Gastroesophageal reflux disease

GERD is a common chronic gastrointestinal disorder, and its prevalence in Asia is increasing. Classical symptoms of heartburn and regurgitation are common presentations. There is no standard criterion for the diagnosis of GERD, and 24-h pH monitoring lacks sensitivity in NERD. Furthermore, diagnostic studies for gastroesophageal reflux disease have several limitations. A short course of PPI is often used in clinical practice as a diagnostic test for gastroesophageal reflux disease. Elderly patients with GERD usually present with atypical manifestations, and they tend to develop more severe disease. PPI remains the mainstay of treatment for GERD. In a subset of patients who wish to discontinue maintenance treatment, anti-reflux surgery is a therapeutic option.     

Gastroesophageal reflux disease

Opinion Statement Prior to the advent of proton pump inhibitors, internists recommended antireflux surgery primarily for patients whose gastroesophageal reflux disease (GERD) failed to respond to medical therapy. Although many physicians still cling to the notion that antireflux surgery is a procedure best reserved for “medical failures,” today this position is inappropriate. Modern medical treatments for GERD are extraordinarily effective in healing reflux esophagitis. It is uncommon to encounter patients with heartburn or esophagitis due to GERD who do not respond to aggressive antisecretory therapy. Indeed, the very diagnosis of GERD must be questioned for patients whose esophageal signs and symptoms are unaffected by the administration of proton pump inhibitors in high dosages. In the large majority of these so-called refractory patients, protracted esophageal pH monitoring reveals good control of acid reflux by the proton pump inhibitors. This finding indicates that the persistent symptoms usually are not due to acid reflux, but to other problems such as functional bowel disorders. Medical treatment fails in such patients because the diagnosis is mistaken, not because the drugs fail to control acid reflux. Modern antireflux surgery also is highly effective for controlling acid reflux, but fundoplication will not be effective for relieving symptoms in patients whose symptoms are not reflux-induced. Therefore, many patients deemed failures of modern medical therapy would be surgical failures as well. Antireflux surgery is an excellent treatment option for patients with documented GERD who respond well to medical therapy, but who wish to avoid the expense, inconvenience, and theoretical risks associated with lifelong medical treatment. Ironically, surgical therapy for GERD today is best reserved for patients who are medical successes.     

反流性咽喉炎的研究进展

随着对胃食管反流病认识的深入,其对咽喉部的影响越来越受到临床的关注,研究证明它是导致咽喉部疾病的重要致病因素之一。胃食管反流对消化系统影响的研究很多,但其与咽喉反流性疾病的相关研究甚少,很多基层医生对该病还不甚了解。本文主要对反流性咽喉炎的发病机制、临床表现、诊断方法和治疗作一综述。     

Gastroesophageal reflux disease and extraesophageal disease

The patient with extraesophageal manifestations of gastroesophageal reflux disease presents a clinical challenge. Symptom presentation overlaps with other otolaryngologic and pulmonary disease, and heartburn might be infrequent or absent. Endoscopy and pH monitoring are insensitive and therefore not useful in many patients as diagnostic modalities. Thus, antisecretory therapy is used as both a diagnostic trial and as therapy in the majority. Attention to optimizing therapy and judicious use of endoscopy and reflux monitoring are needed to minimize cost and maximize success.     

Gastroesophageal reflux disease in pregnancy

Opinion statement Gastroesophageal reflux disease (GERD) in pregnancy presents a special challenge for the clinician, predominantly because of the potential side effects of pharmacologic interventions on the fetus. Lifestyle and dietary modifications, change in sleeping posture, and antacid medications are emphasized, as these options pose little risk to the fetus. When these interventions are not successful, sucralfate, a mucosal protectant with little to no systemic absorption, should be considered next. Therapy with H₂ receptor antagonists or proton pump inhibitors can be considered in patients with refractory symptoms; though not approved for this use, they are likely safe, particularly in third trimester. Prokinetic agents should be used with extreme caution or avoided altogether in the pregnant patient.     

Gastroesophageal reflux disease and obesity

Logic would suggest that obesity would be a strong risk factor for causing GERD and certainly for exacerbation of GERD. Though the balance of the epidemiologic data support a relationship, true cause and effect cannot be documented. Thus, making the recommendation to lose weight to the GERD patient who is obese is reasonable. Other health reasons, however, supersede GERD as the primary impetus to lose weight.     

Gastroesophageal reflux disease during pregnancy

Approximately two thirds of pregnant patients develop heartburn. The origin is multifactorial, but the predominant factor is a decrease in LES pressure caused by female sex hormones, especially progesterone. Mechanical factors play a small role. Serious reflux complications during pregnancy are rare; therefore EGD and other diagnostic tests are infrequently needed. Symptomatic GERD during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line medical therapy. If symptoms persist, H2RAs should be used. Ranitidine is probably preferred because of its documented efficacy and safety profile in pregnancy, even in the first trimester. Proton-pump inhibitors are reserved for the woman with intractable symptoms or complicated reflux disease. Lansoprazole may be the preferred PPI because of its safety profile in animals and case reports of safety in human pregnancies.     

胃食管反流病与趋化性细胞因子

胃食管反流病(GERD)是一种临床常见病,其病因众多,但迄今为止尚无明确的发病机制.目前,诸多研究表明,趋化性细胞因子在胃食管反流病中有重要作用.此文就促炎症趋化性细胞因子与GERD发病等方面的研究作一综述.     

Gastroesophageal reflux disease in pregnancy

Gastroesophageal reflux disease during pregnancy is common. Altered structure and function of the normal physiological barriers to reflux of gastric contents into the oesophagus explain the high incidence of this problem in pregnant women. For the majority of patients, life-style modifications are helpful, but are not sufficient to control symptoms and medication is required. The optimum management of reflux in pregnant patients requires special attention and expertise, since the safety of the mother, foetus and neonate remain the primary focus. Gastroenterologists and obstetricians should work together to optimise treatment. Typically, one utilises a step-up program that starts with life-style modifications and antacids. If those methods fail, histamine-2 receptor antagonists and proton pump inhibitors are tried. Rarely, promotility agents are used. Initiation of these medications must be undertaken after a careful discussion of risks and benefits with patients. In patients without a prior history of reflux, symptoms usually abate after delivery.     

Gastroesophageal reflux disease in children

In the pediatric population, gastroesophageal reflux most often presents in infancy as effortless regurgitation, but pathologic GERD is accompanied by signs of malnutrition, respiratory diseases, and esophagitis or its complications. Because of the distinctive pathophysiology predisposing infants to GERD, the diagnostic approach must begin with a thorough history that determines the extent of further diagnostic tests and the course of management. Empiric therapy assumes importance in infants with GERD because of the limited differential diagnoses in consideration. Conservative therapy is of utmost importance because of the unique provocative factors in the pathophysiology of infantile GERD. Prokinetic pharmacotherapy takes precedence over acid suppression because of the more important role of motility factors compared with acid secretion in infantile GERD.     

Gastroesophageal reflux disease is a progressive disease

It is controversial whether gastrooesophageal reflux disease represents a spectrum disease from a nonerosive to a complicated one, or whether it is a categorial disease, i.e. it can be divided into three categories, such as nonerosive gastrooesophageal reflux disease, erosive gastrooesophageal reflux disease and Barrett's esophagus (BE) with little or no transition from one category to the other. This controversy might be of general interest, because it has some implications in the management of the patient. However, literature data concerning the natural history of gastrooesophageal reflux disease are very limited, and in particular very few papers have dealt with the issue of describing the natural history of patients with nonerosive gastrooesophageal reflux disease. Aim of the present review is to reassess these scanty data, and to try to demonstrate that progression from milder to more severe forms of gastrooesophageal reflux disease is possible and documented.     

Gastroesophageal reflux disease and chest pain

Gastroesophageal reflux disease (GERD) is highly prevalent in the general population. Heartburn and acid regurgitation are considered the typical presentation of GERD, that however might represent a major pathogenic mechanism in patients with chest pain without coronary artery disease. Chest pain in this instance is often successfully treated with high-dose antisecretory drugs, but the pathogenetic mechanism remains unclear. Further research is needed to clarify the role of GERD on the pathogenesis of chest pain and to ascertain whether a medical or surgical anti-secretory treatment could represent a possible approach. Patients with non-cardiac chest pain of unknown origin should be carefully screened for the occurrence of GERD.     

Gastroesophageal reflux disease and non-esophageal cancer

The association of gastroesophageal reflux disease(GERD) and esophageal cancer is well known.The carcinogenic properties of the gastroduodenal contents may also lead to cancer in target organs for GERD especially considering that they do not have intrinsic protective mechanisms as found in the esophagus.This review focuses on the putative relation between GERD and non-esophageal cancer.Most of the papers reviewed are far from ideal to prove the relationship of extraesophageal cancer and GERD since a small number ofpatients is presented,most do not control cases based on tobacco usage and obesity,and the diagnosis of GERD is variable,not always from an objective measurement such as p H monitoring but relying on symptoms in most reports.Nevertheless,head and neck and lung cancer have a growing incidence parallel to GERD and a shift towards non-smoking,female gender and adenocarcinoma(compared to squamous cell carcinoma) is arising,similar to the example of esophageal cancer with the exception of the female gender.     

Gastroesophageal reflux disease and the larynx

Gastroesophageal reflux disease (GERD) is associated with ear, nose, and throat (ENT) signs and symptoms. Previously, experiments in animal larynx suggested that acid in combination with pepsin resulted in more laryngeal injury than acid alone. Recently, similar experiments expanded on the above observation, finding no laryngeal inflammation with bile acid, trypsin, or combination of bile constituents in alkaline pH values. Combined, experimental evidence highlights the importance of acidic refluxates that contain pepsin and/or bile acids; however, many patients with laryngeal signs suggestive of GERD do not respond to aggressive acid suppression. This has resulted in controversy about the exact nature of relationship between GERD and ENT signs and symptoms. Because the diagnosis is initially suspected after a laryngoscopic examination by the ENT physicians, the suboptimal clinical response may be caused by the poor specificity of this exam in identifying GERD as the cause of patients' laryngeal symptoms. Hence, a multidisciplinary approach is often required in the optimum treatment of these patients.     

Gastroesophageal reflux disease: new treatments

The primary therapeutic endpoint for patients with gastroesophageal reflux disease is complete relief of symptoms and improvement in quality of life. The withdrawal of cisapride has created a vacuum in the prokinetic market, with few promising drugs in the pipeline. Reflux inhibitors are being considered for clinical trials, but as of yet are unavailable. Proton pump inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, providing excellent relief of symptoms and healing of erosive esophagitis. Isomeric technology with esomeprazole as the prototype represents an advance in PPI pharmacology. Antireflux surgery is now more patient-friendly, with shorter hospitalization and less major morbidity compared to open fundoplication, but surgery is at best equal to medical therapy when optimal doses of antisecretory therapy are used. Two endoscopic procedures were recently approved by the U.S. Food and Drug Administration for treatment of gastroesophageal reflux disease: radiofrequency energy delivery to the gastroesophageal junction, and transoral flexible endoscopic suturing. These techniques should be used selectively until we have more data and until results are compared to the safe and highly effective medical therapies.     

Gastroesophageal reflux disease and sleep disturbances

Nighttime reflux during sleep plays a crucial role in several conditions associated with gastroesophageal reflux disease (GERD). Reflux patterns during arousal and sleep are different because of delayed gastric emptying, reduced esophageal peristalsis, decreases in swallowing and salivary secretion, and prolonged esophageal clearance during sleep. Clinical evidence strongly suggests that GERD is associated with sleep disturbances such as shorter sleep duration, difficulty falling asleep, arousals during sleep, poor sleep quality, and awakening early in the morning. New mechanisms on how GERD affects sleep have been recently identified by using actigraphy, and sleep deprivation was found to induce esophageal hyperalgesia to acid perfusion. Thus, the relationship between GERD and sleep disturbances is bidirectional. Among lifestyle modifications, avoidance of a late night meal plays a role in prevention of nighttime reflux. Treatment with a proton pump inhibitor (PPI) improves both nighttime symptoms and subjective sleep parameters, but its effects on objective sleep parameters remain unclear. Better control of nighttime acid secretion by administering a PPI at different times or by providing a double-dose PPI, adding H(2) receptor antagonists, or other new agents is proposed. The effects of such treatments on sleep disturbances remain to be elucidated. GERD patients with sleep disturbances report more severe symptoms and poorer quality of life as compared to those without sleep disturbances. Consequently, GERD should also be classified as GERD with sleep disturbance and GERD without sleep disturbance.