Gastroesophageal reflux disease in Asian countries: Disorder of nature or nurture?

Gastroesophageal reflux disease (GERD) is less prevalent in Asia than in the West, but there is now evidence to suggest that its frequency is rapidly rising in Asia. The different prevalence rates reported in various Asian studies may represent different points in the 'rising' phase of GERD. The cause for the lower but increasing prevalence of GERD in Asia is not known, but genetics and to some extent environmental factors, may have initially protected Asians against GERD. However, with the recent globalization of economies, the associated lifestyle changes in many developing Asian countries may have tipped the balance in favor of the development of GERD.     

Helicobacter pylori and gastro-oesophageal reflux disease: association and clinical implications. To treat or not to treat with anti-H. pylori therapy?

BACKGROUND: It has been reported that patients are at risk of developing reflux oesophagitis after successful anti-Helicobacter pylori therapy, and the presence of the bacterium might be protective against the development of reflux oesophagitis. METHODS: Review of the literature. RESULTS: H. pylori is relevant to the management of oesophagitis because it increases the pH-elevating effect of proton-pump inhibitors. which increase the tendency of H. pylori gastritis to progress to atrophic gastritis, and because eradication of H. pylori increases the likelihood of oesophagitis. H. pylori increases basal gastrin levels, basal acid output, meal-stimulated maximal acid output and 24-h intragastric acidity. The effects on gastric acid production depend on the distribution of gastritis in the stomach. CONCLUSION: H. pylori eradication may induce or exacerbate gastro-oesophageal reflux by its influence on gastric acidity and the antisecretory action of proton-pump inhibitors.     

To SWiTCH or not to SWiTCH?

In this issue of Blood, Ware and Helms report results from the Stroke With Transfusions Changing To Hydroxyurea (SWiTCH) study designed to determine whether hydroxyurea is as effective as transfusions in preventing recurrent strokes in children with sickle cell anemia. The finding of strokes in 7 of 67 children receiving hydroxyurea but none in 66 children who received transfusions led the authors to conclude that hydroxyurea is not effective in mitigating strokes.1     

Gastroesophageal reflux disease and Barrett��s esophagus

Gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. The spectrum of injury includes esophagitis, stricture, the development of columnar metaplasia in place of the normal squamous epithelium (Barrett’s esophagus), and adenocarcinoma. Barrett’s esophagus is a premalignant lesion detected in the majority of patients with esophageal and gastroesophageal adenocarcinoma. The incidence of these cancers has been increasing in the United States and they are associated with a low rate of survival (5-year survival rate, 15–20%). When symptoms of gastroesophageal reflux disease are typical and the patient responds to therapy, no diagnostic tests are necessary to verify the diagnosis. Endoscopy is the primary test in patients whose condition is resistant to empirical therapy but its yield in this setting is low because of the poor correlation between symptoms attributed to the condition and endoscopic features of the disease. Clinical experience suggests that lifestyle modifications may be beneficial for gastroesophageal reflux disease although trials of the clinical efficacy of dietary or behavioral changes are lacking. Abundant data from randomized trials show benefits of inhibiting gastric acid secretion and suggest that proton-pump inhibitors are superior to H2-blockers and that both are superior to placebo. In patients with Barrett’s esophagus, antireflux interventions are intended to control symptoms of reflux and promote healing of the esophageal mucosa. If a patient has symptoms refractory to proton-pump inhibitors or cannot tolerate such therapy, antireflux surgery, most commonly Nissen fundoplication, may be an alternative management approach. In patients with high-grade dysplasia, endoscopic therapies or surgical resection must be considered.     

Rural and urban microbiota: To be or not to be?

A multitude of metagenomic studies has brought to light an enormous richness of human gut microbiota compositions. In this space of possible configurations, clinical specialists are trying to mine the markers of healthy microbiota via case-control and longitudinal studies. We have discovered potentially beneficial communities while examining the microbial diversity in rural Russians in comparison with the urban dwellers. In this addendum, we further examine the data by elaborating on some of the less common types and suggesting the possible co-metabolism of their drivers. In the light of the first validated clinically effective bacterial transplantation, we discuss the concept of a reference healthy microbiota, outline the problems encountered on the way to its restoration in the developed world, and speculate if rural communities can serve as a source for its prototype.     

Newer therapies for Gastroesophageal reflux disease: Numb, burn, or stitch?

Preliminary evidence on the efficacy of endoscopically performed interventional techniques for treatment of gastroesophageal reflux disease has emerged in the last year. Three different techniques—radio frequency-induced thermal injury to the gastroesophageal junction, endoscopic plication of gastric folds, and endoscopic implantation of inert polymers into the gastroesophageal junction—have shown promising short-term results. In this review we describe and critically appraise the available published evidence on the efficacy and safety of these techniques. In addition, we discuss clinical and physiologic aspects that are essential for their evaluation and comparison. The need for well-designed controlled clinical trials that assess the long-term efficacy and safety in a wider spectrum of patients is evident, and hopefully such trials are forthcoming. Operator experience and continued evolution in these techniques are likely to be important determinants.     

Is reflux cough due to gastroesophageal reflux disease or laryngopharyngeal reflux?

Reflux is a common cause of chronic cough. Surveys of patients with chronic cough point to a high association with gastroesophageal disease. Because of our bipedalism and speech, humans are prone to both reflux and aspiration. Whether the reflux of stomach contents into the esophagus alone is sufficient to cause cough or whether reflux into the upper airway is required is unknown. In 50 consecutive patients with chronic cough, symptoms of laryngopharangeal reflux (LPR) paralleled those of gastroesophageal reflux, suggesting no unique syndrome of LPR but that it is part of the protean manifestations of reflux disease.