Gastroesophageal Reflux Disease Symptoms In Patients Research Articles

Are Rice and Spicy Diet Good for Functional Gastrointestinal Disorders?

Rice- and chili-containing foods are common in Asia. Studies suggest that rice is completely absorbed in the small bowel, produces little intestinal gas and has a low allergenicity. Several clinical studies have demonstrated that rice-based meals are well tolerated and may improve gastrointestinal symptoms in functional gastrointestinal disorders (FGID). Chili is a spicy ingredient commonly use throughout Asia. The active component of chili is capsaicin. Capsaicin can mediate a painful, burning sensation in the human gut via the transient receptor potential vanilloid-1 (TRPV1). Recently, the TRPV1 expressing sensory fibers have been reported to increase in the gastrointestinal tract of patients with FGID and visceral hypersensitivity. Acute exposure to capsaicin or chili can aggravate abdominal pain and burning in dyspepsia and IBS patients. Whereas, chronic ingestion of natural capsaicin agonist or chili has been shown to decrease dyspeptic and gastroesophageal reflux disease (GERD) symptoms. The high prevalence of spicy food in Asia may modify gastrointestinal burning symptoms in patients with FGID. Studies in Asia demonstrated a low prevalence of heartburn symptoms in GERD patients in several Asian countries. In conclusion rice is well tolerated and should be advocated as the carbohydrate source of choice for patients with FGID. Although, acute chili ingestion can aggravate abdominal pain and burning symptoms in FGID, chronic ingestion of chili was found to improve functional dyspepsia and GERD symptoms in small randomized, controlled studies.

Retrospective evaluation of patients of gastroesophageal reflux disease treated with laparoscopic Nissen′s fundoplication

AIMS:To evaluate retrospectively the outcome of laparoscopic fundoplication in a cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD).MATERIALS AND METHODS:Forty-two patients with typical symptoms of GERD, who were operated for laparoscopic Nissen's fundoplication from March 2001 to August 2008, were studied. The study was limited to patients with positive findings on upper gastrointestinal (GI) endoscopy done by us and "typical" symptoms (heartburn, regurgitation, and dysphagia) of GERD. Laparoscopic Nissen's fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only one patient who had negative endoscopic findings underwent a 24-h pH monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient's evaluation of outcome, and quality of life after surgery.RESULTS:Relief of the primary symptom responsible for surgery was achieved in 95.24% of patients at a mean follow-up of 28 months. Thirty-five patients were asymptomatic, two had minor gastrointestinal symptoms not requiring medical therapy, three patients had gastrointestinal symptoms requiring medical therapy/Proton Pump Inhibitors (PPI) and in two patients the symptoms worsened after surgery. There were no deaths. Clinically significant complications occurred in six patients. Median hospital stay was 3 days, decreasing from 6 days in the first 10 patients to 3 days in the last 10 patients.CONCLUSIONS:Laparoscopic Nissen's fundoplication is the choice of operation for clinically symptomatic GERD patients.

Clinical Analysis of Recurrence Rate and Symptom Improvement in Gastro-esophageal Reflux Disease Patients

Gastro-esophageal reflux disease (GERD) is a chronic condition, with 50-80% of patients experiencing recurrence within one year following completion of initial treatment. The present study aimed to estimate recurrence rate and treatment response in GERD patients treated with proton pump inhibitor. A total of 207 symptomatic GERD patients, which were confirmed by endoscopy from July 2008 till January 2009, were enrolled. They were divided into non-erosive reflux disease (NERD) group and erosive reflux disease (ERD) group by endoscopic findings. Patients were treated with lansoprazole 15 mg (NERD group) or 30 mg (ERD group) once daily for 8 weeks. The presence of symptoms was assessed in each patient at baseline and post-treatment using a questionnaire. Subsequent symptomatic recurrence on the cessation of therapy in each improved patients was checked by telephone survey or outpatient interview. Ninety-four patients and 113 patients were first diagnosed with NERD and ERD, respectively. The mean post-treatment follow-up period was 24.4+/-8.5 weeks. Recurrence rate was 40.0% (NERD, 43.8%; ERD, 37.1% (p=0.224)). Recurrence time was 10.1+/-5.8 weeks (NERD 9.6 weeks; ERD, 10.6 weeks (p=0.444)). Regarding the symptom improvement after 8 week therapy with lansoprazole, 89.4% (NERD, 85.1%; ERD, 92.9% (p=0.056)) of total patients were symptomatically improved. Forty percentage of GERD patients recurred within 6 months following the completion of 8 week therapy with lansoprazole. Recurrence rate, recurrence time, and rate of symptom improvement were not significantly different between NERD group treated with half dose and ERD group treated with full dose lansoprazole.

Increased Duodeno-Gastro-Esophageal Reflux (DGER) in Symptomatic GERD Patients with a History of Cholecystectomy

Duodenal-Gastro-Esophageal Reflux (DGER) represents an independent risk factor for the development of complicated Gastro-esophageal-reflux-disease (GERD) and Barrett's esophagus. Clinical and epidemiological data suggest a potential association between cholecystectomy (CCE) and augmented bile reflux. 132 patients (67 women, 65 men, median age 55) with typical symptoms of GERD were enrolled in the study and divided in cholecystectomized (CCE-group: n = 107) and non- cholecystectomized (nCCE-group: n = 25) patients. Standardized clinical work-up of patients included combined esophageal 24 h pH-measurement and Bilitec 2000 esophageal manometry and upper endoscopy. In the statistical analysis no differences between the cholecystectomized group (CCE-group, n = 25) and the patients without cholecystectomy (nCCE-group, n = 107) could be observed in quantity or quality of reflux symptoms. Furthermore, neither acid reflux nor severity of inflammation and frequency of Barrett's esophagus significantly differed between the nCCE and CCE-group. However, the percentage of patients with pathological DGER were significantly higher in the CCE-group as compared to the nCCE-group (76 vs. 55 %, p < 0.01). Moreover, the CCE-group revealed significant higher levels of pathological DGER compared to the nCCE-group (15.5 % +/- 14.1 vs. 8.6 % +/- 15.4; p < 0.05). To conclude, our data provide first evidence of elevated DGER after CCE in patients with typical clinical symptoms of GERD using the Bilitec device. Both the frequency and the extent of DGER was significantly increased in the CCE-group. Prospective studies are urgently needed to elucidate the impact of CCE on DGER in patients with clinical symptoms of a reflux disease.

Editor's Summary and Q&A: Gastroesophageal reflux symptoms in adults with skeletal Class III malocclusion examined by questionnaires

Introduction Patients with masticatory dysfunction have a higher incidence of gastrointestinal disorders including gastroesophageal reflux disease (GERD). Masticatory function is significantly lower in patients with skeletal Class III malocclusion than in those with normal occlusion. However, GERD symptoms in patients with skeletal Class III malocclusion are still unknown. The purpose of this study was to examine GERD symptoms and masticatory functions in patients with skeletal Class III malocclusion. Methods Nineteen adult patients with severe skeletal Class III malocclusion (Class III group) and 20 adults with normal occlusion (control group) participated in this study. The results of the Carlsson-Dent self-administered questionnaire (QUEST) and the frequency scale for the symptoms of GERD (FSSG) were compared between the 2 groups, along with occlusal contact area, maximal voluntary bite force, and salivary flow rate. Results The QUEST and FSSG scores were significantly higher in the Class III group. Occlusal contact area and maximal voluntary bite force were significantly smaller in the Class III group. There was no significant difference in the salivary flow rates between the groups. Conclusions GERD symptoms were observed more often in patients with skeletal Class III malocclusion than in normal subjects as determined by the questionnaires. Patients with masticatory dysfunction have a higher incidence of gastrointestinal disorders including gastroesophageal reflux disease (GERD). Masticatory function is significantly lower in patients with skeletal Class III malocclusion than in those with normal occlusion. However, GERD symptoms in patients with skeletal Class III malocclusion are still unknown. The purpose of this study was to examine GERD symptoms and masticatory functions in patients with skeletal Class III malocclusion. Nineteen adult patients with severe skeletal Class III malocclusion (Class III group) and 20 adults with normal occlusion (control group) participated in this study. The results of the Carlsson-Dent self-administered questionnaire (QUEST) and the frequency scale for the symptoms of GERD (FSSG) were compared between the 2 groups, along with occlusal contact area, maximal voluntary bite force, and salivary flow rate. The QUEST and FSSG scores were significantly higher in the Class III group. Occlusal contact area and maximal voluntary bite force were significantly smaller in the Class III group. There was no significant difference in the salivary flow rates between the groups. GERD symptoms were observed more often in patients with skeletal Class III malocclusion than in normal subjects as determined by the questionnaires.

Gastroesophageal reflux symptoms in adults with skeletal Class III malocclusion examined by questionnaires

Patients with masticatory dysfunction have a higher incidence of gastrointestinal disorders including gastroesophageal reflux disease (GERD). Masticatory function is significantly lower in patients with skeletal Class III malocclusion than in those with normal occlusion. However, GERD symptoms in patients with skeletal Class III malocclusion are still unknown. The purpose of this study was to examine GERD symptoms and masticatory functions in patients with skeletal Class III malocclusion. Nineteen adult patients with severe skeletal Class III malocclusion (Class III group) and 20 adults with normal occlusion (control group) participated in this study. The results of the Carlsson-Dent self-administered questionnaire (QUEST) and the frequency scale for the symptoms of GERD (FSSG) were compared between the 2 groups, along with occlusal contact area, maximal voluntary bite force, and salivary flow rate. The QUEST and FSSG scores were significantly higher in the Class III group. Occlusal contact area and maximal voluntary bite force were significantly smaller in the Class III group. There was no significant difference in the salivary flow rates between the groups. GERD symptoms were observed more often in patients with skeletal Class III malocclusion than in normal subjects as determined by the questionnaires.

Gastroesophageal Reflux Disease (GERD) and Irritable Bowel Syndrome (IBS)—Is It One Disease or an Overlap of Two Disorders?

Up to 79% of IBS patients report gastroesophageal reflux disease (GERD) symptoms, and up to 71% of GERD patients report irritable bowel syndrome (IBS) symptoms. There are two principal hypotheses for the common presence of IBS symptoms in GERD patients. The first theory suggests that GERD and IBS overlap in a significant number of patients. The second theory suggests that IBS-like symptoms are part of the spectrum of GERD manifestation. The first theory is supported by genetic studies and similarities in gastrointestinal sensory-motor abnormalities potentially due to general gastrointestinal disorder of smooth muscle or sensory afferents. The other theory is primarily supported by studies demonstrating improvement of IBS-like symptoms in GERD patients receiving anti-reflux treatment. The close relationship between GERD and IBS could be explained by either GERD affecting different levels of the GI tract or a high overlap rate between GERD and IBS due to similar underlying GI dysfunction.

Yield of 24-Hour Esophageal pH and Bilitec Monitoring in Patients with Persisting Symptoms on PPI Therapy

Current management algorithms propose pH monitoring under proton pump inhibitors (PPIs) in suspected gastroesophageal reflux disease (GERD) with insufficient treatment response, but recent observations challenge this approach because of its low yield. To perform an audit of the outcomes of pH monitoring under PPI therapy in our unit, and to study the yield of additional nonacid reflux monitoring. All pH monitoring studies under antireflux therapy since 1997, with or without simultaneous Bilitec monitoring, were analyzed. From 1997 to 2003, 347 patients (157 men, mean age 49.4 +/- 0.8 years) underwent pH studies on PPI therapy (28% half-, 67% full-, and 5% double-dose PPI) for persisting typical (53%) or atypical (75%) symptoms. In 184 patients, simultaneous Bilitec monitoring was performed. Esophageal pH monitoring on PPI was pathological in 105 (30%) patients. Pathological pH monitoring on PPI was associated with typical reflux symptoms (64 versus 52%, P = 0.03), and a higher prevalence of persisting esophagitis (54 versus 36%, P < 0.005) and of hiatal hernia (58 versus 27%, P < 0.005). Bilitec monitoring on PPI therapy was pathological in 114 (62%) patients, of which 74 (40%) had normal pH monitoring. Adding Bilitec increased the rate of abnormal results over pH monitoring alone, from 38% to 69% on half-dose, from 27% to 69% on full-dose, and from 0% to 38% on double-dose PPI. The rate of abnormal pH monitoring in symptomatic GERD patients while on PPI therapy is relatively low, especially in those on double-dose PPI. Combined pH and Bilitec monitoring significantly increased the rate of ongoing pathological reflux compared to pH alone in refractory to PPI therapy GERD patients.

The Effect of Auditory Stress on Perception of Intraesophageal Acid in Patients With Gastroesophageal Reflux Disease

Most patients with gastroesophageal reflux disease (GERD) report that stress exacerbates their symptoms, yet mechanisms underlying this association remain unknown. We sought to determine the effect of an acute laboratory stressor on perceptual and emotional responses to intraesophageal acid perfusion in healthy controls and patients with GERD. Forty-six patients with heartburn and 10 healthy controls underwent upper endoscopy and, if negative, pH monitoring. Assessment of psychologic factors and health-related quality of life was done by a questionnaire. Perceptual and emotional responses to intraesophageal acid at baseline, during auditory stress, and during an auditory control condition were determined using a randomized crossover design. Plasma levels of norepinephrine, adrenocorticotropic hormone, and cortisol were assessed. Twenty-nine subjects were identified as nonerosive reflux disease and 17 as erosive esophagitis. Quality of life, psychologic profile, and personality assessment variables were similar among the 2 patient groups and the controls. There was a significant reduction in mean lag time to initial symptom perception and an increase in mean intensity rating and mean acid perfusion sensitivity score in the 2 patient groups during the stress period, which was not seen during the control condition. Healthy controls demonstrated lack of a significant change in all parameters of stimulus response functions to acid, regardless of condition. Acute auditory stress can exacerbate heartburn symptoms in GERD patients by enhancing perceptual response to intraesophageal acid exposure. This greater perceptual response is associated with greater emotional responses to the stressor.

Molecular Changes at the Esophagogastric Junction (EGJ) in Patients with Symptomatic Gastroesophageal Reflux Disease (GERD) in the Absence of Histological Columnar Metaplasia (CM)

Purpose: We developed a novel monoclonal antibody, mAb Das-1, that recognizes Barrett's epithelium (BE) with 100% sensitivity and specificity. mAb Das-1 reacts with normal colon epithelium but does not react with normal esophagus, EGJ epithelium, gastric or small intestinal epithelium. COX-2 is expressed in the presence of inflammation and in BE. However, expression of these markers at the EGJ in patients with symptomatic GERD with normal histology is unknown. Methods: Patients with symptomatic GERD (N = 86) were enrolled prospectively and 3 to 4 quadrantic biopsy specimens were taken from EGJ during endoscopy. Using immunoperoxidase assays, mAb Das-1 and anti-COX-2 antibody reactivity was assessed in serial sections of paraffin blocks of EGJ biopsy tissue. Thirty-six patients had normal histology, 50 had esophagitis and none had CM. Fourteen samples with adenocarcinoma of the esophagus were included. Normal biopsy specimens from the esophagus (N = 6), small bowel (N = 10) and colon (N = 15) were included as controls. Results: mAb Das-1 reactivity at EGJ was observed in 4 of 36 (11%) patients with normal histology and 7 of 50 (14%) with esophagitis. COX-2 reactivity was found in 9 of 36 (25%) with normal histology and 20 of 50 (40%) with esophagitis. All 14 patients with adenocarcinoma reacted with both mAb Das-1 and anti-COX-2. Three of 4 (75%) patients with mAb Das-1 positivity with normal histology were also reactive to COX-2. COX-2 expression was absent in all control specimens. However, mAb Das-1 reactivity was present in colon epithelium but absent from esophagus and small bowel epithelium. Conclusions: A metaplastic process expressing colonic phenotype of epithelium is found in 13% of EGJ biopsy tissue of symptomatic GERD patients in the absence of histologic CM. COX-2 expression was found in 34% of EGJ tissue of symptomatic GERD patients without CM. These data indicate that subclinical molecular changes at the EGJ, including metaplastic process, occur in some patients with GERD. This strongly supports the existence of a “pre-Barrett's” metaplastic stage. Such molecular diagnosis of early metaplastic process may allow initiation of early interventional treatment against further progression with PPI or other therapy.

Amelioration of Gastroesophageal Reflux Symptoms following Roux-en-Y Gastric Bypass for Clinically Significant Obesity

Symptoms of gastroesophageal reflux disease (GERD) are frequent in patients with clinically significant obesity and are reported to improve after Roux-en-Y gastric bypass (RYGB). The purpose of this study is to determine timing and duration of improvement of GERD symptoms in patients undergoing RYGB. Prospectively collected data from patients who underwent RYGB from January 1998 to August 2004 were analyzed. Patients answered a standardized questionnaire pre- and postoperatively inquiring about frequency of GERD symptoms (none, one episode/ week, one episode/day, more than one episode/day) and medication use. Of 606 patients undergoing RYGB, 239 patients (39%) reported GERD symptoms preoperatively (mean age 43 +/- 1 years; body mass index 51 +/- 1 kg/m2). Of these, 89 per cent of patients reported improved at 3 months post-op and 94 per cent of patients 9 months post-op (P < 0.001). Medication usage decreased from 30 per cent to 3 per cent by 3 months and 5 per cent beyond 9 months (P < 0.001). Percentage of excess weight loss was 18 +/- 1 per cent and 75 +/- 2 per cent at 3 and 9 months, respectively. Symptoms of GERD significantly improve and use of antireflux medications is reduced after RYGB independent of weight loss. RYGB may be the treatment of choice for GERD in obese patients.

The Role of Esophageal pH Monitoring in Symptomatic Patients on PPI Therapy

Ambulatory pH monitoring while on therapy is often recommended in gastroesophageal reflux disease (GERD) patients with continued symptoms. However, to date, little data exist to justify this indication. To assess the role of pH monitoring in symptomatic patients despite aggressive therapy with typical or extra esophageal GERD. Retrospective review of 2,291 ambulatory pH tracings (1999-2003) identified subgroup of studies performed on proton pump inhibitor (PPI) therapy. Patients with prior fundoplication or Barrett's esophagus were excluded. Patients grouped on predominant presenting GERD symptoms: typical (heartburn and regurgitation) or extra esophageal (chest pain, cough, hoarseness, sore throat, shortness of breath, asthma). The distribution of abnormal pH parameters in each group calculated and univariate analyses assessed the probability of abnormal pH in each group. Abnormal cutoff values traditionally used in clinical practice and more stringent cutoff values used to determine distribution of abnormality as a function of cutoff values. A total of 250 patients (mean age 54.3 yrs, 59% female) underwent pH monitoring on either daily (b.i.d.) or twice daily (q.d.) on PPI therapy: 115 (46%) with extra esophageal and 135 (54%) with typical GERD symptoms. Extra esophageal GERD patients were more likely to undergo pH monitoring on b.i.d. PPIs (OR = 2.7; 95% CI = 1.6-4.4; p < 0.01). 52 (93%) of typical and 74 (99%) of extra esophageal GERD patients on b.i.d. PPIs tested normal. The odds of a normal pH values were 11 times higher for patients on b.i.d. PPIs (OR = 11.4; 95% CI = 4.3-30.1, p < 0.01) than those on q.d. PPIs. 1) The likelihood of an abnormal esophageal pH for symptomatic GERD patients on b.i.d. PPI is very small. 2) In this group of patients failing b.i.d. PPIs causes other than GERD should be sought.

Asthma and gastroesophageal reflux disease: Effect of long-term pantoprazole therapy

To define the prevalence of gastroesophageal reflux disease (GERD) in mild persistent asthma and to value the effect of pantoprazole therapy on asthmatic symptoms. Seven of thirty-four asthmatic patients without GERD served as the non-GERD control group. Twenty-seven of thirty-four asthmatic patients had GERD (7/27 also had erosive esophagitis, sixteen of them presented GERD symptoms. An upper gastrointestinal endoscopy was performed in all the subjects to obtain five biopsy specimens from the lower 5 cm of the esophagus. Patients were considered to have GERD when they had a dilation of intercellular space (DIS) >0.74 mum at transmission electron microscopy. Patients with GERD were treated with pantoprazole, 80 mg/day. Forced expiratory volume in one second (FEV1) was performed at entry and after 6 mo of treatment. Asthmatic symptoms were recorded. The required frequency of inhaling rapid acting beta2-agonists was self-recorded in the patients' diaries. Seven symptomatic patients presented erosive esophagitis. Among the 18 asymptomatic patients, 11 presented DIS, while all symptomatic patients showed ultrastructural esophageal damage. Seven asymptomatic patients did not present DIS. At entry the mean of FEV(1) was 1.91 L in symptomatic GERD patients and 1.88 L in asymptomatic GERD patients. After the treatment, 25 patients had a complete recovery of DIS and reflux symptoms. Twenty-three patients presented a regression of asthmatic symptoms with normalization of FEV(1). Four patients reported a significant improvement of symptoms and their FEV(1) was over 80%. GERD is a highly prevalent condition in asthma patients. Treatment with pantoprazole (80 mg/day) determines their improvement and complete regression.

Gastro esophageal reflux disease is associated with absence from work: Results from a prospective cohort study

To study the association of gastro-esophageal reflux disease (GERD) with the absence from work and to estimate the extent of loss in gross domestic product due to inability to work. Analysis was based on the prospectively gathered data of a large European cohort study involving 6 215 symptomatic GERD patients (ProGERD). Among these patients, 2 871 were initially employed. The calculation of the loss of gross domestic product was based on the assumption that the prevalence of GERD was about 15% in Germany. According to the German Federal Statistical Office, the mean gross wage of employees was 150 EUR/d in 2002. The data of 2 078 employed patients who were prospectively followed up for over 2 years were analyzed. At study entry, the patients reported a mean of 1.8 d per year of inability to work. During the prospective follow-up under routine clinical care, the proportion of patients reporting days with inability to work decreased from 14% to 6% and the mean number of days per year with inability to work decreased to 0.9 d. Assuming a prevalence of troublesome GERD of 15% in the employed German population, the loss of gross domestic product amounted to 668 million EUR/year in Germany. GERD causes a relevant impairment on the national economics by absence from work. The presented data demonstrate the importance of GERD, not only for patients and health insurance companies, but also for the community at large.

Development and evaluation of FSSG: frequency scale for the symptoms of GERD

The aim of this study was to produce a simplified questionnaire for evaluation of the symptoms of gastroesophageal reflux disease (GERD). A total of 124 patients with an endoscopic diagnosis of GERD completed a 50-part questionnaire, requiring only "yes" or "no" answers, that covered various symptoms related to the upper gastrointestinal tract, as well as psychosomatic symptoms. The 12 questions to which patients most often answered "yes" were selected, and were assigned scores (never = 0; occasionally = 1; sometimes = 2; often = 3; and always = 4) to produce a frequency scale for symptoms of GERD (FSSG). Sensitivity, specificity, and accuracy of the FSSG questionnaire were evaluated in another group of patients with GERD and non-GERD. The usefulness of this questionnaire was evaluated in 26 other GERD patients who were treated with proton pump inhibitors for 8 weeks. When the cutoff score was set at 8 points, the FSSG showed a sensitivity of 62%, a specificity of 59%, and an accuracy of 60%, whereas a cutoff score of 10 points altered these values to 55%, 69%, and 63%. The score obtained using the questionnaire correlated well with the extent of endoscopic improvement in patients with mild or severe GERD. This new questionnaire is useful for the objective evaluation of symptoms in GERD patients.

Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results

Objective Preoperative 24-hour pH testing is controversial in surgical patients who have symptomatic gastroesophageal reflux disease (GERD) and endoscopic evidence of esophagitis. The objective of this study was to compare the clinical outcomes of Nissen fundoplication for symptomatic reflux between patients with normal and abnormal preoperative pH testing. Methods Patients were selected from a prospective database of patients who underwent laparoscopic esophageal procedures between January 1997 and December 2001 at our institution. Only patients having typical symptoms of GERD (heartburn and/or reflux), preoperative pH testing, manometry, and endoscopy and who had at least 6 months of post-operative follow-up were included in the study. Fifteen patients had normal preoperative DeMeester scores (DMS) (median 11.4, range 3.3 to 14.7). These were compared with 208 consecutive patients having abnormal preoperative DMS (median 49.6, range 15.2 to 250). Logistic regression modeling was performed to identify variables significant for poor outcome. Differences between means were tested using appropriate parametric or nonparametric tests. Results There were no statistically significant differences in demographics, preoperative symptom score (mean 2.9 ± 1.1 vs. 3.1 ± 0.68, P = 0.30), or preoperative grade of esophagitis ( P = 0.37) between the 2 groups. After a median follow-up of 8.8 months (range 6 to 36), 6 (40%) of the patients having normal preoperative DMS and 17 (8.1%) of the patients having abnormal preoperative DMS continued to have typical GERD symptoms ( P <0.01, B error = 0.02). The most significant factor for poor outcome in the regression model was normal preoperative pH (odds ratio 9.02, P <0.01). Conclusions Symptomatic GERD patients with normal preoperative 24-hour pH test results have significantly worse subjective outcomes after Nissen fundoplication compared with patients having abnormal preoperative pH test results. To minimize poor symptomatic outcomes after antireflux surgery, a policy of routine preoperative pH testing is advised.

Are there unmet needs in acid suppression?

The development of proton-pump inhibitors (PPIs) caused impressive improvements in the control of gastric acid secretion. The clinically related consequences are most clearly expressed in the therapy of gastroesophageal reflux disease (GERD). Despite these glamorous outcomes, there still are unmet clinical needs. Ideally, full 24-h control of gastric acid secretion should be available to fine tune acid suppressant therapy to the individual clinical needs. Full control of acid secretion with oral PPI therapy in the presence of a healthy non-Helicobacter pylori-infected gastric mucosa is difficult, if not impossible, at present. However, there are circumstances in which full control is desirable if not essential (intensive care, esophageal columnar metaplasia, etc.). In particular, the so-called nocturnal acid breakthrough is difficult to control, particularly in patients with esophageal columnar metaplasia. But even for ordinary GERD, full symptom control and patient satisfaction is often lacking, necessating additional over-the-counter medication for control of remaining symptoms. A recent Gallup interview of 1000 symptomatic GERD patients stressed the frequency of nocturnal symptoms, insufficiently controlled with standard PPI therapy. Current PPIs are also suboptimal for 'on-demand' therapy in Non-Erosive Reflux Disease (NERD)/GERD. Moreover, rebound acid secretion after abrupt stopping of PPI therapy may favour early symptomatic relapse, necessating step-down therapy to prevent prolongation of the need of acid suppression.

Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial

Background & Aims : Gastroesophageal reflux disease is a prevalent disorder that often requires long-term medical therapy or surgery. The United States Food and Drug Administration recently cleared new endoluminal gastroesophageal reflux disease treatments; however, no controlled trials exist. Methods : We randomly assigned 64 gastroesophageal reflux disease patients to radiofrequency energy delivery to the gastroesophageal junction (35 patients) or to a sham procedure (29 patients). Principal outcomes were reflux symptoms and quality of life. Secondary outcomes were medication use and esophageal acid exposure. After 6 months, interested sham patients crossed over to active treatment. Results : At 6 months, active treatment significantly and substantially improved patients’ heartburn symptoms and quality of life. More active vs. sham patients were without daily heartburn symptoms (n = 19 [61%] vs. n = 7 [33%]; P = 0.05), and more had a >50% improvement in their gastroesophageal reflux disease quality of life score (n = 19 [61%] vs. n = 6 [30%]; P = 0.03). Symptom improvements persisted at 12 months after treatment. At 6 months, there were no differences in daily medication use after a medication withdrawal protocol (n = 17 [55%] vs. n = 14 [61%]; P = 0.67) or in esophageal acid exposure times. There were no perforations or deaths. Conclusions : Radiofrequency energy delivery significantly improved gastroesophageal reflux disease symptoms and quality of life compared with a sham procedure, but it did not decrease esophageal acid exposure or medication use at 6 months. This procedure represents a new option for selected symptomatic gastroesophageal reflux disease patients who are intolerant of, or desire an alternative to, traditional medical therapies.

Goals of therapy and guidelines for treatment success in symptomatic gastroesophageal reflux disease patients

Important new data have established symptomatic gastroesophageal reflux disease (GERD) as a disorder in its own right. Despite major advances in management, this disorder still presents many challenges. With the absence of visible disease (i.e., esophageal erosions), symptom relief must be a primary aim in treating patients with symptomatic GERD; in particular, reflux patients suffer from several different symptoms, but relief of heartburn and acid regurgitation should be the principal concern in clinical practice. Epigastric pain and other upper GI symptoms usually improve with active treatment. From a methodological standpoint, complete symptom relief is an attractive outcome measure. However, not all patients expect complete absence of symptoms in the long term, and many reflux patients are willing to continue a treatment strategy that provides substantial but less than absolute symptom control. Patients with symptomatic GERD have significantly impaired health-related quality of life (HRQOL) which, when heartburn is resolved, often improves to levels equal to or better than that found in the normal, healthy population. However, some reflux sufferers may not report symptoms and have apparently normal HRQOL measures owing only to the fact that they self-impose rigorous lifestyle restrictions to prevent heartburn—restrictions that may, in turn, eventually lead to HRQOL impairment. A full and complete evaluation of treatment success should be able to detect this pattern. Data on the long-term prognosis and risk of complications associated with treatment for symptomatic GERD are scarce and incomplete. However, the prevention of erosive esophageal damage, strictures, and adenocarcinoma should be a goal of long-term treatment success, even in symptomatic GERD.

Diagnosis of symptomatic gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) encompasses a heterogeneous group of patients with differences in sensitivity to esophageal acid exposure, perception of pain, and physiological tissue involvement. The most difficult patients to understand are those who have a great symptom burden but no endoscopic evidence of esophageal mucosal involvement. These patients with symptomatic GERD (also called nonerosive reflux disease and endoscopy-negative reflux disease) present a diagnostic challenge. Diagnostic tests, like ambulatory pH monitoring, the acid perfusion test, and intraesophageal balloon distension, have limited reliability in patients with this form of GERD whose symptoms may exhibit poor correlation with acid exposure or mechanostimulation. The recent interest in a proton pump inhibitor therapeutic trial to identify the group of symptomatic GERD patients (having ruled out risk factors for more morbid conditions) who will respond to these agents has considerable appeal. It has been shown effective in about 75% of patients, and offers a simple approach to managing the difficult-to-diagnose patient even while further diagnostic procedures are carried out.