Weeks Of Proton Pump Inhibitor Therapy Research Articles

Longitudinal Microbiome Changes in Children Exposed to Proton Pump Inhibitors.

Proton pump inhibitor (PPI) use has been associated with an increased risk of gastrointestinal and upper respiratory infections in children. There are limited longitudinal data on the effect of PPI in children. The goal of this prospective observational study was to compare the stool and oropharyngeal microbiome of children before and after starting PPIs. We prospectively recruited participants from a gastroenterology clinic. Consented participants provided stool samples and oropharyngeal swabs at baseline and after 8 weeks of PPI therapy. Microbiome changes were measured by analyzing 16S sequencing from both body sites at both time points. Thirty-four participants completed the study and provided samples both at baseline and after 8 weeks on PPI therapy. Of those, 24 participants had sufficient sequencing from both stool and oropharyngeal samples at both time points. There were no differences between the pre-PPI and post-PPI samples using beta-diversity metrics in either the oropharynx or stool. There were, however, significant changes in specific taxa. There was an enrichment of Streptococcus in the stool after PPI use and a reduction in the relative abundance of Bifidobacterium , Peptostreptococcus , and Turicibacter ( P -values < 0.01). Furthermore, there was an increase in the relative abundance of oropharyngeal bacteria in the stool after PPI therapy. This enrichment of oropharyngeal bacteria in the stool was most prominent in younger participants. Further investigation is needed to determine the clinical and microbial factors that predispose or protect against microbiome changes due to PPI use and why young children are more susceptible to this PPI effect.

Study of the empirical role of proton pump inhibitor therapy on laryngopharyngeal reflux

Background: Laryngopharyngeal reflux (LPR) is a highly prevalent disease and commonly encountered in the otolaryngologist’s office. Study to evaluate the presentation of different signs and symptoms of LPR along with evaluating the role of empiric PPI (proton pump inhibitor) in the management of LPR by observing its effect on RFS and RSI. Methods: A prospective observational study was conducted on 100 cases having different symptoms of LPR. Reflux symptom index (RSI) and Reflux finding score (RFS) were used to diagnose LPR. Patients were put on PPI (Pantoprazole 40 mg OD for 12 weeks) and followed up at 4,8 and 12 weeks and successive RSI and RFS scores were evaluated. The results were compiled and analyzed statistically. Results: Among all symptoms, most common presenting symptom of LPR was foreign body/sensation of something sticking in throat (80%). Upon pharmacological therapy with PPIs (Pantoprazole), the mean RSI score changed from 22.94±5.83 to 11.19±2.97 at 12 weeks of PPI therapy. The mean RFS score changed from 12.93±3.55 to 6.86±2.86 at 12 weeks of PPI therapy. The change in the RFS and RSI score was highly significant (p=0.001). Conclusions: LPR is a common condition presenting in ENT settings, the symptoms and signs of which may be complex. RFS and RSI score are valuable tools for diagnosing LPR. PPIs are proven to be effective therapy for LPR, more studies are encouraged to affirm the efficacy of PPIs over other management options.

Randomised clinical trial: the use of alginates during preinvestigation proton pump inhibitor wash-out and their impact on compliance and symptom burden

Background/aimsInvestigation of gastro-oesophageal reflux disease is usually performed off proton pump inhibitors (PPIs). This can exacerbate symptoms, potentially impacting investigation accuracy if patients circumvent the preinvestigation instructions. There are no...

Percent reduction of the ulcer size at 4 weeks is a predictor of the complete healing of endoscopic submucosal dissection-induced gastric ulcers

Background and study aimsEndoscopic submucosal dissection (ESD) is widely used as a treatment modality for gastric mucosal neoplasia. While proton pump inhibitors (PPIs) have been used for the control of artificial ulcers created by ESD (ESD-ulcers), complete healing of the ulcers is not always achieved in all the cases. The purpose of this study was to identify the clinical factors that are predictive of refractory ESD-ulcers. Patients and methodsWe recruited 90 patients with 102 artificial ulcers that formed after the patients underwent ESD for gastric tumours. All the patients received a 20-mg capsule of esomeprazole daily until the 56th day after ESD, and underwent endoscopy at 1, 4, 6 and 8 weeks after the ESD. We analyzed the clinical factors that were associated with the complete healing at 8 weeks after the ESD (CH-8w). The ulcers in the scar stage were defined as the complete healing in this study. ResultsOf the 102 ESD-ulcers, 16.7% failed to show complete healing after the 8 weeks of PPI therapy. Univariate analysis identified the percent reduction of the ulcer size at 4 weeks after ESD (PR-4w) as being significantly associated with CH-8w. Multivariate analysis identified ulcer location in the lower-third of the stomach and PR-4w > 95% as being independently correlated with the CH-8w (odds ratio = 4.86 and 7.89, respectively). Analysis of the area under the receiver operating characteristic (AUROC) curve demonstrated that the AUROC curve of PR-4w for predicting the CH-8w was 0.78. ConclusionBased on the results of our study, endoscopic observation at 4 weeks after ESD would help in the early identification of refractory ESD-ulcers.

Reclassifying Functional Heartburn Using Impedance pH in Refractory GERD Patients

Introduction: Background: Functional heartburn as a term has changed in meaning over the years. The most recent definition was introduced based upon Rome IV criteria, as typical heartburn symptoms in the presence of normal upper endoscopy findings (including normal biopsies), normal esophageal pH testing, and a negative association between symptoms and reflux events. Functional heartburn is very common, affecting women more than men. The majority of GERD patients respond to 4-8 weeks of proton-pump inhibitors therapy but up to 40% will demonstrate partial or complete lack of response. This defines the refractory group. 24 hr-impedance pH is the current gold standard for diagnosing all GERD types including acid and non-acid reflux. Symptom index is used as an adjunctive diagnostic tool to link symptoms to specific reflex events. Aim: The aim of the study is to review and reclassify functional heartburn patients using impedance pH.2767 Figure 1 No Caption available.Methods: Retrospective chart review of patient who continued to have GERD symptoms despite being on antisecretory therapy. We reviewed impedance pH studies for adult patients (>18 years old) between 2012-2018. Only patients with refractory symptoms were included. Data including esophageal acid exposure, number of reflux episodes (acids and non-acid), symptoms index and upper endoscopy findings (including esophageal biopsies) were collected. The data was reviewed and classified based on reflux events and symptom index. Cut off for abnormal of reflux episodes was 48, counting both acid and nonacid episodes. All patients were studied while on PPI therapy, once or twice a day. Results:Results 166 patients were included, 68% were females, mean age was 51±19 years, and 62% were on once daily PPI dosing.73% had positive symptom index (see figure). Conclusion: Patients with persistent GERD symptoms on PPI therapy represent a heterogenous group. Exclusively using pH esophageal monitoring, such as in the current functional heartburn classification, risks missing patients who's persistent symptoms are due to non-acid reflux.

Patient Outcomes and Cost of Referral Patterns of Patients With Proton Pump Inhibitor Refractory Gastroesophageal Reflux Disease Undergoing Esophageal pH and Impedance Testing

Introduction: The American College of Gastroenterology recommends that patients with gastroesophageal reflux disease (GERD) undergo esophageal pH and impedance for symptoms persisting following an 8 week trial of proton pump inhibitor (PPI) therapy. Research suggests that early referral is cost effective in evaluating PPI refractory GERD. Methods: A retrospective chart review was performed on all patients that underwent esophageal pH/impedance studies from December 2010 to June 2015. DeMeester score, total acid and non-acid reflux events, reflux symptom index scores, demographics, prior specialty appointments, and testing related to GERD symptoms was recorded. Workup cost was estimated using the minimum Medicare facility payment. Results: A total of 119 patients underwent pH/impedance testing with a mean age of 48 years (SD 13.0, range 21 - 76). No patients had pH/impedance evaluations prior to 8 weeks of PPI therapy. 46 (39%) patients had positive DeMeester scores, and 64 (53.8%) were referred by a non-primary care provider. Non-primary care specialties and primary care managers (PCM) had 26/64 (41%) and 20/55 (36%) positive pH/impedance tests, respectively. Of 55 patients referred by a PCM, 19 were previously seen by another specialty, with 6/19 (32%) of those having positive pH/impedance studies. No significant difference was found in the prevalence of positive testing between the three referral pattern groups (χ2=0.5068; P=0.7762) (table 1). Evaluation and workup costs averaged (95% CI) $184.00($181.46 - $186.54) from primary care referrals, $420.58 ($302.14 - 539.02) for primary care with previous subspecialty evaluation, and $353.65 ($264.12 - 443.18) for subspecialty referrals independent of PPI usage. Costs differed between primary care referrals and primary care with subspecialty referrals (P=0.0005) and primary care and subspecialty referrals (P=0.0014) but not between primary care with subspecialty referrals and subspecialty referrals (P=0.3649). Conclusion: A majority of the patients referred for pH/impedance testing were previously evaluated by another medical or surgical subspecialty. There was no difference in positive study between referral patterns. Additionally, the cost of workup for the PPI refractory GERD was higher in patients with any previous subspecialty workups when compared to direct primary care referrals. Therefore, the additional cost of workup of symptoms related to GERD does not demonstrate increased prevalence of positive pH and impedance studies. Early referral from primary care to gastroenterology for patients with refractory GERD after a trial of PPIs could reduce costs by eliminating unnecessary referrals to other specialties.Table: Table. Number of positive and negative DeMeester scores based on referral pattern for pH and impedance testing

Eight Weeks of Esomeprazole Therapy Reduces Symptom Relapse, Compared With 4 Weeks, in Patients With Los Angeles Grade A or B Erosive Esophagitis

There is disagreement over the ideal duration of initial proton pump inhibitor (PPI) therapy for gastroesophageal reflux disease, and whether prolonged therapy increases healing of the esophagitis and prevents symptom relapse. We performed a multicenter, prospective, randomized, controlled study to compare the efficacies of 4 weeks vs 8 weeks of PPI therapy in reducing reflux symptoms and preventing symptom relapse in patients with Los Angeles grade A or B erosive esophagitis. Consecutive patients with symptomatic Los Angeles grade A or B erosive esophagitis were assigned randomly to groups given daily esomeprazole (40 mg) for 4 weeks (n = 207) or 8 weeks (n = 201) as their initial treatment. Patients with complete symptom resolution were switched to on-demand therapy until the end of week 20. All patients underwent follow-up endoscopy at the end of week 20. Symptom relapse was defined as 2 or more episodes of troublesome reflux symptoms per week or ingestion of PPI for more than 7 days within 4 weeks, owing to reflux symptoms. The 4-week and 8-week groups had comparable rates of complete symptom resolution (77.9% vs 82.1%). However, the cumulative 12-week incidence of symptom relapse was higher for the 4-week group than for the 8-week group (62.5% vs 47.8%; difference, 14.7%; 95% confidence interval, 3.7%-25.7%; P = .009). No significant difference was observed between groups in the proportions of patients with sustained healing at the end of week 20 (49.6% vs 40.9%; P = .160). Prolonging PPI therapy from 4 weeks to 8 weeks does not appear to increase the rate of complete symptom resolution in patients with mild erosive esophagitis. However, 8 weeks of PPI therapy reduces symptom relapse, compared with 4 weeks, in patients with Los Angeles grade A or B erosive esophagitis. ClinicalTrials.gov number: NCT01874535.

Atypical Manifestation of Gastroesophageal Reflux Disease: A Disease With a Thousand Faces

Atypical Manifestation of Gastroesophageal Reflux Disease: A Disease With a Thousand Faces

Alteration of microbiota in esophagitis and Barrett's esophagus and further modification by PPI treatment.

16 Background: Gastroesophageal reflux can cause inflammation, metaplasia, dysplasia and cancer of the esophagus. The incidence of esophageal adenocarcinoma (EAC) has increased almost six fold in the past 30 yrs despite the increased use of Proton Pump Inhibitors (PPIs) to treat reflux. Recently, erosive esophagitis has been shown to increase the risk of EAC relative to patients with normal esophagus (NE). The reason for this remains unknown. Aim: To determine whether the microbiota of gastric refluxate and esophageal biopsies differs between patients with heartburn and NE vs. patients with abnormal esophageal mucosa [esophagitis or Barrett's esophagus (BE)] and to elucidate the effect of PPIs on bacterial communities. Methods: Gastric fluid and esophageal biopsies were collected during endoscopy from 13 BE/esophagitis patients and from 7 with NE. To reveal how PPIs alter the microbiota, samples were obtained from 8 of the patients (2 NE, 4 esophagitis and 2 with BE), before and after 8 weeks of PPI therapy. DNA was extracted and 16S rRNA gene pyrosequencing of microbial communities was performed. Results: Significant differences in the composition of gastric fluid bacteria, but not the esophagus-associated microbiota, were found between patients with heartburn and NE vs. patients with esophagitis and/or BE. Notably, Enterobacteriaceae (specifically Escherichia and Enterobacter) were significantly enriched in gastric fluid of patients with BE/esophagitis (P=0.01) compared to NE. PPIs had a remarkable effect on microbial communities both in the stomach and the esophagus. In gastric fluid, Moraxellaceae were decreased (P=0.016), whereas Erysipelotrichaceae were increased (P=0.031) following PPI treatment. Esophageal biopsies revealed genera belonging to the Microccocaceae, known to be opportunistic human pathogens, which increased following PPIs (P =0.031). Conclusions: Gastric fluid microbiota is modified in heartburn patients with esophagitis and/or Barrett's esophagus compared to patients with normal esophagus. PPI treatment markedly alters gastric and esophageal microbial populations. These modified bacterial communities may predispose to inflammation, dysplasia and cancer.

Esophageal Mucosal Breaks in Gastroesophageal Reflux Disease Partially Responsive to Proton Pump Inhibitor Therapy

Approximately 20-30% of patients with gastroesophageal reflux disease (GERD) do not experience complete symptom resolution during proton pump inhibitor (PPI) therapy. The aim of this study was to determine the prevalence of esophageal mucosal breaks among patients who have a partial response to PPI therapy. This was an analysis of data from a phase 2b clinical trial carried out to assess the efficacy and safety of a reflux inhibitor, lesogaberan (AZD3355), as an add-on to PPI therapy in this patient population (clinicaltrials.gov reference: NCT01005251). A total of 661 patients with persistent GERD symptoms who had received a minimum of 4 weeks of PPI therapy were included in the study. The prevalence of esophageal mucosal breaks was assessed according to (i) the most recent endoscopy results from within the previous 24 months, if available ("historical" endoscopies), and (ii) the results of endoscopies performed at study baseline ("baseline" endoscopies). Baseline endoscopies were not carried out in patients who had a historical endoscopy showing an absence of esophageal mucosal breaks. Historical endoscopy results were available for 244 patients, of whom 48 (19.7%) had esophageal mucosal breaks. Baseline endoscopies were carried out in 465 patients, of whom 146 (31.4%) had esophageal mucosal breaks. Sensitivity analyses showed a prevalence of esophageal mucosal breaks of 20-30%. In both the historical and baseline endoscopies, most esophageal mucosal breaks were Los Angeles grades A or B. In patients with GERD symptoms partially responsive to PPI therapy, mild-to-moderate severity esophageal mucosal breaks are common (prevalence 20-30%), and may contribute to symptom etiology.

Gastroesophageal Reflux

Gastroesophageal Reflux

PPI therapy is equally effective in well‐defined non‐erosive reflux disease and in reflux esophagitis: a meta‐analysis

Symptomatic response to proton pump inhibitor (PPI) therapy in patients with non-erosive reflux disease (NERD) is often reported as lower than in patients with erosive reflux disease (ERD). However, the definition of NERD differs across clinical trials. This meta-analysis aims to estimate the rate of symptom relief in response to PPI in NERD patients. MEDLINE (1966-2010), Cochrane Comprehensive Trial Register (1997-2010) and EMBASE (1985-2010) databases were searched and manual searches from studies' references were performed. Randomized clinical trials were selected that included patients with heartburn, and analyzed the effect of short-term PPI treatment. The primary outcome of selected studies was defined as complete or partial heartburn relief. Two reviewers independently extracted data and assessed study quality of selected articles. Random effects models and meta-regression were used to combine and analyze results. The pooled estimate of complete relief of heartburn after 4 weeks of PPI therapy in patients with ERD was 0.72 (95% CI 0.69-0.74) (32 studies), vs 0.50 (0.43-0.57) (eight studies) in empirically treated patients, 0.49 (0.44-0.55) (12 studies) in patients defined as non-erosive by negative endoscopy, and 0.73 (0.69-0.77) (two studies) in patients defined as non-erosive by both negative endoscopy and a positive pH-test. In well-defined NERD patients, the estimated complete symptom response rate after PPI therapy is comparable to the response rate in patients with ERD. The previously reported low response rate in studies with patients classified as NERD is likely the result of inclusion of patients with upper gastrointestinal symptoms that do not have reflux disease.

Withdrawing PPI Therapy After Healing Esophagitis Does Not Worsen Symptoms or Cause Persistent Hypergastrinemia: Analysis of Dexlansoprazole MR Clinical Trial Data

OBJECTIVES:Withdrawal of proton pump inhibitors (PPIs) may induce symptoms in healthy volunteers, suggesting that discontinuing PPI therapy induces acid-peptic disease. Similar assessments in patients with documented acid-related disorders are lacking.METHODS:We performed a retrospective analysis of data from 287 Helicobacter pylori-negative erosive esophagitis (EE) patients healed after 4 or 8 weeks of therapy with dexlansoprazole modified release (MR) or lansoprazole, and then randomized to placebo in 6-month maintenance trials. We compared serum gastrin levels and 24-h heartburn severity before enrollment in the healing trials (baseline) and after receiving placebo in the 6-month maintenance trials.RESULTS:Mean gastrin values at maintenance months 1 and 3 were essentially unchanged (median changes, 1.0 and −1.0 pg/ml), showing that gastrin normalized within 1 month of discontinuing PPIs and remained flat. Mean heartburn severity at maintenance month 1 was <1 on a 5-point scale (1=mild) and significantly lower than at baseline (median decrease, 0.41 points; P≤0.001). Heartburn severity in patients healed at week 4 or 8 with either PPI was generally similar, suggesting that neither longer exposure nor more potent therapy was associated with rebound. In those with month 2 data, mean heartburn severity at months 1 and 2 was significantly lower than baseline (median decrease, 0.54 and 0.58 points; both P<0.001), indicating an ongoing symptom response for 2 months after PPI withdrawal.CONCLUSIONS:In H. pylori-negative EE patients, there was no indication of recurring heartburn symptom worsening beyond baseline levels within 2 months of discontinuing 4–8 weeks of PPI therapy.

Increase of weakly acidic gas esophagopharyngeal reflux (EPR) and swallowing‐induced acidic/weakly acidic EPR in patients with chronic cough responding to proton pump inhibitors

Gastro-esophageal reflux disease (GERD)-related chronic cough (CC) may have multifactorial causes. To clarify the characteristics of esophagopharyngeal reflux (EPR) events in CC patients whose cough was apparently influenced by gastro-esophageal reflux (GER), we studied patients with CC clearly responding to full-dose proton pump inhibitor (PPI) therapy (CC patients). Ten CC patients, 10 GERD patients, and 10 healthy controls underwent 24-h ambulatory pharyngo-esophageal impedance and pH monitoring. Weakly acidic reflux was defined as a decrease of pH by >1 unit with a nadir pH >4. In six CC patients, monitoring was repeated after 8 weeks of PPI therapy. The number of each EPR event and the symptom association probability (SAP) were calculated. Symptoms were evaluated by a validated GERD symptom questionnaire. Weakly acidic gas EPR and swallowing-induced acidic/weakly acidic EPR only occurred in CC patients, and the numbers of such events was significantly higher in the CC group than in the other two groups (P < 0.05, respectively). Symptom association probability analysis revealed a positive association between GER and cough in three CC patients. Proton pump inhibitor therapy abolished swallowing-induced acidic/weakly acidic EPR, reduced weakly acidic gas EPR, and improved symptoms (all P < 0.05). Most patients with CC responding to PPI therapy had weakly acidic gas EPR and swallowing-induced acidic/weakly acidic EPR. A direct effect of acidic mist or liquid refluxing into the pharynx may contribute to chronic cough, while cough may also arise indirectly from reflux via a vago-vagal reflex in some patients.

This Month in Gastroenterology

This Month in Gastroenterology

Should Patients with Severe Reflux Esophagitis Undergo Repeat Endoscopy After 8 to 12 Weeks of Proton Pump Inhibitor (PPI) Therapy to Exclude Underlying Barrettʼs Esophagus (BE)? Preliminary Results from Two Prospective Trials

Purpose: Retrospective reports have suggested that 5-25% of patients with reflux esophagitis (RE) at baseline, who undergo repeat esophagogastroduodenoscopy (EGD) following PPI therapy, have concomitant BE—most short in segment length. Given the retrospective nature of these reports, it is not clear how many patients had intestinal metaplasia of the cardia misdiagnosed as BE. We are recruiting subjects with RE into 2 prospective studies, each with different primary aims. A uniting secondary aim is to assess the prevalence of suspected and unsuspected BE in patients with RE treated with PPI therapy for 8-12 weeks. Methods: Subjects from two studies were pooled for this analysis. Study A's primary aim is to assess the role of compliance in GERD symptom resolution in subjects with Los Angeles (LA) grades B, C and D RE. Follow-up EGD was left to the discretion of the primary physician. Study B's primary aim is to compare the percent of subjects with LA grades C and D RE who achieve resolution after 8 weeks PPI treatment (morning vs. bedtime dosing). Follow-up EGD was mandatory. Endoscopists were not informed of the subject's participation in a research study. Subjects previously diagnosed with BE were excluded from this analysis. Results: Study A recruited 50 subjects [25 (50%) male, mean age 56 (SD 15), B=40, C=5, D=5], of whom 10 [4 (40%) male, mean age 58 (SD 15), B=7, C=1, D=2] had a follow-up EGD. To date, Study B has recruited 57 subjects of which 45 [31 (69%) male, mean age 56.8 (SD 13), C=27, D=18] have undergone a follow-up EGD. Thus, 55 subjects (B=7, C=28, D=20, BMI 31.5) have undergone baseline and follow-up EGD after 8-12 weeks PPI therapy and are the subjects of this analysis. Five (C=3, D=2) of 55 (9%) subjects were newly diagnosed with biopsy-proven BE at follow-up EGD [overall 2 (40%) male; mean age 55 (SD 11); BMI 35.3, short (< 3 cm) N=4 (2 male, lengths ranging from islands to 2 cm); long (>3 cm) N=1 (0 male, 5 cm). In 5 (100%) cases, BE was unexpected. The BMI of the 50 RE subjects who did not have BE at follow up EGD was 31.3 (p=0.16). Conclusion: In this prospective study, 10% of subjects with LA grade C or D RE had concomitant BE that could not be recognized during the initial endoscopy in the setting of diffuse inflammation. Unsuspected BE was not found in subjects with LA grade B RE. Subjects with RE and BE tended to be more obese than subjects with RE alone, although this finding did not achieve statistical significance. These prospective results suggest that patients with severe LA grade C or D disease undergo repeat EGD after 8 to 12 weeks of PPI therapy to exclude underlying BE. Disclosure: Dr Alexander - Consulting Meritigae Pharmacia and Wyeth; Research Funding - Merck, Novartis, and Glaxo Smith Kline. Dr Howden - Consultant - Santarus and Takeda, Speakers Bureau - Santarus and Takeda. Dr Romero - Grant/Research Support and Consultant, Santarus, makers of omeprazole/sodium bicarbonate (Zegerid), and Grant/Research Support and Consultant, AstraZeneca, makers of esomeprazole (Nexium). No disclosures for: Drs Jung, Francis, Arora, Grothe, Enders, Dabade, Murray, Farrugia, Kane, Buttar, Crowell, Locke, Wong Kee Song, Wang, Prasad, Sharma, Namasivayam, and Achem, and Mrs Geno, Fredericksen, and Diehl. This research was supported by an industry grant from AstraZeneca funded Study A in this abstract. They supplied esomeprazole. Santarus funded Study B in this abstract. They supplied omeprazole/sodium bicarbonate. Note, they are both referred to as PPI therapy. The names of their products are not described in the abstract.

A decade‐long sour‐taste sensation successfully treated with a proton‐pump inhibitor

We report a case study of a 54-year-old Japanese woman who persistently suffered from a sour-taste sensation in her mouth for 10 years, and was treated with a proton-pump inhibitor (PPI). She found sour-tasting meals irritable, and after eating such meals the sour-taste sensation worsened. She also complained of eructation and regurgitation. Upper gastrointestinal (GI) endoscopy showed duodenal erosion, superficial gastritis, and erosive oesophagitis. After 2 weeks of PPI therapy (lansoprazole, 30 mg day(-1)) the sour taste subjectively decreased to 70%, and after 6 weeks the symptoms disappeared. In addition to increased sensitivity of the mouth, gastro-oesophageal reflux might have created her obstinate sour-taste sensations. It is suggested that in such cases PPI therapy should be attempted.