Severe Heartburn Research Articles

Lower and Upper Gastrointestinal Symptoms Differ Between Individuals With Irritable Bowel Syndrome With Constipation or Chronic Idiopathic Constipation.

Background/AimsWe evaluated the distribution of lower and upper gastrointestinal (GI) symptoms among individuals with irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) in a nationwide survey.MethodsIndividuals (≥ 18 years of age) were identified from a nationwide sample of > 70 000 United States adults. Participants completed the National Institutes of Health GI Patient Reported Outcomes Measurement Information System (NIH GI-PROMIS) questionnaire. Symptom frequency and intensity in the prior 7 days were assessed using validated PROMIS scores. Odds ratios (OR) with 95% confidence intervals (CI) were calculated to compare symptom prevalence in IBS-C vs CIC, and one-way ANOVA was used to assess differences in PROMIS scores. Regression analysis was performed to adjust for demographic variables.ResultsNine hundred and seventy adults met eligibility criteria (275 with IBS-C, 734 with CIC). Demographics were similar among groups except for education, marital and employment status, and income. Adjusting for demographic differences, GI-PROMIS scores of global GI symptoms were higher in IBS-C (251.1; 95% CI, 230.0–273.1) compared to CIC (177.8; 95% CI 167.2–188.4) (P < 0.001). Abdominal pain was more prevalent (OR, 4.3; 95% CI, 2.9–6.6) and more severe (P = 0.007) in IBS-C. Constipation was more severe in IBS-C (P = 0.011). Incontinence was more common (OR, 2.9; 95% CI, 1.3–6.3) but just as severe (P = 0.389) in IBS-C versus CIC. Regarding upper GI symptoms, the prevalence of dysphagia, heartburn, and nausea were similar. However, IBS-C individuals had more severe heartburn (P = 0.001).ConclusionGI symptoms are generally more severe in IBS-C compared to CIC, however abdominal pain, bloating, and upper GI symptoms still commonly occur in CIC.

Prevalence and Predictors of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) might be associated with a new onset or worsening of gastroesophageal reflux disease (GERD). We aim to evaluate the prevalence of post-LSG GERD symptoms and its predictors. We included patients who underwent primary LSG at a university hospital from 2009 to 2015. We used the GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire and included questions regarding regurgitation to evaluate symptoms before and after LSG; each item was scored from 1 to 5 based on the symptom severity. A total of 213 patients (mean age, 36.08±10.22years; 48.36% were men) were included. The mean preoperative body mass index (BMI) was 47.84kg/m2, mean percent total weight loss was 37.99% (95% CI, 36.64 to 39.34), mean percent excess weight loss was 84.14% (95% CI, 80.91 to 87.36), and the mean percent excess BMI loss was 84.17% (95% CI, 80.94 to 87.41). The mean heartburn score while standing increased (0.71 vs. 1.09, p<0.01) as well as the score of heartburn requiring a diet change (0.67 vs. 1.16, p<0.01) post-LSG. The scores for dysphagia, odynophagia, and regurgitation increased. New-onset heartburn was reported in 47.06% of our cohort. Those with high preoperative BMIs were less likely to develop new-onset or worsening symptoms of GERD (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95-0.99). More severe heartburn symptoms while standing were associated with higher risks of developing or worsening GERD symptoms (OR, 1.22; 95% CI, 1.01-1.47). None of the other variables could predict the development or worsening of the GERD symptoms. Symptoms of heartburn and regurgitation are common after LSG; however, none of the variables preoperatively could strongly predict patients who would develop new onset or experience worsening of symptoms postoperatively.

Alginate antacid (Gaviscon DA) chewable tablets reduce esophageal acid exposure in Chinese patients with gastroesophageal reflux disease and heartburn symptoms.

To assess the efficacy of Gaviscon Double Action (DA) alginate antacid chewable tablets for reducing esophageal acid exposure in Chinese patients with gastroesophageal reflux disease (GERD). Altogether 44 patients reporting moderate to severe heartburn symptoms underwent two pH monitoring visits. The treatment sequence was randomized to patients received DA alginate antacid or placebo at one visit and the alternate treatment 7 days later. After a standardized reflux-provoking meal, patients took four tablets of DA alginate antacid or placebo. Esophageal pH was measured for 4 h post-dosing using an electrode positioned 5 cm above the lower esophageal sphincter. The primary end-point was the percentage of 4-h post-dosing period with pH <4. Secondary end-points were number of acid reflux episodes (pH <4), longest reflux time and DeMeester scores. All 44 patients completed the study and provided data for analysis. With DA alginate antacid, the mean percentage time with pH <4 was 5.1%, significantly less (P = 0.0003) than with placebo (14.8%). DA alginate antacid was statistically significantly superior (P = 0.0290) to placebo (from at least twofold to threefold better) for all other end-points. Two patients reported two mild adverse events (AEs) that resolved within a month of completing the study. No patients had serious and/or severe AEs and none withdrew due to AEs. DA alginate antacid was statistically significantly superior to placebo in reducing post-prandial acid exposure without serious clinically relevant health risks. These findings suggest DA alginate antacid tablets are appropriate for treating acid reflux in Chinese GERD patients with heartburn symptoms.

Issue Highlights

Issue Highlights

World Gastroenterology Organisation Global Guidelines: GERD Global Perspective on Gastroesophageal Reflux Disease.

PROBIOTICS—THE CONCEPTHistory and DefinitionsA century ago, Elie Metchnikoff (a Russian scientist, Nobel laureate, and professor at the Pasteur Institute in Paris) postulated that lactic acid bacteria (LAB) offered health benefits capable of promoting longevity. He suggested that “intestinal autoint

Exfoliative Ösophagitis unter Dabigatran

History | A 77-year-old woman was admitted with severe chest pain, heartburn, dysphagia and odynophagia. She had been on dabigatran for 13 months due to atrial fibrillation and arterial hypertension. Investigations and findings | Endoscopy of the esophagus revealed sloughing of mucosal casts, predominantly in the upper half of the organ. Treatment and course | The patient was placed on pantoprazol, local anaesthetic antacid and i. v. fluids. Dabigatran was discontinued. The symptoms disappeared within 3 days. Control endoscopy after 12 days showed complete healing of the esophageal mucosa. Conclusion | The intake of dabigatran was associated with exfoliative esophagitis, possibly due to caustic tissue damage by prolonged drug contact.

A case of gastroesophageal anisakiasis complicated with mediastinitis

Esophageal anisakiasis is a rare disease, accounting for about 0.2% of all cases of anisakiasis. A 26-year-old woman visited our hospital because of severe epigastric pain and heart burn several hours after eating pickled mackerel, which progressively worsened, and subsequently presented with fever. Contrast CT showed marked hypertrophy of the gastric wall and a significant edematous change in the lower esophagus, in addition to inflammation of the mediastinum. Upper gastrointestinal endoscopy revealed an Anisakis worm in the gastric corpus and lower esophagus. After removing it by endoscopy, her condition immediately improved. The present patient was complicated with mediastinitis. It was suggested that anisakiasis can become severe in an esophagus with a thin wall, as can be the case with the small intestine, where the worm may burrow in some cases. As in this case, we can achieve the marked amelioration of anisakiasis through the removal of worms. Thus we should perform endoscopy in the early stage. In addition, since some patients may ingest several worms of Anisakis, we should carefully check whether or not worms burrow in sites other than the stomach, where worms have already been identified.

Laparoscopic Floppy Nissen Fundoplication

There are few published reports on the outcomes of ≥ 10 years after a laparoscopic floppy Nissen fundoplication (LFNF). From April 1994 to January 2012, 567 patients underwent LFNF and the outcomes of 211 cases were determined (from April 1994 to October 2000). Outcomes at ≥ 11 years after surgery was available for 178 patients (84.3%) of which 167 (93.8%) had no heartburn or mild heartburn, 8 (4.5%) had moderate heartburn, and 3 had (1.7%) severe heartburn. Dysphagia was nonexistent or mild in 153 (85.9%), whereas the remaining 14.1% presented moderate to severe symptoms. Reports of 69.1% patients showed none or mild symptoms of abdominal bloating, that of 23% patients showed moderate discomfort, and reports of 7.8% showed severe bloating. Satisfaction score was 8.6 (of 10). A further surgical procedure was required for 7 patients (3.9%): 4 for recurrent reflux and 3 for dysphagia (2 for a tight wrap and 1 for a tight esophageal hiatus). Postoperative dysphagia sufficient for an endoscopic dilatation was observed in 4 patients (2.3%), where 3 were successfully managed with a single dilatation procedure and the last patient underwent several dilatations before adequate swallowing. LFNF is an effective long-term treatment for gastroesophageal reflux disease, yielding similar results to open fundoplication.

Barrett's esophagus and the risk of obstructive sleep apnea: a case-control study.

BackgroundPrior studies suggest that obstructive sleep apnea may be associated with gastroesophageal reflux disease, a strong risk factor for Barrett’s esophagus. The goals of this pilot case–control study were to determine whether Barrett’s esophagus patients have an increased likelihood of obstructive sleep apnea and to determine whether nocturnal gastroesophageal reflux symptoms affect the relationship between Barrett’s esophagus and obstructive sleep apnea risk.MethodsPatients with Barrett’s esophagus completed the Berlin Questionnaire, a validated survey instrument identifying subjects at high risk for obstructive sleep apnea. Two outpatient control groups were recruited: 1) EGD Group, subjects matched to Barrett’s esophagus cases by age, race, and gender with esophagogastroduodenoscopy negative for Barrett’s esophagus; and 2) Colonoscopy Group, patients getting colonoscopy. Rates of scoring at high risk for obstructive sleep apnea were compared. Respondents were also questioned regarding severity of their typical gastroesophageal reflux symptoms and presence of nocturnal gastroesophageal reflux symptoms.ResultsThe study included 287 patients (54 Barrett’s esophagus, 62 EGD, and 171 colonoscopy subjects). Barrett’s esophagus patients were slightly older than colonoscopy patients and more obese. 56% (n = 30) of Barrett’s esophagus subjects scored at high risk for obstructive sleep apnea, compared with 42% (n = 26) of EGD subjects (OR 1.73, 95% CI [0.83, 3.62]) and 37% (n = 64) of colonoscopy patients (OR 2.08, 95% CI [1.12, 3.88]). The association between Barrett’s esophagus and scoring at high risk for obstructive sleep apnea compared with colonoscopy patients disappeared after adjusting for age. Barrett’s esophagus patients reported more severe typical heartburn and regurgitation symptoms than either control group. Among all subjects, patients with nocturnal reflux symptoms were more likely to score at high risk for obstructive sleep apnea than patients without nocturnal reflux.ConclusionsIn this pilot study, a high proportion of Barrett’s esophagus subjects scored at high risk for obstructive sleep apnea. Having Barrett’s esophagus was associated with more severe gastroesophageal reflux symptoms, and nocturnal reflux symptoms were associated with scoring at high risk for obstructive sleep apnea. The need for obstructive sleep apnea screening in Barrett’s esophagus patients with nocturnal gastroesophageal reflux symptoms should be further evaluated.

Quality of life following laparoscopic Nissen fundoplication: Assessing short-term and long-term outcomes

To investigate the quality of life following laparoscopic Nissen fundoplication by assessing short-term and long-term outcomes. From 1992 to 2005, 249 patients underwent laparoscopic Nissen fundoplication. Short-term outcome data including symptom response, side effects of surgery, endoscopy, and patient's perception of overall success were collected prospectively. Long-term outcomes were investigated retrospectively in patients with a median follow-up of 10 years by assessment of reflux symptoms, side effects of surgery, durability of antireflux surgery, need for additional treatment, patient's perception of success, and quality of life. Antireflux surgery was considered a failure based on the following criteria: moderate to severe heartburn or regurgitation; moderate to severe dysphagia reported in combination with heartburn or regurgitation; regular proton pump inhibitor medication use; endoscopic evidence of erosive esophagitis Savary-Miller grade 1-4; pathological 24-h pH monitoring; or necessity to undergo an additional surgery. The main outcome measures were short- and long-term cure rates and quality of life, with patient satisfaction as a secondary outcome measure. Conversion from laparoscopy to open surgery was necessary in 2.4% of patients. Mortality was zero and the 30-d morbidity was 7.6% (95%CI: 4.7%-11.7%). The median postoperative hospital stay was 2 d [interquartile range (IQR) 2-3 d]. Two hundred and forty-seven patients were interviewed for short-term analysis following endoscopy. Gastroesophageal reflux disease was cured in 98.4% (95%CI: 95.9%-99.6%) of patients three months after surgery. New-onset dysphagia was encountered postoperatively in 13 patients (6.7%); 95% reported that the outcome was better after antireflux surgery than with preoperative medical treatment. One hundred and thirty-nine patients with a median follow-up of 10.2 years (IQR 7.2-11.6 years) were available for a long-term evaluation. Cumulative long-term cure rates were 87.7% (81.0%-92.2%) at 5 years and 72.9% (64.0%-79.9%) at 10 years. Gastrointestinal symptom rating scores and RAND-36 quality of life scores of patients with treatment success were similar to those of the general population but significantly lower in those with failed antireflux surgery. Of the patients available for long-term follow-up, 83% rated their operation a success. For the long-term, our results indicate decreasing effectiveness of laparoscopic antireflux surgery, although most of the patients seem to have an overall quality of life similar to that of the general population.

A Rare Case of Small Bowel Angioedema with Normal C4 Level

Introduction: Angioedema is self-limited, localized subcutaneous (or submucosal) swelling, which results from extravagation of fluid into interstitial tissues. Angioedema may occur in isolation, accompanied by urticaria, or as a component of anaphylaxis. We describe a case of isolated angioedema of the bowel, a rare presentation, occurring in a man with normal C4 and C1q level. Case Description: A 23-year-old male with H/O no medical problems was admitted to our hospital for nausea, vomiting and abdominal pain for one day duration. He ate a large omelet for breakfast and few hours later developed urticaria, nausea and severe heartburn. He went to the nearest ER, where he was discharged on Benadryl and proton pump inhibitors. In the evening his symptoms progressed and nausea/vomiting worsened. He also had a colicky abdominal pain and diarrhea. The recent allergic triggers like tattoos, soaps, new foods, parenteral injections, detergents, medications like angiotensin-converting enzyme inhibitors, could not be identified. Family history was significant for allergic reaction in his father that caused him to break out in hives. Examination shows multiple urticarial lesions on both arms and shoulders. Lips are swollen and abdomen is soft with epigastric tenderness. CT scan of abdomen shows mild enteritis with mildly distended small bowel. Patient did not improve to initial conservative treatment consisting of nasogastric tube and antiemetics, but improved markedly with the steroid treatment. The patient work up including C4 level; C1 inhibitor antigenic level; C1q level was negative. Discussion: Angioedema affecting the bowel wall presents as colicky abdominal pain, sometimes accompanied by nausea, vomiting and/or diarrhea. Bowel wall edema can often be visualized by abdominal CT. It is seen in patients on ACE inhibitors and in those with hereditary or acquired C1 inhibitor deficiency. The particular case was unique because of normal C4 and C1 inhibitor antigenic level. The patient improved on antihistamines and steroids. High degree of suspicion for bowel wall angioedema is needed in a patient presenting with urticaria, severe nausea and vomiting, who is not improving with conservative treatment.

A Prospective Multicenter Registry of Patients with Chronic Gastroesophageal Reflux Disease Receiving Transoral Incisionless Fundoplication

This study was undertaken to validate previously reported safety and symptomatic outcomes of transoral incisionless fundoplication (TIF), evaluate the relative benefit of TIF within different gastroesophageal reflux disease (GERD) subgroups, and to determine predictors of success in community settings. Between January 2010 and February 2011, 100 consecutive patients who underwent TIF procedures at 10 centers were enrolled in this prospective, open-label, multicenter, single-arm study. Symptom improvement and objective outcomes of TIF were analyzed at 6-month follow-up. One hundred TIF procedures were performed. No complications were reported. Median GERD symptom duration was 9 years (range 1 to 35 years) and median duration of proton pump inhibitor (PPI) use was 7 years (1 to 20 years). Maximal medical therapy resulted in incomplete symptom control for 92% of patients; GERD Health-Related Quality of Life (GERD-HRQL) total score was normalized in 73%. Median heartburn and regurgitation scores improved significantly, from 18 (range 0 to 30) and 15 (range 0 to 30) on PPIs before TIF to 3 (range 0 to 25) and 0 (range 0 to 25), respectively; p < 0.001. Median Reflux Symptom Index scores were reduced after TIF from 24 (range 14 to 41) to 7 (range 0 to 44); p < 0.001. Eighty percent of patients were completely off PPIs after TIF vs 92% of patients on PPIs before TIF. Preoperative factors associated with clinical outcomes were less severe heartburn (total GERD-HRQL ≤ 30, p = 0.02) and the presence of esophagitis (p < 0.02). Transoral incisionless fundoplication is safe and effective in multiple community-based settings in the treatment of medically refractory GERD, as demonstrated by an absence of complications, excellent symptom relief, and complete cessation of PPIs at 6-month follow-up.

Symptoms and esophageal motility based on phenotypic findings of scleroderma

Scleroderma esophagus is characterized by ineffective peristalsis and reduced esophageal sphincter pressure. Esophageal disease in scleroderma can precede cutaneous manifestations and has been associated with Raynaud's phenomenon (RP) and pulmonary fibrosis (PF). The objective of the study is to evaluate the impact of cutaneous findings, RP, and PF on demographics, symptoms, and esophageal motility in patients with scleroderma. Scleroderma patients with esophageal involvement were included after review of esophageal manometries and charts over a 6-year period. High-resolution esophageal manometry was performed. Patients completed a symptom questionnaire. The study enrolled 28 patients (22 females; mean age 50.3 ± 12.8 years) with scleroderma esophagus. Patients without skin involvement (n= 12) reported more severe heartburn (P= 0.02), while those with cutaneous findings (n= 16) had more frequent dysphagia with solids (P= 0.02). Patients with RP (n= 22) had lower amplitude of distal esophageal contractions (P= 0.01) than those without RP (n= 6). Patients with PF (n= 11) reported more severe coughing and wheezing (both P= 0.03) than those without lung disease (n= 17). This study highlights subgroups of patients with scleroderma esophagus according to phenotypic findings of dermatologic changes, RP, and PF. Heartburn and dysphagia are important symptoms that may be associated with different stages of disease progression based on skin changes in scleroderma. RP was associated with greater esophageal dysmotility. Coughing and wheezing were more severe in patients with PF.

Three-dimensional endoscopic optical coherence tomography imaging of cervical inlet patch

A 30-year-old white man with established Barrett's esophagus (BE) and continued symptoms of chronic severe heartburn, persistent cough, throat irritation, and asthma was referred for surveillance EGD at the VA Boston Healthcare System. During retraction of the endoscope, a pink circular lesion (A) was observed under white light endoscopy in the upper esophagus (spanning 20-22 cm from the incisors). Three-dimensional endoscopic optical coherence tomography (OCT) images were obtained of the region under direct visualization with white light by passing the probe through the standard accessory channel.

Fully covered removable nitinol self-expandable metal stents (SEMS) in malignant strictures of the esophagus: a multicenter analysis

Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia. 37 patients underwent placement of a SEMS during a 3 year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures. SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain (n = 6), severe heartburn (n = 1), and upper gastrointestinal bleeding requiring SEMS revision (n = 1). Dysphagia scores improved significantly from 3.2 ± 0.4 before stent placement to 1.4 ± 1.0 at 1 month (P < 0.0001), 1.1 ± 1.2 (P < 0.0001) at 3 months, and 1.3 ± 1.4 (P = 0.0018) at 6 months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture (n = 3), stent malfunction (n = 5), and stent migration (n = 3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3 ± 143.6 (range, 13-680) days. Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required.

Risk Factors for Nocturnal Reflux in a Large GERD Cohort

Nocturnal gastroesophageal reflux disease (GERD) has been associated with severe complications including erosive esophagitis, peptic stricture, and even esophageal adenocarcinoma and is known to cause a decreased health-related quality of life. However, there is limited information on independent predictors of nocturnal GERD. The aim of this study was to examine the relationship between nocturnal GERD and patient demographics, symptoms, clinical and endoscopic findings. Consecutive patients presenting to the gastrointestinal endoscopy unit for evaluation of GERD symptoms undergoing index endoscopy were asked to complete a validated GERD questionnaire. Demographics, clinical features, and endoscopic findings were recorded. Nocturnal GERD was defined as awakening at night by heartburn or acid regurgitation. Patient factors were compared using χ and Mann-Whitney U test. All factors that were statistically significant (P<0.05) were entered into a stepwise logistic regression to evaluate for independent predictors of nocturnal GERD. Of 908 GERD patients evaluated, 665 (73.2%) reported nocturnal symptoms. The majority of the patients were male (93%) and White (83%) with a mean age of 57.2 years (SD 12.7). On univariate analysis, younger age, higher body mass index, daily heartburn, heartburn duration of >5 years, severe heartburn, daily regurgitation, regurgitation duration >5 years (all P<0.05), and presence of hiatal hernia (P=0.02) were significantly associated with the presence of nocturnal GERD. On multivariate analysis, severe heartburn [3.3 (2.1 to 5.1), P<0.01] and daily heartburn [1.5(1.1 to 2.3), P=0.03], daily regurgitation [2.2 (1.1 to 4.2), P=0.025], and regurgitation duration of >5 years [1.7 (1.2 to 2.4), P<0.01], and presence of hiatal hernia [1.4 (1.1 to 2.0), P=0.03] were all independent risk factors for nocturnal GERD. Results of this large prospective cohort study of GERD patients suggest that nocturnal symptoms are reported by 3 quarters of patients. Patients with frequent and severe daytime symptoms are significantly more likely to experience nocturnal symptoms. There was no significant difference in the prevalence of Barrett esophagus between patients with and without nocturnal GERD. Finally, presence of a hiatus hernia on endoscopy is also an independent risk factor for nocturnal GERD.

Predictors of Long-term Outcome After Laparoscopic Esophagomyotomy and Dor Fundoplication for Achalasia

To identify predictors of long-term outcome of laparoscopic Heller myotomy for achalasia, including predictors of heartburn and recurrent dysphagia, which occasionally develop postoperatively. Retrospective review using interviews of patients. Academic university hospital. One hundred sixty-five patients with achalasia who underwent a laparoscopic esophagomyotomy and Dor fundoplication. Dysphagia and heartburn before and after the operation were assessed on a 4-point Likert scale, as were postoperative dilations, reoperations, and antacid use. Potential predictors were age, race, sex, body mass index, weight loss, duration of symptoms, manometry findings, esophageal diameter, previous treatment, and operative technique. Follow-up averaged 62 (range, 1-174) months. Dysphagia frequency was once a week or less in 128 patients (78%), several times per week in 25 (15%), and daily in 12 (7%). Satisfaction scores averaged 3.7 on a 4-point scale. Thirty patients (18%) required a postoperative dilation, and 6 (4%) underwent another operation. The only predictor of postoperative dysphagia was duration of symptoms longer than 10 years (odds ratio, 0.2; P = .03). Preoperative dilations predicted the need for postoperative dilations (odds ratio, 2.4; P = .03). Only 20 patients (12%) reported heartburn more than once weekly, although 75 (45%) reported taking antacids. No variable predicted postoperative heartburn or antacid use. Long-term outcomes after laparoscopic esophagomyotomy were excellent across a wide spectrum of disease severity and presentations. Previous treatments, such as balloon dilation or botulinum toxin (Botox) injection, did not portend worse outcomes. When the myotomy was extended 2 cm onto the stomach and a Dor fundoplication was performed, severe heartburn was rare.

Prevalence of and impact of pantoprazole on nocturnal heartburn and associated sleep complaints in patients with erosive esophagitis

Studies in the United States have revealed that gastroesophageal reflux disease (GERD) patients often suffer from nocturnal symptoms, sleep disturbance, and impaired quality of life. In a large subset of patients, these symptoms persist in spite of acid suppressive therapy. The aim of the present study was to assess the prevalence of heartburn and associated sleep complaints and the response to standard medical therapy with pantoprazole in primary and secondary care esophagitis patients in Belgium. Questionnaires were provided to consecutive patients presenting to primary and secondary care physicians with esophagitis. The questionnaire evaluated the presence of typical reflux symptoms, alarm symptoms, risk factors, and sleep quality impairment as a result of reflux episodes. Results are shown as mean ± standard deviation and compared by Student's t-test or chi-square test. A total of 4061 primary and 5261 secondary care patients (50% female, mean age 53 ± 0.2 years, body mass index of 25.7 ± 0.1 kg/m(2) ) were recruited. Eighty-four percent of patients reported sleep disturbance attributable to nighttime reflux, including typical nighttime supine reflux symptoms (72%), difficulties to fall asleep (39%), waking up during the night (45%), morning fatigue (35%), and reflux symptoms when waking up in the morning (47%). Mild, moderate, or severe nighttime heartburn were reported by, respectively, 30, 35, and 12%, and these numbers were 26, 28, and 6% for nighttime regurgitation. Alcohol (19%), smoking (22%), higher esophagitis grades (grades 2, 3, and 4 in, respectively, 31, 7, and, 7%), alarm symptoms (27%), and more severe heartburn and regurgitation during daytime were all significantly associated with all dimensions of sleep disturbance (P < 0.0001). Obesity was only related to symptoms in supine position and when waking up (P < 0.0001). After 1.4 ± 0.0 months of treatment with pantoprazole, any sleep disturbance had improved in more than 75% of patients, with resolution of nighttime heartburn and regurgitation in, respectively, 75 and 83%. The majority of patients presenting with reflux symptoms and esophagitis in primary or secondary care experience nighttime heartburn and regurgitation, and sleep disturbance by nighttime symptoms is present in 84%. Smoking, alcohol use, higher grades of esophagitis, more severe typical reflux symptoms during daytime, and the presence of alarm symptoms are risk factors for GERD-related sleep disturbance. On standard therapy with pantoprazole, nighttime symptoms improved in more than 75%. These observations support a direct relationship between GERD and sleep disturbance.

The Effect of Dexlansoprazole MR on Nocturnal Heartburn and GERD-Related Sleep Disturbances in Patients With Symptomatic GERD

Nocturnal heartburn and related sleep disturbances are common among patients with gastroesophageal reflux disease (GERD). This study evaluated the efficacy of dexlansoprazole MR 30 mg in relieving nocturnal heartburn and GERD-related sleep disturbances, improving work productivity, and decreasing nocturnal symptom severity in patients with symptomatic GERD. Patients (N=305) with frequent, moderate-to-very severe nocturnal heartburn and associated sleep disturbances were randomized 1:1 in a double-blind fashion to receive dexlansoprazole MR or placebo once daily for 4 weeks. The primary end point was the percentage of nights without heartburn. Secondary end points were the percentage of patients with relief of nocturnal heartburn and of GERD-related sleep disturbances over the last 7 days of treatment. At baseline and week 4/final visit, patients completed questionnaires that assessed sleep quality, work productivity, and the severity and impact of nocturnal GERD symptoms. Dexlansoprazole MR 30 mg (n=152) was superior to placebo (n=153) in median percentage of nights without heartburn (73.1 vs. 35.7%, respectively; P<0.001). Dexlansoprazole MR was significantly better than placebo in percentage of patients with relief of nocturnal heartburn and GERD-related sleep disturbances (47.5 vs. 19.6%, 69.7 vs. 47.9%, respectively; P<0.001), and led to significantly greater improvements in sleep quality and work productivity and decreased nocturnal symptom severity. Adverse events were similar across treatment groups. In patients with symptomatic GERD, dexlansoprazole MR 30 mg is significantly more efficacious than placebo in providing relief from nocturnal heartburn, in reducing GERD-related sleep disturbances and the consequent impairments in work productivity, and in improving sleep quality/quality of life.

Giant Gastric Lipoma Presenting with Dyspepsia

Purpose: A 61-year-old Hispanic female presented with severe heartburn and bloating. She had been taking Nexium 40 mg daily with minimal relief. She denied abdominal pain, dysphagia, vomiting or weight loss. Upper endoscopy revealed a 10 cm smooth, yellowish, extra-mucosal semi-pedunculated mass in the body of the stomach. The esophagus and duodenum were normal. Endoscopic ultrasound revealed a uniformly hyperechoic submucosal mass in the stomach, consistent with a lipoma. Mucosal biopsies and FNA were negative for malignancy. In view of the patient's persistent symptoms, she underwent a hand assisted laparoscopic wedge resection of the stomach. A smooth, soft, yellowish mass in the body of the stomach near the greater curvature was removed. Pathology confirmed the mass to be a lipoma. Discussion: Gastric lipomas are an extremely rare cause of dyspepsia. Lipomas are the most common benign mesenchymal tumor. Lipomas may develop in all organs throughout the body. In the gut, lipomas present as submucosal fatty tumors. The most common locations include the esophagus, stomach, and small intestine. Symptoms may occur from luminal obstruction or bleeding. Microscopically, gastric lipomas consist of well-differentiated adipose tissue surrounded by a fibrous capsule. Giant gastric lipomas are not clearly defined in the literature, and the largest reported was up to 12 cm. We recommend use of the term GIANT for lipomas greater than 10 cm. Gastric lipomas >2 cm in size can be symptomatic. Hemorrhage, abdominal pain, obstruction, and dyspepsia represent the most common symptoms associated with gastric lipomas, although the vast majority are asymptomatic and discovered incidentally. Surgical resection remains the treatment of choice for symptomatic lipomas. Endoscopically, gastric lipomas typically appear as smooth submucosal masses with a yellowish hue. Since the lipoma is submucosal, standard mucosal biopsies typically are inadequate to establish a histologic diagnosis. Clues such as “tenting”, “cushion or pillow sign” help identify the lesion. Our case is unusual not only due to the size of the lipoma, but demonstrated that a lipoma can mimic dyspepsia in its clinical setting.Figure