Reflux In Patients Research Articles

Gradual cessation of proton pump inhibitor (PPI) treatment may prevent rebound acid secretion, measured by the alkaline tide method, in dyspepsia and reflux patients

Gastro esophageal reflux disease and ulcer related or non-ulcer dyspepsia, attacks 20% of the Western population. These millions of patients are treated continuously with PPI for different periods, many for many years. Recently, rebound acid hypersecretion was recognized as a major clinical event after cessation of PPI therapy. Sustained hypergastrinemia due to daily PPI therapy causes increased acid-secretory capacity that appears when the drug is stopped. The transient increase in blood and urinary pH following gastric secretion has been termed the alkaline tide phenomenon. Carbonic acid, formed in the presence of the enzyme carbonic anhydrase, neutralizes intracellular hydroxyl ions produced as a result of luminal acid secretion. The bicarbonate generated is removed from the cell via the baso-lateral chloride bicarbonate exchanger. We have shown in several studies that this phenomenon parallels acid secretion. Thus, stimulation of acid secretion with test meal increased base excess maximally after 45min and these changes parallel peak acid output measured in gastric aspirate. We hypothesize that gradual step down cessation of PPI will prevent this clinical relevant event. By measuring alkaline tide after PPI cessation we may prove this hypothesis.

이비인후과 질환 별 일상적 스트레스 비교

Background and Objectives: Stress is defined as excited state resulted from interaction of body and mind. It is subjective notion in that the amount of stress can be different in each person from same event. Nevertheless, there have been many studies to find objective measure to assess stress and many questionnaires have been developed. In our study, we tried to measure the amount of stress of representative diseases of Otorhinolaryngology and head and neck surgery using ‘Daily Hassless Scale’, one of well known stress questionnaire. Materials and Methods: 276 people including 36 people of normal control, 20 patients of chronic sinusitis, 20 of laryngopharyngeal reflux, 20 of obstructive sleep apnea, 19 of nasal septal deviation, 20 of facial palsy, 20 of vocal nodule, 21 of allergic rhinitis, 20 of hearing disturbance, 20 of dizziness, 21 of tinnitus, 23 of chronic otitis media and 16 of preauricular fistula were enrolled to our study. They were made to fill up the questionnaire form when they visited our clinic. The questionnaire is composed of 36 questions and each is 4 point scale. We statistically compared total stress score and health related score. Results: Laryngopharyngeal reflux and allergic rhinitis patients group showed significantly higher stress score than control group (p=0.003). Laryngopharyngeal reflux, facial palsy, vocal nodule, allergic rhinitis patients group showed significantly higher score than control group in sum of four health related questions (p=0.000). Conclusion: Laryngopharyngeal reflux, facial palsy, vocal nodule, allergic rhinitis patients group were suffered from higher stress than other otolaryngology disesases and these shoud be considered during managing patients. (J Clinical Otolaryngol 2011;22:65–71)

Heterogeneity in Esophageal Motility in Reflux Patients With Different Symptom Presentation: Studies With Combined Impedance and Manometry

peristalsis could be modulated by baclofen and mosapride. Methods: In all 15 healthy subjects (5 female, mean age 22, range 20-26 yr), secondary peristalsis was generated by slow and rapid mid-esophageal injections of air after a baseline recording of esophageal motility. Three separate sessions with 40 mg oral baclofen, 40 mg oral mosapride or placebo were randomly performed to test their effects on esophageal secondary peristalsis with at least a 1-week interval. Results: Baclofen significantly increased the threshold volume for triggering secondary peristalsis during slow air distension (P = 0.003) and rapid air distension (P = 0.002). Baclofen significantly reduced the rate of secondary peristalsis by rapid air distension from 90% to 30% (P = 0.0002). Despite increasing basal LES pressure (P = 0.03), baclofen did not affect any of peristaltic parameters by primary or secondary peristalsis. Mosapride significantly decreased the threshold volume for triggering secondary peristalsis during rapid air distension (P = 0.04). Secondary peristalsis was triggered more frequently in response to rapid air distension after application of mosapride (P = 0.02). Mosapride significantly increased pressure wave amplitudes of secondary peristalsis during slow (P = 0.001) and rapid air distension (P = 0.002). Conclusions: Inhibition of baclofen on the triggering of secondary peristalsis presents during esophageal distension, indicating that sensory part of secondary peristalsis is probably mediated by the GABAB receptors. However, baclofen does not lead to any motility change in secondary peristalsis as induced by either slow or rapid air distension. Mosapride appears to enhance sensitivity to distension-induced secondary peristalsis and facilitates secondary peristaltic contractility, suggesting the involvement of 5-HT4 in the modulation of esophageal secondary peristalsis in humans.

Chemoradiotherapy or Pharyngo-Laryngo-Esophagectomy for Cervical Esophageal Squamous Cancer

determinant of the need to tailor the type of fundoplication. The aim of this study was to determine normal values for the RBP in asymptomatic subjects and in patients before and after a Nissen fundoplication. Methods: The ramp bolus pressure (RBP) was determined by measuring the mean pressure preceding the upstroke of the contraction wave 5cm above the lower esophageal sphincter (LES) (Figure). We measured the RBP in 53 asymptomatic volunteers and 37 patients with reflux symptoms before and after a Nissen fundoplication. All of the reflux patients had an excellent outcome and none had dysphagia at the time of postoperative evaluation. Results: A RBP was present in 97% of normal subjects and 100% of patients. The mean (SD) amplitude of the RBP in normal subjects was 6.8 (3.7) mmHg. The RBP in reflux patients was significantly lower than that in normal subjects [3.6 (7.0) mmHg, p<0.003]. After Nissen fundoplication, the RBP increased to 12.0 (3.2) mmHg and was significantly greater than the preoperative values (p<0.0001). The 95th percentile value for RBP in normal subjects was 10.4 mmHg and after Nissen fundoplication was 20.0 mmHg. Conclusion: The ramp bolus pressure is a frequent manometric finding that indicates the degree of outflow resistance in the LES region. This amplitude increases after a Nissen Fundoplication. These findings suggest that a contraction amplitude above 20mmHg is necessary to overcome the resistance of a Nissen fundoplication and this threshold may be a better determinant of the need to tailor the type of fundoplication performed.

Mind or mesentery? do the type, frequency and severity of reflux symptoms in patients with coeliac disease and inflammatory bowel disease shed light on their cause?

IntroductionCoeliac Disease and Inflammatory Bowel Disease (IBD) are associated with an increased prevalence of reflux. Speculated reasons for this include disturbances of gastrointestinal (GI) motor function and disturbances of visceral...

581 DOUBLE HIT VERSUS OTHER INJECTION TECHNIQUES USING DEXTRANOMER/HYALURONIC ACID: DOES TECHNIQUE OR VOLUME MATTER?

You have accessJournal of UrologyPediatrics: Imaging/Infections & Vesicoureteral Reflux1 Apr 2011581 DOUBLE HIT VERSUS OTHER INJECTION TECHNIQUES USING DEXTRANOMER/HYALURONIC ACID: DOES TECHNIQUE OR VOLUME MATTER? Daniel DaJusta, Nicol Bush, Song Zhang, and Warren Snodgrass Daniel DaJustaDaniel DaJusta Dallas, TX More articles by this author , Nicol BushNicol Bush Dallas, TX More articles by this author , Song ZhangSong Zhang Dallas, TX More articles by this author , and Warren SnodgrassWarren Snodgrass Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1391AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The optimal injection technique to correct vesicoureteral reflux using dextranomer/hyaluronic acid (Dx/HA) remains uncertain. We have previously published similar success rates using intra-orifice (IO) injection compared to hydrodistention implantation technique (HIT). In an effort to improve Dx/HA success, we combined HIT plus intra-orifice injection (Double HIT) and now evaluate if this technical modification resulted in higher reflux resolution. METHODS Since 2002, a single surgeon has prospectively maintained Dx/HA surgical outcomes in consecutive, non-selected refluxing patients using 4 successive injection techniques: traditional STING, IO, HIT, and then Double HIT. Patients lacking post-procedure cystogram and those with neurogenic bladder were excluded. Univariate and multivariate logistic regression analyses were used to evaluate reflux resolution rates at 12 weeks. Risk factors (covariates) included surgical techniques on an intention-to-treat basis, patient age, gender, reflux grade, injected volume, dysfunctional elimination syndrome, and orifice location. P-values < 0.05 were considered significant. RESULTS Of 400 patients, 342 (85.5%) underwent postoperative cystogram, of whom 295 (86.3%) were female. The number of patients with maximum reflux grades I–V, respectively, were 8 (2.3%), 162 (47.4%), 125 (36.6%), 34 (9.9%), and 13 (3.8%). A single Dx/HA injection resolved the reflux in 244 (71.4%). By technique, 129 (37.7%) patients underwent STING, 72 (21%) IO, 57 (16.7%) HIT, and 84 (24.6%) attempted Double HIT injections, with success rates of 65%, 73%, 70%, and 80%, respectively. Mean injected volumes per ureter were higher for double HIT than STING, IO, and HIT (0.77mL vs. 0.55, 0.50, 0.68, respectively, p<0.04). Despite overall 80% success with Double HIT, technique did not improve odds of reflux resolution when adjusted for other risk factors. On multivariate analysis, high grade IV–V reflux was the only statistically significant variable, increasing the odds of failure 2.7-fold (p=0.005, 95% CI 1.3–5.3). CONCLUSIONS Despite increased Dx/HA volumes, Double HIT technique did not improve odds of reflux resolution when adjusted for other risk factors, with an overall reflux resolution rate of 71.4% after a single Dx/HA injection. Multiple logistic regression revealed only grades IV–V reflux as a statistically significant predictor, increasing the risk of continued reflux after a single injection 2.7-fold. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e234 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel DaJusta Dallas, TX More articles by this author Nicol Bush Dallas, TX More articles by this author Song Zhang Dallas, TX More articles by this author Warren Snodgrass Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Combined lung‐sound and reflux‐monitoring: a pilot study of a novel approach to detect nocturnal respiratory symptoms in gastro‐oesophageal reflux disease

Increased prevalence of respiratory symptoms has been commonly reported in patients with gastro-oesophageal reflux disease (GERD). To introduce a novel Lung-Sound-Monitoring device that allows simultaneous measurement of both nocturnal respiratory symptoms and episodes of acidic and biliary refluxes. Nocturnal respiratory symptoms (coughing and wheezing) were continuously recorded in 20 healthy subjects and 30 reflux patients with respiratory symptoms in parallel to combined pH-monitoring and Bilitec measurement. Analysis could be completed in 20 healthy subjects and in 25 patients with reflux. A clear temporal correlation to reflux phases was detected in 49% of coughing and 41% of wheezing events, respectively. Moreover, 89% of the coughing and 100% of the wheezing events succeeded reflux episodes. Finally, the technique was capable of assessing a statistically significant difference between patients and controls regarding the occurrence of these symptoms. Our pilot study establishes the Lung-Sound-Monitoring system as a unique tool to measure objectively the temporal correlation between gastroesophageal reflux and the appearance of respiratory symptoms. It represents a useful technique to identify patients with respiratory symptoms due to reflux, and therefore allows one to determine and quantify the impact of therapeutic interventions such as antireflux therapy on respiratory symptoms.

Acid exposure and esophageal motility following laparoscopic fundoplication: A comparative randomized study.

Review: Gastro-esophageal reflux disease is one of the most widely spread diseases allover the world. The principle underlying its surgical management is the creation of a mechanical antireflux barrier between the esophagus and the stomach through the creation of either a total (360 degree), or partial anterior or posterior fundal wraps around the lower esophageal end. The ability of surgery to mechanically control the reflux has been documented. The pathogenesis of gastro-esophageal reflux disease is essentially a motility-related problem with varying contributory elements. The role of different techniques in correcting the underlying motility disorder has been little studied in the randomised literature. Aim: The aim of this study was to compare the ability of the laparoscopic partial posterior and the laparoscopic total fundoplication techniques in objectively controlling the reflux and correcting the underlying esophageal motility disorder in gastro-esophageal reflux patients on the mid-term. Patients and methods: In the period between June 1998 and July 2007, 40 patients considered for antireflux surgery in the department of surgery, Tanta University Hospital, were prospectively recruited and randomised to undergo either laparoscopic total (Nissen) or laparoscopic partial posterior (Toupet) fundoplication. In addition to the clinical follow-up, objective follow up through esophageal manometry, 24-h pH monitoring and upper gastrointestinal endoscopy were performed 24 months after operation and compared to the same data recorded preoperatively. Results: Both the total and the partial posterior fundoplication techniques showed excellent control of heartburn and regurgitation postoperatively. This correlated well with the postoperative endoscopic findings, where both techniques were equally effective in correcting hiatus hernias and healing reflux esophagitis. In the Nissen group, the lower esophageal resting pressure significantly increased postoperatively from a median of 23, to 33 mmHg (p 0.05). Length of the abdominal component was significantly increased postoperatively from a median of 3 to 4 cm and from a median of 2 to 4 cm in the Nissen and Toupet groups respectively (p 0.05). No significant changes were found in the esophageal body contraction amplitude on comparing the pre and postoperative values in both groups (p>0.05). The median total acid exposure time in the Nissen and Toupet groups was significantly reduced from a preoperative 13% to 1% and from 17 % to 0% respectively, with similar reduction in the number of pH proven reflux episodes from a median of 24 to 2 and from 30 to 2 respectively (p < 0.01). The small number of cases with Barrett’s metaplasia in our study made it difficult to draw hard conclusions on the difference between the two surgical techniques in this particular type of patients. Conclusion: The partial posterior and total fundoplication techniques are equally effective in restoring the lower esophageal pressure profile and in objectively controlling the reflux on the mid-term. No changes in the esophageal body contraction amplitude could be found with either technique. No objective advantages could be demonstrated for either technique to support a tailored approach.

Correlation of serum pepsinogens and gastrin‐17 with atrophic gastritis in gastroesophageal reflux patients: A matched‐pairs study

An algorithm (GastroPanel) for the non-invasive diagnosis of atrophic gastritis has been previously proposed, based on serum pepsinogen-I, gastrin-17, and Helicobacter pylori (H. pylori) antibodies. The aim of the present study was to evaluate whether serum markers correlate with and predict gastric atrophy in gastroesophageal reflux disease (GERD) patients. The baseline data of the prospective ProGERD study, a study on the long-term course of GERD (n=6215 patients), served to select patients with atrophic gastritis diagnosed in biopsies from gastric antrum and corpus, and control cases without atrophy. A total of 208 pairs were matched for age, sex, GERD status (erosive vs non-erosive), presence of Barrett's esophagus, and histological H. pylori status were retrieved. Serum pepsinogen-I, gastrin-17, and H. pylori antibodies were determined using specific enzyme immunoassays. A significant negative correlation was found between the degree of corpus atrophy and the level of serum pepsinogen-I. A previously-reported negative correlation between the degree of antral atrophy and serum gastrin-17 could not be confirmed. The low sensitivity (0.32) and specificity (0.70) of the GastroPanel algorithm were mainly due to over diagnosis and under diagnosis of advanced atrophy in the antrum. The diagnostic validity of the GastroPanel algorithm to diagnose gastric atrophy non-invasively is not sufficient for general use in GERD patients.

Non-pharmacological intervention for gastro-oesophageal reflux disease in primary care

Up to 50% of patients with gastro-oesophageal reflux disease (GORD) have persistent symptoms despite taking proton pump inhibitors (PPIs) regularly. Lifestyle advice is available to patients, but no previous UK study has tested a behavioural change intervention to help patients self-manage their symptoms. To determine whether a primary care, nurse-led intervention to address behaviours that promote GORD symptoms results in symptom improvement, an increased sense of control, and a reduced requirement for prescribed medication. A group intervention focusing on diet and stress was delivered to patients with reflux symptoms, recruited in rural general practices. General practice in England. Forty-two subjects (male 19, female 23) aged 31-86 years took part. Pre- and post-intervention data were gathered using the Brief Illness Perception Questionnaire (BIPQ), the GORD Impact Scale (GIS), and the Hospital Anxiety and Depression Scale (HAD). There was a significant improvement (BIPQ P<0.001, GIS P = 0.008) 3 months after the intervention. There was no reduction in PPI use or change in HAD score. The greatest improvements were demonstrated in domains measuring the patient's sense of control, perception of symptoms, and understanding of reflux. Patients reported benefits including understanding relevant anatomy and physiology, learning behavioural techniques to change eating patterns and manage stress, identifying actual and potential triggers, and developing and executing action plans. An education programme for GORD enhances self-management, brings perceived symptom improvement, and promotes a sense of control at 3 months. This type of behavioural intervention, alongside medical management, could improve symptom control for reflux patients with refractory symptoms and should be the subject of a controlled trial.

Effect of low-proof alcoholic beverages on duodenogastro-esophageal reflux in health and GERD

Alcoholic beverages are known to increase acidic gastro-esophageal reflux (GER) and the risk of esophagitis. Moreover, duodenogastro-esophageal reflux (DGER), containing bile acids, was shown to harmfully alter the esophageal mucosa, alone and synergistically with HCl and pepsin. However, studies directly addressing potential effects of different low proof alcoholic beverages on DGER in health and disease are missing. Bilitec readings for beer and white, rose, and red wine were obtained in vitro from pure and from mixtures with bile. One-hour DGER monitoring and pH-metry were performed in 12 healthy subjects and nine reflux patients with DGER after ingestion of a standardized liquid meal together with 300 mL of water, white wine, and in the volunteers, beer and rose wine. Bilitec measurement was found to be feasible in the presence of beer, white wine, and using a threshold of 0.25, rose wine. However, the presence of red wine resulted in extinction values above this threshold. The consumption of all investigated alcoholic beverages, especially of white wine, triggered increased acidic GER, both in healthy participants and patients with reflux disease. In contrast, no relevant DGER was found after intake of alcoholic beverages. Fiber-optic bilirubin monitoring can be used for DGER monitoring in combination with alcoholic beverages, except with red wine. Low-proof alcoholic beverages are a strong trigger of GER, but not of DGER, both in healthy subjects and patients with reflux disease.

Association Between Proximal Histological Esophagitis and Atypical Reflux Symptoms in Patients with GERD

Purpose: Globus sensation, chest pain, chronic cough are suggested as atypical or extraesophageal manifestations for gastroesophageal reflux disease (GERD). Increased proximal esophageal acid reflux is observed in reflux patients with extraesophageal symptoms. Although histological abnormalities have been described in patients with GERD, the association between proximal esophageal inflammation and atypical reflux symptoms remains unclear. The aim of this study was to investigate the prevalence of atypical symptoms and histological reflux esophagitis (HRE) in patients with GERD. We also addressed the question of whether proximal HRE correlated with these atypical symptoms. Methods: The study involved 92 prospective patients (55 women, age 46, 20-82 yr) with typical symptoms (heartburn and/or regurgitation) suggestive of GERD. Endoscopical evidence of erosive esophagitis was diagnosed according to Los Angeles classification. Endoscopic biopsies were taken 3 cm and 13 cm above the gastroesophageal junction to assess the presence of HRE. Results: Of all GERD patients, there were 28 patients with globus sensation (30.4%), 45 patients with chest pain (48.9%), 32 patients with chronic cough (34.8%). Forty-seven patients were found to have normal endoscopy (NE) (51.1%), and 45 patients with erosive esophagitis (EE) (48.9%). HRE was detected in 48 patients (52.2%) for distal esophagus, whereas 42 patients (45.7%) had proximal histological esophagitis. Distal HRE occurred 23 of 45 patients with EE (51.1%) and 25 of 47 patients with NE (53.2%) (p=NS), while proximal HRE occurred in 19 of 45 patients with EE (42.2%) and 23 of 47 patients with NE (48.9%) (p=NS). No statistical difference was found regarding the prevalence of any atypical symptom between EE and NE patients. Proximal HRE did not correlate well with the presence of any atypical symptom. Conclusion: Atypical reflux symptoms appear to be equally present in patients with and without erosive esophagitis. Histological reflux esophagitis can be detected in both proximal and distal esophagus regardless of the presence of erosive esophagitis as noticed by endoscopy. None of atypical reflux symptoms correlates with proximal histological reflux esophagitis, suggesting that proximal esophageal inflammation may play a limited role, if any, in the generation of these symptoms.

Systematic review and meta-analysis of laparoscopic Nissen (posterior total)versusToupet (posterior partial) fundoplication for gastro-oesophageal reflux disease

Laparoscopic Nissen fundoplication (LNF) is currently considered the surgical approach of choice for gastro-oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) has been said to reduce troublesome dysphagia and gas-related symptoms. A systematic review and meta-analysis of randomized clinical trials (RCTs) was performed to compare LNF and LTF. Four electronic databases (MEDLINE, Embase, Cochrane Library and ISI Web of Knowledge CPCI-S) were searched and the methodological quality of included trials was evaluated. Outcomes included recurrent pathological acid exposure, oesophagitis, dysphagia, dilatation for dysphagia and reoperation rate. Results were pooled in meta-analyses as risk ratios (RRs) and weighted mean differences. Seven eligible RCTs comparing LNF (n = 404) with LTF (n = 388) were identified. LNF was associated with a significantly higher prevalence of postoperative dysphagia (RR 1.61 (95 per cent confidence interval 1.06 to 2.44); P = 0.02) and dilatation for dysphagia (RR 2.45 (1.06 to 5.68); P = 0.04). There were more surgical reinterventions after LNF (RR 2.19 (1.09 to 4.40); P = 0.03), but no differences regarding recurrent pathological acid exposure (RR 1.26 (0.82 to 1.95); P = 0.29), oesophagitis (RR 1.20 (0.78 to 1.85); P = 0.40), subjective reflux recurrence, patient satisfaction, operating time or in-hospital complications. Inability to belch (RR 2.04 (1.19 to 3.49); P = 0.009) and gas bloating (RR 1.58 (1.21 to 2.05); P < 0.001) were more prevalent after LNF. LTF reduces postoperative dysphagia and dilatation for dysphagia compared with LNF. Reoperation rate and prevalence of gas-related symptoms were lower after LTF, with similar reflux control. These results provide level 1a support for the use of LTF as the posterior fundoplication of choice for GORD.

De novo erosive esophagitis in duodenal ulcer patients related to pre-existing reflux symptoms, smoking, and patient age, but not to Helicobacter pylori eradication: a one-year follow-up study

It remains unclear whether the Helicobacter pylori eradication may cause or provoke gastroesophageal reflux disease. Therefore, we aimed to elucidate the role of H. pylori eradication and other factors in the development of erosive esophagitis in patients with duodenal ulcer. We enrolled 183 H. pylori-positive duodenal ulcer patients without erosive esophagitis. Final endoscopy was performed 12 months later or in case if ulcer relapse was suspected. H. pylori was diagnosed by the urease test and histology if the results of at least one of the tests were positive. A total of 142 patients were assigned to the eradication treatment. The control group included 41 volunteers--20-mg omeprazole b.i.d. for 4 weeks was administered. A total of 150 patients completed the study. Of the 119 patients, 70 (58.8%) were cured from H. pylori, and in 49 (41.2%) of patients, treatment of H. pylori was unsuccessful. All 31 controls remained H. pylori-positive. At the final endoscopy, erosive esophagitis was found in 19 (12.7%) patients. Erosive esophagitis developed in 8 (11.4%) successfully eradicated patients, in 9 (18.4%) unsuccessfully treated patients, and in 2 (6.5%) controls (P>0.05 comparing the groups). Multivariate logistic regression analysis revealed 3 factors at baseline, which were significant (P<0.05) in predicting the occurrence of erosive esophagitis: age more than 43 years (OR, 4.96; 95% CI, 1.47-16.71), nonerosive gastroesophageal reflux disease (OR, 3.96; 95% CI, 1.34-11.68), and smoking (OR, 3.17; 95% CI, 1.01-9.17). H. pylori eradication did not influence the incidence of erosive esophagitis in patients with duodenal ulcer during a one-year follow-up period. Pre-existing nonerosive gastroesophageal reflux disease, smoking, and older age are important predictors of de novo development of erosive esophagitis.

Persistent Reflux Symptoms in the Proton Pump Inhibitor Era: The Changing Face of Gastroesophageal Reflux Disease

Given the widespread use of potent acid suppressive therapies and primary caregivers’ increasing comfort with prescribing these medications at high doses, the patient population presenting to gastroenterologists for symptoms of gastroesophageal reflux disease (GERD) has changed. Whereas previous consultation often revolved around the control of erosive disease and other mucosal manifestations of GERD, and terminated with the prescription of proton pump inhibitor (PPI) therapy, gastroenterologists often now only enter the scene after failure of PPI therapy, for symptoms either resistant or only partially responsive to these medications. Because of the high proportion of subjects with esophagitis who are healed with PPI, 1,2 upper endoscopy of such individuals is low yield, 3 with only a small minority demonstrating erosive disease. The care of such patients is challenging. High-quality evidence supporting useful diagnostic testing or alternative effective therapies is largely lacking. However, the number of subjects with GERD symptoms incompletely or nonresponsive to PPI therapies is high, and their utilization of healthcare resources is substantial. The purpose of this mini-review is to examine the definition and epidemiology of esophageal GERD symptoms incompletely responsive to PPI therapy, the potential pathophysiologic mechanisms behind these symptoms, the differential diagnosis and evaluation of such patients, and current and developing therapeutic options.

1060 Cleavage of E-Cadherin is More Specific Than Dilated Intercellular Spaces (DIS) Within Esophageal Epithelium (EE) for the Diagnosis of Gastroesophageal Reflux Disease (GERD)

INTRODUCTION: Maintenance of closure of the lower esophageal sphincter (LES) in resting state is central to the prevention of gastroesophageal reflux disease (GERD). There are many factors which contribute to the maintenance/failure of the “reflux barrier” of the LES. Here we present a detailed analysis of the anatomy and corresponding biomechanics of the gastroesophageal junction (GEJ) with the AIM of identifying structural differences, and consequent functional differences, in GEJ between normal subjects and GERD patients. METHODS: Three dimensional (3D) reconstructions of the GEJ from transverse magnetic resonance images (MRI) of 12 healthy volunteers and 12 reflux patients were studied for different breathing and meal phases. The orientation of the GEJ and the proximal stomach (angle φ in fig. 1), and the angle of His (θ in fig. 1) were evaluated with respect to an anatomical reference of the midpoint of the vertebrae. Biomechanical analysis of the GEJ was performed for both groups of subjects using the finite element (FE) methods to assess the mechanical consequences of the structural parameters of the GEJ. RESULTS: The angle of His increased with meal and inspiration in both normals and patients, however it always remained more acute (p=0.002) in volunteers (47.23±1.65°) than patients (54.62±1.66°). Interestingly, the orientation of GEJ and proximal stomach in patients was similar to volunteers during fasting, but became more postero-anterior during subsequent fed states. In addition the span of gastric contact with GEJ increased significantly with meal in volunteers (p=0.002) whereas patients showed no such change. FE simulations based on real geometry of the GEJ from 3D reconstruction showed higher intraluminal pressure in the GEJ with pressurization of the stomach when the angle of His was more acute. CONCLUSIONS: The difference in orientation of the GEJ and proximal stomach is possibly the reason for changes in angle of His between normals and patients. Structural and biomechanical differences in the GEJ between normals and patients indicate existence of a virtual “flap valve” in normals which might be dysfunctional in GERD patients.

PWE-071 The natural history of Barrett's oesophagus: the view from a UK district general hospital: Abstract PWE-071

Introduction All patients diagnosed with gastro-oesophageal reflux disease (GERD) in our DGH over the last 3 decades have been systematically followed up. We present the outcome of BE cohort diagnosed 1977–2006 and followed until 31.10.2009, set against the numbers of newly diagnosed GERD. Methods BE was diagnosed visually and confirmed by histology in about 90%. Follow-up (FU) was by surveillance endoscopy+biopsy in the fit or clinically (clinic visit/telephone survey) with endoscopy reserved for alarm symptoms in the others. The GI database closed for non-BE GERD 31.12.2001 but continues for BE. Results BE and GERD 1977-2001 Comparison 1. Incidence (Abstract 071): Both GERD and BE rose in successive 5-year periods. 2. Demography: BE patients were a decade older than reflux patients (mean age at presentation 62 vs 52 years); both had a slight male preponderance (BE 62%, GERD 55%). 3. Complications: Presentation with complications was more common in BE patients (haemorrhage and/or anaemia 10% vs 5%, stricture 10% vs 2%). 4. Mortality. BE 316/752 (42%), GERD 2799/11 622 (24%), mean FU 6 years, range 0–31. BE 1977-2009 Natural history. 1. Numbers continued to rise, 364 diagnosed in the final 5 years (2002-06), totalling 1116. 2. Oesophageal adenocarcinoma (EAC). 53 who presented with or developed EAC within 1 year are excluded as prevalent cancers. Outcome: The remaining 1063 BE had total FU of 6885 patient-years (mean 6.5 years range 0–31) during which 42 (4%) developed EAC, that is, 1 tumour per 164 patient-years of FU. The mean time from diagnosis of BE to EAC was 9 years (range 13 months–24.4 years) occurring at a mean age of 71 years (range 50–86). 3. Mortality: 320/1063 (30%) died during follow-up, 27 (2.5%) from EAC, 54 (5%) from other tumours, the remaining 239 (22%) mainly from cardio-vascular and respiratory causes. 4. Surveillance group, development of EAC, potentially curative resection and outcome. Endoscopic FU: EAC n=26; resection 12; 6/12 died from tumour. Clinical FU: EAC n=11; resection 4; all 4 died from tumour. No FU: EAC n=5; resection 1, still alive. Conclusions (1). During BE follow-up 4% developed EAC. (2) 8% of BE deaths were from EAC but the vast majority from other causes, perhaps reflecting their older age. (3) Surveillance. The rising prevalence of BE and increasing use of endoscopic therapy for early cancer in those unfit for resection has nevertheless strengthened the case for surveillance.

S1498: Short Term Outcomes of Concomittant Antireflux Surgery With BARRx Ablation for Barrett's Esophagus

There is no consensus regarding the ideal treatment of Barretts esophagus (BE). Barrets radiofrequency ablation (BRFA) has been shown to be a safe and effective treatment for patients with BE. Protocols vary with regard to indications, and to the best post-procedure treatment. In particular, the timing of treatment for Barretts patients who would benefit from anti-reflux procedures (ARS) remains in debate. Theoretically, ARS is an ideal treatment adjunct for BRFA patients. However, ablating reflux patients with large hiatal hernias or dilated esophagus can be challenging and ineffective due to the irregular anatomy.

PWE-079 Use of antisecretory medication after antireflux surgery for patients with gastro-oesophageal reflux disease: a systematic review of non-randomised studies

<h3>Introduction</h3> Although antireflux surgery is effective for selected patients with gastro-oesophageal reflux disease (GERD), some patients require further antireflux medication after a variable period. We have previously reported that 14% (95%CI 9% to 20%) of patients require antisecretory medication after antireflux surgery (ARS), based on a meta-analysis of 18 RCTs.1 Since most surgical studies examining the efficacy of ARS are not randomised, we aimed to investigate the need for further ARM after ARS in recent non-randomised studies. <h3>Methods</h3> MEDLINE and EMBASE databases were searched from 2005 up to Oct 2009 for published, English-language, non-randomised studies investigating the efficacy of ARS for GERD in adults, and reporting the use of ARM after ARS. The proportions of patients using ARM after ARS were sample size weighted and pooled by applying a random-effects model using StatsDirect 2.7.2®. <h3>Result</h3> In total, 24 clinical studies met inclusion criteria with follow-up ranging from 0 to 3 months to &gt;10 years and most were single arm observational studies. Some studies reported data for more than one time point. Most surgical interventions were fundoplication, while a few studies only stated “anti-reflux surgery”. When all studies were pooled, regardless of the follow-up time point and only considering the last measured data for the same study, 20% (95% CI 13% to 28%) of patients required ARM after ARS (25 arms, n=7739). The corresponding data for the use of PPIs were 18% (11–25%, 20 arms, n=5994). When subgroup analyses were performed for different follow-up periods, the proportions of patients who required ARM after ARS were 15% (8–23%, 5 arms, n=1680), 24% (12–37%, 7 arms, n=1301), 18% (9–30%, 12 arms, n=5929), and 27% (18–37%, 5 arms, n=1447) for &lt;1 year, 1–3 years, 3–5 years, and 5–10 years, respectively. The corresponding data for the use of PPIs were 14% (6–24%, 4 arms, n=836), 36% (18%–56%, 3 arms, n=225), 12% (3–25%, 9 arms, n=3572), and 21% (15–28%, 5 arms, n=1447). <h3>Conclusion</h3> After antireflux surgery, 20% of patients still require antireflux medication in non-randomised studies, and this proportion increases with the duration of follow-up to 27% after 10 years. This figure from non-randomised studies, which is higher than that from randomised studies, is probably more representative of the unmet need in clinical practice. However, some important issues remain unanswered, including the reasons for taking ARM after ARS, and the effect of loss to follow-up in long-term observational studies. Furthermore, how best to manage reflux patients who fail surgical treatment requires further investigation.

The role of psychological distress in laryngopharyngeal reflux patients: a prospective questionnaire study

To determine the role of psychological distress in laryngopharyngeal reflux patients and evaluate the correlation between symptoms, laryngeal signs, pH monitoring results and psychological profile. Prospective study. Hanyang University Hospital, a university teaching hospital and tertiary referral center. One hundred and six patients who were diagnosed with laryngopharyngeal reflux by 24-h ambulatory double probe pH monitoring and 119 healthy controls visiting our health promotion center from January 2006 to June 2007. The psychological profile of laryngopharyngeal reflux patients measured by the Symptom Checklist-90-Revised questionnaire were evaluated and compared with those of healthy controls. The correlation between reflux symptom index, reflux finding score, parameters of pH monitoring and the Symptom Checklist-90-Revised profiles were also evaluated. On the Symptom Checklist-90-Revised questionnaire, the total mean T-scores of the nine symptom dimensions and three global indices of the laryngopharyngeal reflux patients were all below 50. The Global Severity Index, which indicates overall psychological distress, was normal in all of the patients. On comparison with the control group, no statistically significant difference was noted in the psychological profile except on the Somatisation scale where laryngopharyngeal reflux patients showed significantly higher scores. Reflux symptom index showed significant positive correlation with the number of reflux episodes, percentage of time which pH fell below 4 in total positions, and DeMeester score of the upper probe. The nine symptom dimensions and three global indices of Symptom Checklist-90-Revised questionnaire did not show any correlation with reflux symptom index, reflux finding score and the parameters of the 24-h ambulatory double probe pH monitoring. Laryngopharyngeal reflux patients did not demonstrate any significant level of psychological distress and their symptom severity showed significant positive correlation with reflux severity.