Differential diagnosis of GERD

It was widely accepted that the prevalence of GERD is lower in Oriental countries compared to Western countries. But the incidence of GERD has recently increased in Japan. The most commonly recognized manifestation of GERD is heartburn or a substernal burning sensation in the chest. Most patients with reflux esophagitis complain of typical symptoms such as heartburn, regurgitation or dysphagia. However, some patients complain of atypical symptoms such as hoarse voice, chronic cough, adult-onset asthma or vocal cord polyps. It is not always easy to diagnose atypical symptomatic patients as GERD. If patients who complain of these atypical symptoms have not improved with common medical treatment, GERD should be the consideration in its differential diagnosis.     

安徽省铜陵地区胃食管反流病临床流行病学调查

目的了解安徽铜陵地区消化门诊胃食管反流病(GERD)患病率及其临床与内镜特点并分析其危险因素。方法针对铜陵3家市级医院2008年6至8月消化内科门诊连续就诊人群,根据国内通用的GERD临床诊断标准(RDQ总积分≥12分)和洛杉矶RE内镜诊断标准进行GERD调查和诊断。结果7 352例消化门诊连续就诊患者中共调查出GER症状患者1072例,GERD199例。GERD患病率为2.7%,其中RE1.3%,NERD1.4%。RE男女比例为3.09∶1,NERD为1.14∶1。40~60岁GERD患者占61.8%。各反流症状发生率依次为反酸78.4%、烧心74.4%、反食52.3%、胸痛40.7%;咽部异物感、夜间咳嗽、声嘶等食管外症状发生率依次为43.2%、12.6%、10.7%。内镜RE分级A级59例(62.8%)、B级26例(27.7%)、C级4例(4.3%)、D级5例(5.3%)。多因素分析显示吸烟、高脂饮食、不良心绪和经济状况差是GERD的危险因素。结论该地区GERD患者率较低(2.7%),40~60岁人群为GERD高发人群。临床以反酸、烧心、反食、胸痛为主要表现,食管外症状占一定比例。心理社会因素可能参与了GERD发病。     

Recent advances in the treatment of GERD in the elderly: focus on proton pump inhibitors

The prevalence of gastroesophageal reflux disease (GERD) increases with age, and older people are more likely to develop severe disease. Studies of elderly patients with GERD indicate differences in presentation and diagnosis, compared with GERD in younger adults. Indeed, an older patient with GERD may present with atypical symptoms such as dysphagia, vomiting, weight loss, anaemia and anorexia, and less frequently with typical symptoms such as heartburn or acid regurgitation. These findings are attributed to pathophysiological changes in esophageal function that occur with age. Therefore, GERD in elderly patients is more likely to be poorly diagnosed or undiagnosed. Although few studies have concentrated specifically on elderly patients, the proton pump inhibitors (PPIs) have been shown to be more effective than histamine receptor antagonists for healing reflux esophagitis and for preventing its recurrence when they are given as maintenance therapy. In addition, the PPIs seem to be safe both in short- and in long-term therapy of elderly patients with GERD.     

Epidemiology of GERD in Japan

To determine the epidemiological characteristics of Japanese patients with gastroesophageal reflux disease(GERD), we investigated the prevalences of heartburn, reflux esophagitis(RE), hiatus hernia and Barrett's mucosa, and assessed the correlations among them. In total, 15.4 % (725/4,723) of patients had heartburn twice or more per week and 42.2% had symptoms of heartburn, including those who had heartburn once or less per week, and 16.7 % (602/3,608) of patients had RE. The prevalences of hiatus hernia and Barrett' s mucosa were 49.3 % (1,263/2,560) and 20.8% (536/2,577), respectively. There was a weak correlation between RE and heartburn, but 75.5% of patients who had heartburn did not have any endoscopic abnormalities, and 40.1% of patients without endoscopic abnormalities had heartburn, suggesting the presence of endoscopy-negative GERD. Results also showed that 26.2 % of patients had RE associated with hiatus hernia, and there was a correlation between the two. There was a weak correlation between Barrett' s mucosa and RE and between Barrett' s mucosa and hiatus hernia.     

Extraesophageal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may manifest as laryngitis, asthma, cough, or noncardiac chest pain. Diagnosing these extraesophageal manifestations may be difficult for primary care physicians because most patients do not have heartburn or regurgitation. Diagnostic tests have low specificity, and a cause-and-effect association between GERD and extraesophageal symptoms is difficult to establish. Response to aggressive acid suppression is often the best indication of GERD etiology in a patient with extraesophageal symptoms.     

Relationship between gastric motility and the pathophysiology of GERD

Various factors contribute to the reflux symptoms such as heartburn and regurgitation in patients with GERD. There have been some reports on delayed gastric emptying or impaired gastric myoelectrical activity in those with GERD. The reason for the direct relationship between reflux symptoms and gastric hypomotility in GERD patients is still unclear. Gastric distension and impaired fundic relaxation as a result of disturbed gastric motility might play a partial role in acid reflux to the esophagus. Gastric hypomotility appears to be an important causative factor in the reflux symptoms in some GERD patients.     

Diagnosing gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common condition with a variety of clinical manifestations and potentially serious complications. This article reviews available methods for diagnosing GERD. A clinical history of the classic symptoms of GERD, heartburn or acid regurgitation, is sensitive enough to establish the diagnosis in patients without other complications. Esophagogastroduodenoscopy is the best way to evaluate suspected complications of GERD, but endoscopic findings are insensitive for the presence of pathological reflux, and therefore they cannot reliably exclude GERD. The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux is the 24-hour ambulatory esophageal pH monitoring test, and this study should be used for the evaluation of refractory symptoms and extraesophageal manifestations of GERD. A formal acid-suppression test is helpful in the evaluation of the atypical GERD symptom of noncardiac chest pain. Optimal use of currently available tests for GERD may allow for more efficient diagnosis and better characterization of the pathological manifestations associated with GERD.     

Reflux esophagitis--a community-wide increase in incidence

Gastroesophageal reflux disease (GERD) is a common disease increasing in incidence and prevalence in the industrialised countries. It is a chronic disease with a large spectrum of clinical manifestations. The leading symptom is heartburn, however the disease may also present with extraesophageal symptoms or stay asymptomatic. Motility disorders of the upper GI tract with the key feature of impaired LES are the cause for pathologic gastroesophageal reflux in the terminal esophagus. The relationship of H. pylori infection with GERD is part of the current discussion. The Savary Miller classification for grading of refluxesophagitis is now proposed for substitution by the Los Angeles classification for the assessment of erosive lesions. Besides complications such as bleeding or strictures the main risk is the development of Barrett esophagus and adenocarcinoma. Proton pump inhibitors are the therapy of choice for healing as well as in longterm therapy and prophylaxis. New endoscopic interventional therapies for treatment of GERD and related diseases should be used only in controlled studies.     

Reflux esophagitis--Japan and Western countries

Although reflux esophagitis (RE) is a common disease of the upper gastrointestinal tract in Western countries, its prevalence is still low in Asian countries, including Japan. On the other hand, the prevalence of H. pylori infection and atrophic gastritis are very high in Japan in comparison to that of other developed countries. Atrophic gastritis decreases gastric acid secretion, which is much lower in the Japanese compared to that in Western persons. The main mechanism of RE is reflux of gastric acid into the esophagus from the stomach. A decrease in gastric acid secretion induced by atrophic gastritis might prevent this acid reflux. This may be the reason RE is an uncommon disease in Japan.     

Diagnosis and treatment of gastroesophageal reflux disease in the elderly

Gastroesophageal reflux disease poses special diagnostic and therapeutic challenges in the elderly. These patients may not report the classic symptoms of dysphagia, chest pain, and heartburn, and they are more likely to develop severe disease and complications such as esophageal ulceration and bleeding. Therapeutic options include lifestyle changes, medication, and surgery. Polypharmacy and changes in renal, hepatic, and gastrointestinal function can complicate treatment. Proton pump inhibitors can help optimize disease management. The most common primary presenting symptoms of GERD in the elderly are regurgitation, dysphagia, dyspepsia, vomiting, and noncardiac chest pain, rather than heartburn. Because the elderly commonly take multiple drugs for various comorbidities, drug interactions and treatment responses must be carefully assessed in this patient population. Nonpharmacologic measures may be helpful but often do not relieve nighttime GERD symptoms.     

GERD: guidance in changing life-style

Gastroesophageal reflux disease (GERD) is increasing due to adoption of a western life style and an aging society in recent years. The symptoms of GERD, such as heartburn, regurgitation of gastric contents into the mouth, and chest pain, decrease QOL, and continuous treatment is necessary. Treatment of GERD is mainly drug therapy; however, it is believed that providing guidance in changing life-style and providing information about the disease will permit long-lasting relief of the symptoms.     

Therapeutic approaches to non-erosive GERD--comparison between the Western countries and Japan

Some patients with heartburn may not show endoscopic evidence of esophagitis. They were called as "endoscopy-negative GERD", "non-erosive reflux disease (NERD)" or "symptomatic-GERD". Symptom of heartburn might be more severe in Europe and United States when compared to those in Japan. NERD patients seem to be more resistant to pharmaco-therapy and surgical procedures, and it seems to be more prominent in patients in the Western countries than those in Japan. Differences between the Western countries and Japan might be based on the difference of the diet habit, but the contamination of functional gastrointestinal disorders might be also involved.     

递减法抗反流药物治疗阻塞性睡眠呼吸暂停综合征合并反流性食管炎的疗效分析

目的探讨递减法抗反流药物治疗阻塞性睡眠呼吸暂停综合征（OSAS）合并反流性食管炎（RE）患者的临床疗效。方法对伴有反酸、胃灼热等反流症状的29例中重度OSAS患者，经夜间多导睡眠图（PSG）、胃镜检查确诊后，采用递减法给予抗反流药物治疗6个月后观察临床疗效，同时复查PSG及胃镜。结果治疗8周后，29例患者胸骨后疼痛、胃灼热、反酸、白日嗜睡等症状明显改善，症状积分明显下降，与治疗前比较有显著差异。治疗6个月后，患者胸骨后疼痛、胃灼热、反酸、白日嗜睡等症状较治疗前及治疗8周后明显改善，且呼吸暂停低通气指数（AHI）较治疗前明显降低；最低血氧饱和度（LS02）有增加，但与治疗前比较无显著差异。治疗后，RE愈合22例，明显好转6例，有效率高达97％。结论递减法抗反流药物可有效治疗RE，部分降低AHI，且对血氧饱和度无明显影响，但不能完全缓解OSAS，可作为辅助治疗。     

Definition and classification of GERD

Gastro-esophageal reflux disease(GERD) is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Traditionally, it was defined as a condition in which either or both of reflux esophagitis and reflux symptoms can be identified. The Montreal definition expanded the category of GERD to complications of esophagitis and extra-esophageal symptoms with or without established evidence on the correlation with GERD. Symptomatic patients those who lacks the evidence of mucosal breaks are called as NERD. Functional heartburn, defined in Rome III, is similar in symptoms but different in the responsiveness to PPIs. Increasing knowledge will clarify what the gastroesophageal reflux really causes health problems.     

Approach to gastroesophageal reflux disease in primary care: Putting the Montreal definition into practice

OBJECTIVE

To apply the recently published Montreal definition of gastroesophageal reflux disease (GERD) in primary care.

SOURCES OF INFORMATION

The Montreal definition of GERD was developed by an international consensus group of experts in GERD and primary care physicians using rigorous evidence-based methods along with modern consensus development techniques and a patient-centred approach.

MAIN MESSAGE

Gastroesophageal reflux disease can be diagnosed in primary care based on symptoms alone without additional diagnostic testing. Symptoms reach a threshold where they constitute disease when they are troublesome (cause difficulty) to patients. In addition to the cardinal symptoms of heartburn and regurgitation, people with GERD can also have sleep disturbances, chest pains, or respiratory symptoms. Monitoring patients’ response to proton pump inhibitor therapy can confirm the success of management. Treatment for symptoms of GERD can also heal underlying reflux esophagitis if it is present.

CONCLUSION

Primary care physicians can diagnose and manage GERD confidently in most patients by investigating and treating troublesome symptoms without the need for additional investigations or referral to specialists.     

Gastroesophageal reflux disease: clinical manifestations.

Gastroesophageal reflux disease (GERD) is generally a lifelong illness that affects many people, but its significance is often underestimated. Chronic abnormal gastric reflux results in erosive esophagitis in up to 60% of patients with GERD. Esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma are the most serious complications of GERD. Although heartburn and acid regurgitation are the most common complaints, extraesophageal symptoms such as noncardiac chest pain, laryngitis, coughing, and wheezing can be manifestations of GERD. Unfortunately, the severity of symptoms is not a reliable indicator of the severity of erosive esophagitis. Endoscopy is the preferred method to diagnose and grade erosive esophagitis, and various classification systems are used to grade disease severity. The Los Angeles Classification is a valid and widely accepted system to evaluate the severity of erosive esophagitis. The immediate goals of treatment are to provide effective symptomatic relief and to achieve healing in patients with esophageal damage. The treatment regimen often begins by prescribing a therapy to reduce gastric acid secretion. A proton pump inhibitor is the preferred agent for many patients. Because GERD is a chronic, relapsing disease, long-term maintenance therapy is usually necessary to relieve symptoms, prevent complications, and improve the quality of life in patients with GERD.     

Endoluminal gastroplication. A new therapeutic endoscopic procedure for gastroesophageal reflux disease.

It is estimated that more than 15 million Americans suffer daily from gastroesophageal reflux disease (GERD) (De Vault, 1995). The spectrum of symptoms for GERD ranges from simple heartburn and regurgitation to persistent esophageal tissue damage with subsequent development of serious complications. The frequent occurrence and intensity of GERD symptoms can severely impact a person's quality of life (Behar, 1990). Until recently, treatment options included a lifetime of drug therapy, disagreeable daily lifestyle changes, and the possibility of invasive surgery. In 2000, the Food and Drug Administration cleared a new endoscopic tool called the EndoCinch, a device that enables endoscopic endoluminal gastroplication as an outpatient procedure for the treatment of GERD. Endoscopic endoluminal gastroplication has been shown to be a safe and effective therapeutic outpatient procedure offering sustainable clinical benefits and cost savings to patients suffering with GERD (Patel, 2001; Raijman, 2001; Weiland, 2001). The purpose of this article is to present an overview of GERD with a particular focus on management of the disease using this new procedure.     

Esophageal pH monitoring

According to westernization of dairy life-style and aging, gastroesophageal reflux disease (GERD) with its physical symptoms such as heartburn is increasing in Japan. Although typical GERD has reflux esophagitis, GERD patients without abnormal endoscopic findings called non-erosive GERD (NERD) have been paid great attention. And more, the association between GERD and chronic respiratory diseases or laryngeal disease has been reported. To catch the more information about clinical questionnaire of GERD cases, esophageal pH monitoring is a useful method because of evaluating the direct condition of acid exposure of esophagus. Recently the new wireless pH monitoring system have been developed, this system is less stress than conventional method and has performance of pH recording for continuous 48 hours time. The widespread usage of pH monitoring system is expected to give us the new knowledge of GERD, NERD and GERD associated diseases.     

Clinical manifestations and complications of gastroesophageal reflux disease (GERD)

Gastroesophageal reflux-induced diseases are among the most common disorders and are associated with classical oesophageal manifestations of gastroesophageal reflux disease (GERD) including a range of symptoms such as heartburn, acid regurgitation and chest pain, and also organic manifestations such as oesophagitis, oesophageal strictures and ulcerations, Barrett's oesophagus and oesophageal adenocarcinoma. Recognition of its impact on other organ systems, extra-oesophageal reflux diseases, such as the ear, nose and throat (ENT) region and the bronchopulmonary system, as well as its contribution to symptoms such as chest pain and sleep disturbances, is also increasing. This paper addresses the symptoms, diseases and complications in which the abnormal reflux of gastric content to the oesophagus and adjacent organ systems is believed to be a frequent contributory factor.