Refractory Reflux Esophagitis Research Articles

Prevalence and risk factors for medication-refractory reflux esophagitis in patients with systemic sclerosis in Japan.

Patients with systemic sclerosis (SSc) often have esophageal motility abnormalities and weak esophago-gastric junction (EGJ) barrier function, which causes proton pump inhibitor (PPI)-refractory reflux esophagitis (RE). The aims of this study were to clarify the current management of RE and prevalence and risk factors of medication-refractory RE in patients with SSc in Japan. A total of 188 consecutive patients with SSc who underwent both esophageal high-resolution manometry (HRM) and esophagogastroduodenoscopy (EGD) were reviewed. The presence of RE and grades of the gastroesophageal flap valve (GEFV) were assessed. Esophageal motility was assessed retrospectively according to the Chicago classification v3.0. When RE was seen on a standard dose of PPI or any dose of vonoprazan (VPZ), it was defined as medication-refractory RE. Approximately 80% of patients received maintenance therapy with acid secretion inhibitors regardless of esophageal motility abnormalities. Approximately 50% of patients received maintenance therapy with PPI, and approximately 30% of patients received VPZ. Medication-refractory RE was observed in 30 patients (16.0%). In multivariable analyses, the number of EGD and absent contractility were significant risk factors for medication-refractory RE. Furthermore, combined absent contractility and GEFV grade III or IV had higher odds ratios than did absent contractility alone. Patients with persistent reflux symptoms and those with absent contractility and GEFV grade III or IV should receive maintenance therapy with strong acid inhibition to prevent medication-refractory RE.

Efficacy of Vonoprazan Fumarate Tablets in Refractory Reflux Esophagitis

To evaluate the efficacy of vonoprazan fumarate tablets in refractory reflux esophagitis and to provide new insights into the clinical management of refractory reflux esophagitis. A total of 60 refractory reflux esophagitis E patients meeting the inclusion criteria were recruited and assigned via random number table method to receive either conventional treatments (control group) or vonoprazan fumarate plus conventional treatments (treatment group), with 30 cases in each group. Traditional Chinese medicine decoction was administered for adjuvant therapy. Outcome measures included clinical symptom score, gastroesophageal reflux disease healthrelated quality of life scores, esophageal mucosal damage, serum inflammatory factors, serum calcitonin gene related peptide, 5-hydroxytryptamine levels and relapse. Vonoprazan fumarate resulted in milder esophageal mucosal damage and symptoms, and a lower incidence of recurrence vs. conventional treatment alone (p<0.05). Patients with vonoprazan fumarate showed higher quality of life and lower inflammatory factor levels vs. those without (p<0.05). No documented safety events were found during the administration of vonoprazan fumarate. Vonoprazan fumarate tablets are effective in acid suppression, reducing serum calcitonin gene related peptide and 5-hydroxytryptamine levels in refractory reflux esophagitis patients, alleviating the inflammatory response and promoting esophageal mucosal healing with a high safety profile. Vonoprazan fumarate tablets supplemented with traditional Chinese medicine decoction offers a viable option for the treatment of refractory reflux esophagitis. Further studies are required prior to clinical promotion.

The Clinical Feature of Reflux Esophagitis Patients Visiting a Single Korean Medicine Hospital: A Retrospective Study

Objectives: This study investigated the clinical characteristics and symptoms of patients with reflux esophagitis (RE) visiting a Korean medicine hospital.Methods: We retrospectively reviewed the medical records of patients with an RE diagnosis who visited a Korean medicine hospital from June 15, 2020, to April 15, 2021. We analyzed the clinical characteristics and the results of a symptoms questionnaire.Results: Our sample included 1,151 patients (711 females). The median age was 58 years; the most common age bracket was 60-69 years. A total of 837 patients (72.7%) presented with symptoms lasting more than one year, and 1,035 (89.9%) had been prescribed medications for more than three months before visiting a Korean medicine hospital. Belching (77.6%) and acid regurgitation (70.9%) were the most frequent symptoms, followed by epigastric pain (61.6%) and throat globus (58.5%). Throat globus was the most bothersome symptom, and 72.4% of the patients experienced the symptom on more than five days in the preceding two weeks. Patients with a longer symptom duration were older (p&lt;0.01) and more likely to be overweight (p=0.03). Patients experiencing symptoms for more than five years were more likely to report throat globus (p=0.02), hoarseness (p&lt;0.01), and coughing (p&lt;0.01).Conclusions: Most RE patients visiting a Korean medicine hospital were females in their sixties with chronic and refractory RE. Atypical symptoms (belching, epigastric pain, and throat globus) were common. Throat globus was highly prevalent in severe cases, suggesting that it warrants attention when treating RE patients.

Efficacy of Vonoprazan for Refractory Reflux Esophagitis after Esophagectomy

Background: Refractory reflux esophagitis (RRE), unresponsive to conventional proton-pump inhibitors (PPIs), is a complication in esophagectomy with gastric pull-up. Vonoprazan (VPZ), a novel potassium-competitive acid blocker, has been available in Japan since 2015. Here, we investigated the efficacy of VPZ on PPI-resistant RRE after esophagectomy with gastric pull-up. Methods: This was a single-center retrospective study. We used the revised Los Angeles (r-LA) classification based on the Los Angeles classification and the modified Los Angeles classification to evaluate abnormal forms of mucosal breaks such as lateral spreading consistently. Patients who underwent esophagectomy with gastric pull-up and had RRE grade B–D as per the r-LA classification, despite using standard-dose PPIs or double dose of rabeprazole, were included. Sixteen patients who switched to VPZ (20 mg/day) and 14 patients who continued PPIs were assigned to the VPZ and PPI groups, respectively. Endoscopic observations were reviewed by 3 endoscopists using the r-LA classification to ensure consistent diagnosis, while the treatment arm and patient information were blinded to evaluators. We defined mucosal breaks that improved by at least one grade after treatment as improved mucosa and recovery to grade M or N as mucosal healing. Results: The percentage of patients with improved mucosa in the VPZ and PPI groups was 81.3 and 14.3%, respectively (p < 0.001). The rate of mucosal healing was 68.8 and 7.1%, respectively (p = 0.001). Conclusion: VPZ significantly improved PPI-resistant RRE after esophagectomy with gastric pull-up.

Therapeutic Response to Twice-daily Rabeprazole on Health-related Quality of Life and Symptoms in Patients with Refractory Reflux Esophagitis: A Multicenter Observational Study.

Objective To investigate the effect of twice-daily rabeprazole doses on health-related quality of life in refractory patients. Methods and Patients Reflux esophagitis patients with an insufficient response to once-daily proton pump inhibitor therapy (Los Angeles Classification grade A-D) received rabeprazole 10 mg or 20 mg twice daily for 8 weeks. The health-related quality of life (SF-8™) and symptoms, using the Frequency Scale for the Symptoms of Gastroesophageal reflux disease, were evaluated before treatment and at weeks 4 and 8. Endoscopy was performed at baseline and at weeks 8 and 32 where possible. The rabeprazole dose was determined by the attending physician. Results There were 1,796 patients analyzed for the efficacy of the twice-daily treatment. Of these cases, 1,462 were treated with rabeprazole 10 mg twice daily, and 334 were treated with rabeprazole 20 mg twice daily. The factors that affected the selection of the twice-daily rabeprazole dose by physicians were evaluated, and as expected, “endoscopic findings when treatment was started” had a strong effect on the selection of the rabeprazole dose. With both regimens, health-related quality of life and subjective symptoms were significantly improved at weeks 4 and 8 compared to baseline (p<0.001). The recurrence rate of erosive esophagitis at week 32 was 9.7% in rabeprazole twice daily-treated patients and 28.4% in proton pump inhibitor (PPI) once daily-treated patients. Both regimens were well tolerated. Conclusion Twice-daily treatment with rabeprazole improved the subjective symptoms and health-related quality of life in patients with refractory reflux esophagitis more effectively than the standard once-daily dose.

The added diagnostic value of postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on-therapy impedance-pH monitoring.

On-therapy impedance-pH monitoring in proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) yielded conflicting results. We aimed to assess the diagnostic value of postreflux swallow-induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) in PPI-refractory heartburn. On-therapy impedance-pH tracings from 189 consecutive patients with PPI-refractory heartburn were blindly reviewed. Patients were subdivided into refractory reflux esophagitis (RRE), healed reflux esophagitis (HRE), non-erosive reflux disease (NERD), and functional heartburn (FH) according to endoscopic and conventional impedance-pH findings. The diagnostic accuracy of PSPW index and MNBI in separating NERD from FH was assessed with receiver-operating-characteristic (ROC) analysis. Objectively documented persistent reflux remission at 3-year follow-up in 53 patients who underwent laparoscopic fundoplication served to evaluate PSPW index and MNBI as independent predictors of PPI-refractory GERD confirmed by positive surgical outcome. Median PSPW index and MNBI values were significantly lower in 39 RRE (16%; 1145Ω) than in 41 HRE (25%; 1741Ω) and in 68 NERD (29%; 2374Ω) patients, and in all three GERD subgroups compared to 41 FH cases (67%; 3488Ω) (P<.008). At ROC analysis, comparing NERD to FH the area under the curve was 0.886 with PSPW index and 0.677 with MNBI (P=.005). PSPW index was an independent predictor of PPI-refractory GERD (odds ratio 0.6983, P=.012). At on-therapy impedance-pH monitoring, PSPW index and MNBI efficiently distinguish PPI-refractory NERD from FH. The PSPW index represents an independent predictor of PPI-refractory GERD.

Predictors of either rapid healing or refractory reflux oesophagitis during treatment with potent acid suppression.

Little is known regarding patient characteristics that influence the speed of reflux oesophagitis (RO) healing. To investigate patient characteristics that may influence RO healing rates. A post hoc analysis of clinical trial data for potent acid suppression treatment of RO (esomeprazole or AZD0865) was conducted. Group A underwent endoscopy at baseline, week 2 and 4, and group B at baseline, week 4 and 8. Group A patients were sub-grouped as 'rapid' (healed at 2 weeks) or unhealed at 2 weeks. Group B patients were sub-grouped as 'slow' (healed at 8 weeks, not at 4 weeks) or 'refractory' (not healed at 8 weeks). Logistic regression analysis was performed only for comparisons within group A. At 2, 4 and 8 weeks, RO had healed in 68%, 65% and 61% of patients unhealed at previous endoscopy, respectively. Low-grade [vs. high-grade (C or D)] RO was the only independent predictor of rapid healing in group A after logistic regression analysis. Significantly more rapid healers had low grade RO (A or B) at baseline than patients with refractory RO (84% vs. 49%; P < 0.001), and significantly more refractory patients had frequent regurgitation at baseline than slow healers (80% vs. 63%; P = 0.039). Low- (vs. high-) grade RO determines the most rapid benefit from acid suppression. Roughly two-thirds of patients healed with each time increment of potent acid suppression therapy. This suggests that some unhealed patients may still heal with continued therapy and that truly refractory RO is rare. (ClinicalTrials.gov: NCT00206245).

Impairment of chemical clearance is relevant to the pathogenesis of refractory reflux oesophagitis

The pathophysiological mechanisms underlying proton pump inhibitor-refractory reflux oesophagitis has been scarcely studied. To assess impedance-pH parameters relevant to the pathogenesis of refractory reflux oesophagitis. Cases referred for heartburn/regurgitation refractory to high-dosage proton pump inhibitors between January 2008 and December 2012 were reviewed and subdivided into refractory oesophagitis (29 patients, 72% males, median age 50 years), healed oesophagitis (18 patients, 67% males, median age 54 years), and non-erosive reflux disease (49 patients, 53% males, median age 42 years). On-therapy impedance-pH tracings were blindly re-analysed by one observer to assess gastric and oesophageal acid exposure time and chemical clearance as expressed by the post-reflux swallow-induced peristaltic wave index. The median gastric and oesophageal acid exposure time did not differ among the three groups (35%, 34%, 41% and 1.2%, 0.7%, 0.8%, respectively; P>0.05 for all comparisons). A normal oesophageal acid exposure time was found in two thirds of patients with refractory oesophagitis. The post-reflux swallow-induced peristaltic wave index was significantly lower in refractory oesophagitis (16%) than in healed oesophagitis (30%) and non-erosive reflux disease (29%) (P=0.003). Refractory reflux oesophagitis is characterized by impairment of chemical clearance. Adequate acid suppression is found in the majority of patients who would likely not benefit from further proton pump inhibitor dose escalation.

Efficacy of Twice-Daily Rabeprazole for Reflux Esophagitis Patients Refractory to Standard Once-Daily Administration of PPI: The Japan-Based TWICE Study

Approximately 10% of patients with reflux esophagitis (RE) are not cured with the standard 8-week q.d. regimen with a proton pump inhibitor (PPI). Thus, b.i.d. dosing is often used in refractory RE (rRE) patients, although there has been no report of endoscopically confirmed healing with b.i.d. dosing of PPIs. This study aimed to assess the efficacy and safety of 8-week therapy with rabeprazole (RPZ) sodium at 20 mg b.i.d. or 10 mg b.i.d. as compared with RPZ at 20 mg q.d. in patients with RE refractory to the standard PPI regimen in Japan. Endoscopically confirmed rRE patients (Los Angeles grade A-D) who had received a standard PPI regimen for at least 8 weeks were randomized in a double-blind manner into groups receiving RPZ at 20 and 10 mg b.i.d. or 20 mg q.d. (control) daily for up to 8 weeks. The primary efficacy endpoint was the rate of endoscopically confirmed healing after week 8. A total of 337 rRE patients treated at 71 sites were randomized. The rate of endoscopically confirmed healing after 8 weeks was significantly higher in those who received RPZ at 20 mg b.i.d. (77.0%, P = 0.003) and 10 mg b.i.d. (78.4%, P = 0.001) as compared with 20 mg q.d. (58.8%), and the rates of resolution of heartburn after week 8 were 80.0%, 74.0%, and 56.4%, respectively. All treatment regimens were well tolerated. Regimens of RPZ at 20 and 10 mg b.i.d. for 8 weeks were more effective than 20 mg q.d. with regard to endoscopically confirmed healing and symptom resolution of RE refractory to a standard PPI regimen.

Multiple vertebral fractures are associated with refractory reflux esophagitis in postmenopausal women

We examined the frequency of multiple vertebral fractures (MVFs) and esophageal hiatal hernia (HH) in 18 Japanese postmenopausal women (74.1 +/- 9.9 years, mean +/- SD), with refractory reflux esophagitis (RRE) that had needed a proton pump inhibitor for more than 6 months to suppress symptoms such as heartburn and acid regurgitation, as well as in 57 control subjects without RE (71.4 +/- 5.9 years). MVFs (two or more VFs), HH, and both features were found in 11 (61%), 16 (89%), and 11 (61%) subjects, respectively, in the RRE group. All 11 patients with MVFs also had HH, suggesting their strong association. On the other hand, MVFs, HH, and both were found in 15 (26%), 23 (40%), and 8 (14%) subjects, respectively, in those without RE. The differences in frequencies of MVFs, HH, and both between the two groups were significant (chi2 = 7.3, 12.9, and 16.0; P = 0.015, 0.0009, and 0.0002, respectively). When univariate logistic regression analysis was performed with the presence of RRE as a dependent variable and the presence of MVFs, HH, and both as independent variables, MVFs, HH, and both were selected as indices affecting the presence of RRE (age-adjusted odds ratios: 4.34, 11.07, and 10.30; 95% confidential intervals: 1.40-13.45, 2.30-53.22, and 2.96-35.86; P = 0.0109, 0.0027, and 0.0002, respectively). These results show that the presence of MVFs is associated with the presence of RRE in Japanese postmenopausal women, and this association becomes more significant when HH is present. Thus, a kyphotic lumbar spine with MVFs may cause HH and RE by raising the intraabdominal pressure. As recent therapeutic agents for osteoporosis, alendronate and risedronate, are known to be very effective for suppressing the occurrence of new VFs, these agents may also prevent gastrointestinal disorders such as HH and RRE in osteoporotic women when administered to subjects without VFs.

Successful healing of chronic and refractory reflux esophagitis with aciphex may represent the tangible clinical benefit of a continuous search for the best therapeutic regimen resulting in complete resolution of symptoms

Successful healing of chronic and refractory reflux esophagitis with aciphex may represent the tangible clinical benefit of a continuous search for the best therapeutic regimen resulting in complete resolution of symptoms

Successful healing of chronic and refractory reflux esophagitis with aciphex may represent the tangible clinical benefit of a continuous search for the best therapeutic regimen resulting in complete resolution of symptoms

Successful healing of chronic and refractory reflux esophagitis with aciphex may represent the tangible clinical benefit of a continuous search for the best therapeutic regimen resulting in complete resolution of symptoms

Long-term omeprazole treatment in resistant gastroesophageal reflux disease: Efficacy, safety, and influence on gastric mucosa

Background & Aims: The efficacy and safety of long-term acid suppression remains a subject for debate. We report data from patients with refractory reflux esophagitis who were undergoing maintenance therapy with ≥20 mg omeprazole daily for a mean period of 6.5 years (range, 1.4–11.2 years). Methods: Patients with severe reflux esophagitis resistant to long-term therapy with H 2-receptor antagonists and who were not eligible for surgery were evaluated at least annually for endoscopic relapse and histological changes in the gastric corpus. Results: In 230 patients (mean age, 63 years at entry; 36% were ≥70 years), there were 158 relapses of esophagitis during 1490 treatment years (1 per 9.4 years), with no significant difference in relapse rates between Helicobacter pylori–positive and –negative patients. All patients rehealed during continued therapy with omeprazole at the same or higher dose. The annual incidence of gastric corpus mucosal atrophy was 4.7% and 0.7% in H. pylori–positive and –negative patients, respectively, which was mainly observed in elderly patients who had moderate/severe gastritis at entry. In patients with baseline moderate/severe gastritis, the incidences were similar: 7.9% and 8.4%, respectively. Corpus intestinal metaplasia was rare, and no dysplasia or neoplasms were observed. The adverse event profile was as might be expected from this elderly group of patients. Conclusions: Long-term omeprazole therapy (up to 11 years) is highly effective and safe for control of reflux esophagitis. GASTROENTEROLOGY 2000;118:661-669

Helicobacter pylori infection, reflux esophagitis, and atrophic gastritis: an unexplored triangle.

H. pylori causes chronic gastritis, which may progress to peptic ulcer, gastric atrophy, or gastric cancer. However, little is known about the role of H. pylori infection in reflux esophagitis and the relationship between reflux esophagitis and atrophic gastritis needs to be clarified. We sought to identify the possible interrelationships among Helicobacter pylori infection, reflux esophagitis, and atrophic gastritis, to signal areas in which researchers should consider focusing their attention. A broad-based Medline search was performed to identify all related publications addressing H. pylori infection, atrophic gastritis, gastroesophageal reflux disease (GERD), secretion of gastric acid, and gastric motility published between 1966 and July 1997. Whereas some studies have shown no significant association between H. pylori infection and reflux esophagitis, others have observed that the prevalence of H. pylori infection was lower in patients with GERD, implying a protective role. Eradication of H. pylori leads to occurrence of reflux esophagitis in some cases, but the mechanisms inducing posteradication reflux esophagitis are unknown. H. pylori infection may lead to atrophic gastritis (and hence hypochlorhydia) through both bacterial and host factors, although gastric atrophy and subsequent intestinal metaplasia are hostile to H. pylori because of hypochlorhydria. Although it has been reported that long-term proton pump inhibitor therapy for refractory reflux esophagitis may induce or enhance the development of gastric atrophy in H. pylori-infected patients, this relationship has been disputed. H. pylori infection may be negatively associated with reflux esophagitis, but this requires confirmation. Research then needs to focus on whether this is explained through motility- or acid-related mechanisms. The potential costs of maintenance antireflux therapy may need to be taken into account when evaluating the cost effectiveness of anti-H. pylori therapy.

Effect of omeprazole in the treatment of refractory acid-related diseases in childhood: Endoscopic healing and twenty-four-hour intragastric acidity

OBJECTIVE: To determine the clinical efficacy of once-daily treatment with omeprazole in refractory acid-related diseases in children. METHODS: Endoscopic healing and 24-hour intragastric pH values were assessed in 13 patients with refractory reflux esophagitis (n = 5), refractory and/or giant duodenal ulcer (n = 6), or giant gastric ulcer (n = 2). The mean dose of omeprazole was 0.6 mg/kg per day (range, 0.3 to 0.7 mg/kg per day). Pharmacokinetic studies of omeprazole were performed in seven patients. RESULTS: The cumulative healing rates at 2, 4, 6, and 8 weeks of treatment were 46%, 85%, 92%, and 92%, respectively. Esophagitis in one patient did not heal despite increases in doses of up to 1.6 mg/kg per day (40 mg/day). The mean intragastric pH of omeprazole-treated patients was 5.2 (range, 3.0 to 6.6) and mean hydrogen ion activity was 1.78 mmol/L (range, 0.01 to 10.42 mmol/L). There was wide interindividual variation in the reduction of gastric acid production. Mean intragastric H + activity in omeprazole-treated patients was significantly lower than that of control subjects ( p <0.005) and that of patients treated with histamine type 2 (H 2)-receptor antagonists ( p <0.05). Mean intragastric H + activity was not significantly correlated to the area under the concentration-time curve of omeprazole. No severe adverse effects were reported during treatment or at follow-up. CONCLUSIONS: Omeprazole has a potent antisecretory effect and is a suitable alternative for short-term treatment of refractory acid-related diseases; a relatively low dose (0.6 mg/kg per day) appears to be optimal in most patients. Unhealed esophagitis at 8 weeks of treatment was considered to be refractory to omeprazole. (J P EDIATR1996;128:415-21)

Long-term treatment of erosive esophagitis with omeprazole: Does it work?: Klinkenberg-Knol EC, Festen HPM, Jansen JBMJ, Lamers CBHW, Nelis F, Snel P, Luckers A, Dekkers CPM, Havu N, Meuwissen SGM. (Department of Gastroenterology, Free University Hospital, Amsterdam; Groot Ziekengasthauis, Hertogenbosch; State University, Leiden; Sophia Hospital, Zwolle; Slotervaart Hospital, Amsterdam; Jacobus Hospital, Zwijndrecht; St. Ignatius Hospital, Breda; Catholic University, Nijmegan, The

Long-term treatment of erosive esophagitis with omeprazole: Does it work?: Klinkenberg-Knol EC, Festen HPM, Jansen JBMJ, Lamers CBHW, Nelis F, Snel P, Luckers A, Dekkers CPM, Havu N, Meuwissen SGM. (Department of Gastroenterology, Free University Hospital, Amsterdam; Groot Ziekengasthauis, Hertogenbosch; State University, Leiden; Sophia Hospital, Zwolle; Slotervaart Hospital, Amsterdam; Jacobus Hospital, Zwijndrecht; St. Ignatius Hospital, Breda; Catholic University, Nijmegan, The

Long-Term Treatment with Omeprazole for Refractory Reflux Esophagitis: Efficacy and Safety

To evaluate the long-term efficacy and safety of omeprazole in patients with gastroesophageal reflux disease resistant to treatment with histamine-2 (H2)-receptor antagonists. Cohort analytic study with a mean follow-up of 48 months (range, 36 to 64 months). Patients receiving ambulatory care from referral centers. 91 patients with gastroesophageal reflux disease resistant to treatment with an H2-receptor antagonist but subsequently responsive to 40 mg of omeprazole daily. Open maintenance therapy consisting of 20 mg of omeprazole daily in 86 patients and 40 mg daily in 5 patients. Endoscopy to assess healing; side effects, laboratory values, fasting serum gastrin level, and gastric corpus biopsies to assess safety. Esophagitis recurred in 47% of the patients receiving 20 mg of omeprazole daily, but all rehealed after the dose was doubled. Seven of 40 patients (18%) had a second relapse after a mean follow-up time of 24 months (range, 9 to 36 months) that was successfully treated with a further 20-mg dose increment for a mean period of 36 months (range, 6 to 39 months). Median gastrin levels increased initially from 60 ng/L before study entry to 162 ng/L (P < 0.01) with treatment and reached a plateau during maintenance treatment. Very high gastrin levels (> 500 ng/L) were observed in a subgroup (11%) of patients. The incidence of micronodular hyperplasia increased from 2.5% of the patients at first biopsy to 20% at the last biopsy (P = 0.001), with a corresponding progression of gastritis to subatrophic or atrophic gastritis from less than 1% to 25% (P < 0.001), which was more pronounced in patients with very high serum gastrin levels. Maintenance therapy with omeprazole was effective for at least 5 years in patients with gastroesophageal reflux disease resistant to treatment with H2-receptor antagonists. Treatment was accompanied by a persistent increase in serum gastrin levels and an increase of micronodular argyrophil cell hyperplasia and subatrophic or atrophic gastritis.

Omeprazole and high dose ranitidine in the treatment of refractory reflux oesophagitis.

Thirty two consecutive patients (age range 6 months-13.4 years) with severe reflux oesophagitis were randomised to a therapeutic trial for eight weeks during which they received either standard doses of omeprazole (40 mg/day/1.73 m2 surface area) or high doses of ranitidine (20 mg/kg/day). Twenty five patients completed the trial (12 on omeprazole, 13 on ranitidine). At entry and at the end of the trial patients underwent symptomatic score assessment, endoscopic and histological evaluation of the oesophagus, and simultaneous oesophageal and gastric pH measurement; results are given as median (range). Both therapeutic regimens were effective in decreasing clinical score (omeprazole before 24.0 (15-33), after 9.0 (0-18); ranitidine before 19.5 (12-33), after 9.0 (6-12)), in improving the histological degree of oesophagitis (omeprazole before 8.0 (6-10), after 2.0 (0-60); ranitidine before 8.0 (8-10), after 2.0 (2-6), and in reducing oesophageal acid exposure, measured as minutes of reflux at 24 hour pH monitoring (omeprazole before 129.4 (84-217), after 44.6 (0.16-128); ranitidine before 207.3 (66-306), after 58.4 (32-128)) as well as intragastric acidity, measured as median intragastric pH (omeprazole before 2.1 (1.0-3.0), after 5.1 (2.2-7.4); ranitidine before 1.9 (1.6-4), after 3.4 (2.3-5.3)). Serum gastrin concentration was > 150 ng/l in four patients on omeprazole and in three patients on ranitidine. It is concluded that in children with refractory reflux oesophagitis high doses of ranitidine are comparable with omeprazole for the healing of oesophagitis and relief of symptoms; both drugs resulted in efficacious reduction of intragastric acidity and intra-oesophageal acid exposure.

Severe Reflux Esophagitis After Vertical Banded Gastroplasty for Treatment of Morbid Obesity

Herein we describe two patients with medically refractory, severe reflux esophagitis after vertical banded gastroplasty for morbid obesity. Neither patient had symptoms of reflux preoperatively. Both patients underwent conversion to a vertical Roux-en-Y gastric bypass, an operation that prevents acid and peptic reflux and maintains a weight-reducing anatomy. Symptoms of gastroesophageal reflux are common (they occur in approximately 38% of patients) after vertical banded gastroplasty has been performed. Patients with unusually severe reflux may require operative management.

Antral &lt;i&gt;Helicobacter pylori-&lt;/i&gt;Like Organisms in Different States of Gastric Acid Secretion

The frequency of Helicobacter pylori (H.p.) infestation in antral mucosa and the presence of gastritis were investigated in different states of gastric acid secretion. Biopsies were stained by the Warthin-Starry technique and hematoxylin-eosin. Antral H.p. was found in similar frequencies in Zollinger-Ellison syndrome (n = 17; profound acid hypersecretion, associated with duodenal ulcer disease in most cases) and the same number of age-matched controls (35% in each group) whereas H.p. could be detected in 31 out of 33 duodenal ulcer patients (94%). The incidence of H.p. infestation in H2-blocker refractory reflux oesophagitis was low (24%). Treatment of peptic lesions with omeprazole (drug-induced hypochlorhydria) led to a reduction or disappearance of H.p. in 7 out of 10 H.p.-positive patients whereas none of 19 primarily H.p.-negative patients became infected with H.p. during prolonged omeprazole therapy. It is concluded that (1) development of duodenal ulcers (as in gastrinomas) does not necessarily require H.p., and (2) at least in some patients H.p. is reduced in antral mucosa by omeprazole.