are several evolving issues in management. We reviewed the issues related to unmet needs over the past 12 months. A substantial number of patients fail to respond adequately to once or even twice daily proton pump inhibitor (PPI). There is no standard definition of PPI failure in GERD; a universally accepted definition for treatment success is also not available. Differentiation between erosive esophagitis and nonerosive reflux disease can be made but requires endoscopy; but studies still confuse functional heartburn and nonerosive reflux disease, which impacts management. Acid reflux plays an important role in GERD pathogenesis and the precise role of acid requires more studies of differences between erosive esophagitis and nonerosive reflux disease symptom generation and the implication of nocturnal acidification. Several possible mechanisms may explain GERD refractory to PPIs. Management of PPI nonresponders remains a challenge. Objective and precise evaluation of symptoms and treatment response requires study in high-quality trials. New therapeutic approaches are under investigation to answer unmet needs and improve erosive esophagitis healing rates and symptom control.

Reflux esophagitis, high-grade neoplasia, and early Barrett’s carcinoma—what is the place of the Merendino procedure?

Because of the increasing frequency of Barrett's cancer in Western industrialized countries, the management of reflux disease with the potential development of Barrett's esophagus, neoplasia, and early carcinoma is very important. In case of established Barrett's esophagus, the malignant degeneration of the specialized epithelium cannot definitely be prevented by antireflux surgery or continuous medication. Mucosal adenocarcinomas nearly never develop lymph node metastasis and can mostly be treated by endoscopic mucosectomy. The deeper the submucosa is infiltrated, the higher is the rate of lymph node metastasis which is, on the average, 30% for submucosal carcinoma. Therefore, radical subtotal esophagectomy is the treatment of choice for submucosal carcinoma, whereas distal esophageal resection with limited lymph node dissection is only indicated in mucosal carcinoma which cannot be completely removed by interventional endoscopy.

American Gastroenterological Association Institute Technical Review on the Management of Gastroesophageal Reflux Disease

American Gastroenterological Association Institute Technical Review on the Management of Gastroesophageal Reflux Disease

The evolving role of the wireless pH capsule in evaluation of patients with GERD

Ambulatory pH testing can be a valuable diagnostic modality for patients in whom the diagnosis of gastroesophageal reflux disease is uncertain. The utility of conventional catheter-based pH systems has been limited, albeit modestly, by patient discomfort, leading to deviation from dietary and activity limitation during the 24-hour monitoring period. The advent of wireless capsule pH monitoring is a significant advance that enhances both the diagnosis and management of reflux disease. The capsule system has improved the tolerability and acceptance of pH testing by patients. By extending recording periods beyond 24 hours, wireless pH monitoring increases the sensitivity for the diagnosis of reflux and allows incorporation of periods both off-proton pump inhibitor (PPI) and on-PPI testing in a single study. Furthermore, a 48-to 96-hour recording window increases the detection of symptom events that may be temporally associated with reflux episodes using symptom association analyses.

Symptom Assessment

Gastroesophageal reflux disease (GERD) presents symptomatically and the main aim of treatment is to reduce or abolish these reflux-related symptoms. Objective tests such as endoscopy, esophageal pH monitoring, and esophageal histology, identify a high proportion of patients who have reflux-related esophageal injury but they identify a smaller proportion of patients with reflux symptoms and, probably, a yet smaller proportion with atypical, chest pain symptoms. The usefulness of objective tests for determining the role of gastroesophageal reflux in the etiology of extraesophageal respiratory, oropharyngeal and otorhinologic syndromes are even more limited. Symptom assessment is, therefore, crucial for the management of reflux disease. However, the symptomatic manifestations of GERD are protean and, although typical symptoms of heartburn and regurgitation are associated with GERD in a high proportion of individuals, there is no single symptom or combination of symptoms that is diagnostic of GERD, particularly when the esophageal and extraesophageal syndromes are considered. Symptom-based questionnaires developed for the diagnosis of GERD are not, therefore, adequate for the identification of all individuals with GERD although their diagnostic accuracy can be improved by combining them with other diagnostic tests and applying, for example, latent class analysis or Bayesian analysis. Symptom assessment is also crucial in evaluating the effect of therapy in individuals who have a diagnosis, confirmed or presumptive, of GERD. In clinical practice, treatment-induced symptom resolution is generally associated with an improvement in the patient's quality of life and is predictive of an improvement in esophageal injury syndromes; in clinical trials, it is necessary to know that an improvement in symptoms is actually indicative of an improvement in the manifestations of GERD. The need for a validated, symptom-based, evaluative instrument to assess GERD symptoms and their response to therapy has been addressed by the development of a new tool-the ReQuest questionnaire. ReQuest has now been validated in patients with erosive esophagitis, patients with nonerosive reflux disease, and in individuals who do not have reflux disease and it provides an instrument that may be used in clinical research and regulatory studies to document treatment efficacy. In the future, it may also be combined with empiric acid suppression therapy, for example with a proton pump inhibitor, to provide a GERD diagnosis ex juantibus, without the need for supplementary expensive or invasive investigations.

Reflux Symptoms in Professional Opera Choristers

A specific, occupation-related susceptibility of professional singers to experience gastroesophageal reflux was hypothesized. We investigated the prevalence of gastroesophageal reflux symptoms in a series of professional opera choristers in comparison with a general population sample. A total of 351 professional opera choristers from well-known chorus in different Italian regions were identified and a sample of 578 subjects residing in the same areas with a similar distribution in age and sex was selected. Reflux symptoms in the year preceding the survey together with selected individual characteristics and lifestyle habits were investigated in both study groups through a structured questionnaire. Prevalence rate ratios, adjusted for sex, age, body mass index, smoking status, alcohol consumption, and other confounding factors, were computed. Opera choristers reported a statistically significant higher prevalence of heartburn, regurgitation, cough, and hoarse voice than the population sample, with adjusted prevalent rate ratios of 1.60 (95% confidence interval [CI], 1.32-1.94), 1.81 (95% CI, 1.42-2.30), 1.40 (95% CI, 1.18-1.67), and 2.45 (95% CI, 1.97-3.04), respectively. Regurgitation appeared to be associated consistently with the cumulative lifetime duration of singing activity (P = .04) and with the weekly duration of singing activity (P = .005) when different multivariate models were applied. Opera choristers reported a higher prevalence of reflux symptoms than the population sample. Future studies will be needed to clarify whether gastroesophageal reflux in professional opera choristers is stress-induced and therefore may be considered as a work-related disease.

Extraesophageal reflux in children

To summarize and contextualize current concepts in the incidence, diagnosis, management and long-term sequelae of extraesophageal reflux disease in children. Extraesophageal reflux disease is a different disease entity from gastroesophageal reflux disease. The two diseases have a common etiology, refluxate causing mucosal damage, but the extent and location of the damage varies considerably depending on the underlying mucosal characteristics. Extraesophageal reflux disease in children is characterized by a broad set of symptoms and signs that vary according to age at presentation and severity of disease. Serious long-term effects begin in childhood. The role of pepsin, bile acids, pancreatic enzymes, motility disorders, and food allergies have only recently been recognized. Newer diagnostic modalities include multichannel intraluminal pH/impedance, the 48 h Bravo implantable probe, and hypopharyngeal pH monitoring. While proton pump inhibitors provide superior acid suppression compared with histamine-2 blockers, variability in response and lack of efficacy for alkaline refluxate often require other therapeutic interventions. Pediatric extraesophageal reflux disease has variable presentation and a gold standard test is still lacking. Primary treatment includes lifestyle and feeding changes and medical therapy. Ongoing monitoring for recurrence and agreement as to duration of therapy present significant challenges not yet standardized amongst practitioners.

Esophageal pH-Impedance Monitoring and Symptom Analysis in GERD: A Study in Patients off and on Therapy

Combined esophageal pH-impedance monitoring allows detection of nearly all gastroesophageal reflux episodes, acid as well as nonacid. However, the role of nonacid reflux in the pathogenesis of symptoms is poorly known. The aim of this study was to evaluate the diagnostic yield of this technique in patients with suspected reflux symptoms while on or off PPI therapy. The recordings of 150 patients recruited at seven academic centers with symptoms possibly related to gastroesophageal reflux were analyzed. Reflux events were detected visually using impedance (Sandhill, CO) and then characterized by pHmetry as acid or nonacid reflux. The temporal relationship between symptoms and reflux episodes was analyzed: a symptom association probability (SAP) > or =95% was considered indicative of a positive association. One hundred fifty patients were included, 102 women (mean age 52 +/- 14 yr, range 16-84). Among the 79 patients off PPI, five did not report any symptom during the recording period. A positive SAP was found in 41 of the 74 symptomatic patients (55.4%), including acid reflux in 23 (31.1%), nonacid reflux in three (4.1%), and acid and nonacid in 15 (20.3%). In the group of patients on PPI (N = 71, 46 women, mean age 51 +/- 15 yr), 11 were asymptomatic during the study, SAP was positive in 22 of the 60 symptomatic patients (36.7%), including acid reflux in three (5.0%), nonacid reflux in 10 (16.7%), and acid and nonacid in nine (15.0%). The symptoms most frequently associated with nonacid reflux were regurgitation and cough. Adding impedance to pH monitoring improves the diagnostic yield and allows better symptom analysis than pHmetry alone, mainly in patients on PPI therapy. The impact of this improved diagnostic value on gastroesophageal reflux disease management remains to be investigated by outcome studies.

Diagnosis and management of laryngopharyngeal reflux disease

The recent findings and up-to-date practice guidelines for diagnosing, evaluating, and treating gastro-esophageal reflux disease are discussed. The patient complaints for reflux disease are crucial in diagnosis. Although physical examination findings may correlate with laryngopharyngeal reflux, these findings may not improve after an adequate course of treatment. Behavioral modifications are a critical part of improving reflux; however, weight loss has not been shown to improve laryngopharyngeal reflux disease. Patients who used proton-pump inhibitors and histamine blockers were shown to have increased risk of developing Clostridium difficile infections. Laryngopharyngeal reflux has been shown to be a better predictor of Barrett's esophagus than gastroesophageal reflux, although specific screening recommendations have not been determined. Current studies in laryngopharyngeal reflux demonstrate that improvements in physical examination findings are not a reliable way of determining patient improvement. An empiric trial of therapy is the best diagnostic test for laryngopharyngeal reflux. Future studies will examine the role of transnasal esophagoscopy in the screening of the laryngopharyngeal reflux patient for Barrett's esophagus.

Diagnosis and management of laryngopharyngeal reflux disease

Laryngopharyngeal reflux remains a controversial subject for both diagnosis as well as treatment. Nevertheless, there is increasing clinical and experimental evidence to suggest that it is associated with many nonspecific otolaryngological symptoms. Twenty-four hour dual probe pH tests fail to prove or exclude laryngopharyngeal reflux because of insufficient specificity and sensitivity. Therefore, the diagnosis is usually based on a combination of diagnostic signs and symptoms, which cannot be explained by pathology other than laryngopharyngeal reflux. Many signs of laryngopharyngeal reflux, however, are also found in individuals without symptoms. Treatment should consist of high-dose proton-pump inhibitor medication twice daily. Laryngopharyngeal reflux disease is a diagnosis by exclusion, and resolution of symptoms following a 4-month trial of high-dose proton pump inhibitor twice daily is, for all practical purposes, considered proof of the initial diagnosis. Nonresponse does not exclude the diagnosis of laryngopharyngeal reflux disease, however, since proton-pump inhibitors will only reduce the acid component of the refluxate.

Controversies in the diagnosis and management of laryngopharyngeal reflux disease

Controversies in the diagnosis and management of laryngopharyngeal reflux disease

Diagnosis and management of laryngopharyngeal reflux disease

Laryngopharyngeal reflux has shown high prevalence and it is an interesting issue for otorhinolaryngologists, head and neck surgeons, and gastroenterologists. The present paper presents the most recent findings in diagnosis and management of laryngopharyngeal reflux. Clinical presentation of laryngopharyngeal reflux is widely varied and it may be manifested by a wide range of signs and symptoms. Other diseases that affect the larynx may also show the same signs and symptoms, such as, for example, vocal abuse, allergy, asthma, sinusitis, and smoking. Overvaluation of signs and symptoms related to reflux may be responsible for overdiagnosis of laryngopharyngeal reflux disease. The 24-hour dual-probe pH monitoring is considered the gold standard for the diagnosis of laryngopharyngeal reflux disease, and is essential in cases of pharyngolaryngeal complaints. The management of laryngopharyngeal reflux cases should be based on severity of symptoms, laryngoscopic findings, and frequency of reflux episodes. Proton-pump inhibitors are the preferred drugs for managing patients with laryngopharyngeal reflux and the best control can be achieved by prescribing high doses, twice a day. Patients that do not respond satisfactorily to clinical management are candidates for surgical fundoplication. Laryngopharyngeal reflux is characterized by a set of signs and symptoms resulting from extraesophageal manifestations of gastroesophageal reflux disease; however, this set of signs and symptoms may be related to other causes and the results of management, based on clinical presentation, vary widely and have low cure index.

Diagnosis and management of laryngopharyngeal reflux disease

Laryngopharyngeal reflux should no longer be underestimated because of its negative impact on the lives of patients and its potentially dangerous long-term complications. Both laryngopharyngeal reflux and gastroesophageal reflux disease are caused by mucosal injury from acid and pepsin exposure, but the esophagus has intrinsic antireflux defenses that prevent mucosal injury (bicarbonate production, mucosal tissue resistance and esophageal motor function with acid clearance) whereas the pharynx and the larynx do not. Symptoms felt to be most related to reflux (>or= 95%) are throat clearing, persistent cough, heartburn/dyspepsia, globus sensation (lump in the throat) and voice-quality change, while the physical examination findings include (>or= 95%) arytenoid erythema, vocal-cord erythema and edema, posterior commissure hypertrophy, and arytenoid edema. In this regard, the reflux symptom index and the reflux finding score are very useful clinical tools. Patients are proposed an empirical therapeutic trial including behavioural and dietary recommendations and a 3-month twice-daily proton-pump inhibitor therapy. The proton-pump inhibitor should be taken 30-60 min before meals. Nonresponders undergo an assessment, ideally based on esogastroduodenoscopy and ambulatory multichannel intraluminal impedance and pH monitoring. Transnasal esophagoscopy in the outpatient setting is a safe alternative. When medical management fails, patients with demonstrable high-volume reflux and lower sphincter incompetence are often candidates for surgical intervention. The algorithm proposed by Ford has structured and confirmed our attitude on a day-to-day basis.

On-Demand Therapy with Pantoprazole 20 mg as Effective Long-Term Management of Reflux Disease in Patients with Mild GERD: The ORION Trial

Aims: To compare safety and efficacy of on-demand pantoprazole 20 mg/40 mg versus placebo in the long-term management of patients with mild gastroesophageal reflux disease (GERD) after heartburn relief. Methods: A total of 634 patients with endoscopically confirmed GERD grade 0/I and heartburn were included. During the acute phase, patients were treated with pantoprazole 20 mg once daily for 4 weeks. Those patients relieved from heartburn entered the long-term phase, and were randomly assigned to either treatment group pantoprazole 20 mg, 40 mg or placebo. Over 6 months, patients took study medication on demand (antacids as rescue medication) and discontinued the drug once symptoms abated. Results: After 4 weeks a total of 87.1%/90.0% of patients were free of heartburn (ITT/PP), and entered the subsequent long-term phase. The perceived average daily symptom load (placebo: 3.93, pantoprazole 20 mg: 2.91, pantoprazole 40 mg: 2.71, ITT) and the number of antacid tablets taken (average number, placebo: 0.68, pantoprazole 20 mg: 0.45, pantoprazole 40 mg: 0.33, ITT) were significantly higher in the placebo than in both pantoprazole groups (p < 0.0001), with no statistically significant difference between the two pantoprazole groups. The discontinuation rate due to insufficient control of heartburn was significantly lower in both pantoprazole groups compared to placebo (placebo: 10.9, pantoprazole 20 mg: 2.8, pantoprazole 40 mg: 0.9, ITT). Conclusions: Our findings favor on-demand treatment with pantoprazole 20 mg for the long-term management of heartburn in patients with uncomplicated GERD (grade 0/I) with superiority to placebo.