Clinical impact of gastroesophageal reflux disease in patients with subacute/chronic cough

BackgroundWhile gastroesophageal reflux disease (GERD) is one of the commonest causes of subacute/chronic cough along with cough-variant asthma (CVA) and rhinosinusitis, its clinical impact remains unknown. Therefore, we sought to investigate the impact of GERD in patients with subacute/chronic cough.MethodsBetween April 2012 and March 2018, a total of 312 patients presenting subacute or chronic cough lasting for ≥3 weeks [median cough duration, 4.9 (0.7–434) months] underwent diagnostic tests. GERD symptoms and cough-specific QoL were evaluated through the Frequency Scale for Symptoms of Gastroesophageal reflux (FSSG) and the Japanese version of the Leicester Cough Questionnaire (J-LCQ). According to the FSSG domains, patients with GERD were arbitrarily categorized into 3 groups; acid-reflux predominant, dysmotility predominant, and pauci-symptoms groups, respectively.ResultsThe average scores of J-LCQ was 12.5 (SD3.7). One hundred-forty three were diagnosed as having GERD-related cough based on classical reflux symptoms including heartburn and characteristic triggers of cough such as phonation, rinsing, lying, and eating. Most of them (89.8%) had other causative diseases including CVA. Cough lasted longer (p = 0.019) and required a longer time until alleviation (p = 0.003) in patients with GERD than in those without GERD. They also scored lower J-LCQ than counterpart group (p < 0.0001). In terms of symptom stratification, dysmotility predominant group showed significant more response to specific GERD treatments than the remnants (p = 0.002).ConclusionsThese results indicate that GERD is associated with the aggravation of other causes including CVA. Particularly, dysmotility symptoms may be potential therapeutic target for GERD-related cough.     

The utility of endoscopy in the management of patients with gastroesophageal reflux symptoms

Objective: The utility of endoscopy in the management of patients with symptoms of gastroesophageal reflux disease (GERD) is unclear. The purpose of this prospective study was to assess the impact of endoscopy on the subsequent management of patients with uncomplicated reflux symptoms.
Methods: A total of 742 patients underwent endoscopy for symptoms of GERD. Endoscopists recorded the therapy before endoscopy, the findings of endoscopy, and the treatment recommendations after endoscopy.
Results: There was no difference in pre-endoscopy therapy or grade of esophagitis in subjects undergoing endoscopy for failed therapy versus GERD symptoms alone. After endoscopy, the most common strategy for patients taking omeprazole was to maintain or increase the dose. For those taking an H₂ blocker before endoscopy, the most common outcome was to switch the patient to omeprazole, independent of the grade of esophagitis.
Conclusion: Most patients undergoing endoscopy for symptoms of GERD were switched to omeprazole regardless of the endoscopic findings. No esophageal cancer was identified and the incidence of Barrett's esophagus was low. It appears that endoscopy itself did not change the management of patients receiving H₂-blocker therapy. A trial of a proton pump inhibitor before endoscopy should be considered.     

Clinical analysis of endoscopy negative gastroesophageal reflux disease in the elderly]

The purpose of this study was to describe the clinical analysis of endoscopy negative gastroesophageal reflux disease (EN-GERD) in the elderly. 35 elderly patients of both sexes, 60 years or older with EN-GERD, 33 elderly patients with reflux esophagitis and 41 elderly patients as control group were included in this study. All patients witnessed verbal informed consent to participate in the study. EN-GERD was defined as the patients with normal endoscopy despite of heartburn as their chief complaint and who were completely relieved with heartburn after one-week omeprazole treatment. Helicobacter pylori infection between EN-GERD, reflux esophagitis and control were 37.1%, 24.2% and 56.1%, respectively. The gastric mucosal atrophy under endoscopic findings and the serum pepsinogen I, II ratio in EN-GERD had no significant differences with control. A hiatus hernia with EN-GERD was diagnosed 37.1%, which was lower significantly than 87.9% with reflux esophagitis. The motility of the stomach using the acetaminophen method was the same in patients with EN-GERD, reflux esophagitis and control. The anxiety score of the Hospital Anxiety and Depression Scale was significantly higher in the patients with EN-GERD than in those with reflux esophagitis and control. On the other hand, the severity of reflux symptoms in the patients with EN-GERD was similar as those with reflux esophagitis. We concluded that general anxiety plays an important role in the severity of the reflux symptoms in the patients with EN-GERD. As such symptoms in EN-GERD significantly impair the quality of life, further studies of patients with EN-GERD are greatly needed.     

Evaluation of esophageal function in patients with gastroesophageal reflux disease using transnasal endoscopy

Background and Aims:  To investigate the utility of a new method of carrying out esophageal manometry using a narrow gauge manometry catheter via a transnasal endoscope.
Methods:  The Frequency Scale for the Symptoms of gastroesophageal reflux disease (GERD) (FSSG), a GERD-specific questionnaire, was given to 45 subjects. Subjects 
underwent transnasal endoscopy with three dry and three wet (3 mL water) swallows. Direct observations of the primary peristaltic wave and peristaltic pressure measurement were conducted simultaneously.
Results:  Endoscopic observation of lower esophageal motility associated with swallowing revealed dilatation of the esophageal lumen after swallowing, followed by contraction in association with the primary peristaltic wave. The peristaltic pressure was significantly lower with increased FSSG scores for dry swallows ( r  = −0.347, P  = 0.0212), but no significant correlation was seen for wet swallows.
Conclusions:  The significant negative correlation between reflux symptoms and peristaltic pressure in dry swallows was thought to be that reduced pressure immediately rostral to the lower esophageal sphincter leads to decreased clearance following gastric acid reflux, playing a large part in the onset of symptoms.     

Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy

BACKGROUND AND AIMS: There is growing evidence that gastroesophageal reflux disease (GERD) may cause typical laryngeal/pharyngeal lesions secondary to tissue irritation. The prevalence of those lesions in GERD patients is not well established. The aim of this study was to evaluate the prevalence of GERD signs in the laryngopharyngeal area during routine upper gastrointestinal endoscopy. METHODS: Between July 2000 and July 2001, 1,209 patients underwent 1,311 upper gastrointestinal endoscopies and were enrolled in this study. The structured examination of the laryngopharyngeal area during upper gastrointestinal endoscopy was videotaped for review by three gastroenterologists and one otorhinolaryngologist, blinded to the endoscopic esophageal findings. From the 1,209 patients enrolled in this prospective study, all patients (group I, N = 132) with typical endoscopical esophageal findings of GERD (Savary-Miller I-IV) were selected. The sex- and age-matched control group II (N = 132) underwent upper gastrointestinal endoscopy for different reasons, had no reflux symptoms, and had normal esophagoscopy. RESULTS: In the two groups of patients, we found no difference in the prevalence of abnormal interarytenoid bar findings (32%vs 32%), arytenoid medial wall erythema (47%vs 43%), posterior commissure changes (36%vs 34%), or posterior cricoid wall edema (1%vs 3%). The only difference was noted in the posterior pharyngeal wall cobblestoning (66%vs 50%, P= 0.004). CONCLUSION: The results of this large systematic investigation challenge the diagnostic specificity of laryngopharyngeal findings attributed to gastroesophageal reflux.     

A feasibility trial of narrow band imaging endoscopy in patients with gastroesophageal reflux disease

BACKGROUND AND AIMS: Narrow band imaging (NBI) endoscopy system enhances visualization of microvasculature and mucosal patterns. This study assessed the utility of NBI in patients with gastroesophageal reflux disease (GERD) symptoms. METHODS: Patients with and without GERD symptoms completed 2 validated GERD questionnaires prior to enrollment. The distal esophagus was examined by standard white light endoscopy followed by NBI. The features seen only by NBI were compared between GERD patients and controls. RESULTS: Overall, 80 patients (50 GERD, 30 controls) were eligible for final analysis (mean age, 58.4 years; males, 93.7%; white, 82.5%). A significantly higher proportion of patients with GERD had increased number (OR, 12.6; 95% CI: 3.7-42; P < .0001), dilatation (OR, 20; 95% CI: 6.1-65.3; P < .0001), tortuosity of intrapapillary capillary loops (IPCLs) (OR, 6.9; 95% CI: 2.5-19; P < .0001), presence of microerosions (P < .0001), and increased vascularity at the squamocolumnar junction (OR, 9.3; 95% CI: 1.9-43.6; P = .001) compared with controls. On multivariate analysis, increased number (OR, 5.5; 95% CI: 1.4-21.6) and dilatation (OR, 11.3; 95% CI: 3.2-39.9) of IPCLs were the best predictors for diagnosing GERD. The maximum, minimum, and average number of IPCLs/field were significantly greater in the GERD group compared with controls (P < .0001). Although the interobserver agreement for the various NBI findings was very good, the intraobserver agreement was modest. CONCLUSIONS: NBI endoscopy may represent a significant improvement over standard endoscopy for the diagnosis of GERD. These preliminary findings including inter- and intraobserver agreement need to be evaluated in future prospective, controlled, and blinded GERD trials.     

老年胃食管反流病患者临床特征分析

Objective To analyze clinical characteristics of gastroesophageal reflux disease(GERD) in aged patients for improvement of diagnosis and treatemcnt. Methods The reflux disease questionnaire was performed in patients diagnosed as GERD based on Montreal definition and classification as well as Rome Ⅲ criteria.All patients were divided into elderly group (≥65 years) and control group(＜65 years). The incidence of hita[ hernia (HH), the frequencies of esophagitis (based on Los Angeles classification), clinical features, and quality of life were compared between two groups. Results There was no difference between two groups in male/female ratio and morbidity of HH(P＞0.05). In comparison with control group, the frequency of esophagitis graded as LC or LD increased and extra-esophageal symptoms were higher in elderly group (P＜ 0.05), but the lower typical symptoms (heartburn and regurgitation) were seen in the elderly group(P＜0.05). The scores of role physical, bodily pain and role emotional were higher in elderly group than those in control group (P＜0.05). There was no significant differences between two groups in physical function, vitality,social functioning, mental health, and general health. Conclusion The elderly GERD patients often have lower score of typical reflux symptoms (heartburn and regurgitation) and high incidence of severer esophagitis, but their quality of life is not significantly influenced.     

老年胃食管反流病患者临床特征分析

Objective To analyze clinical characteristics of gastroesophageal reflux disease(GERD) in aged patients for improvement of diagnosis and treatemcnt. Methods The reflux disease questionnaire was performed in patients diagnosed as GERD based on Montreal definition and classification as well as Rome Ⅲ criteria.All patients were divided into elderly group (≥65 years) and control group(＜65 years). The incidence of hita[ hernia (HH), the frequencies of esophagitis (based on Los Angeles classification), clinical features, and quality of life were compared between two groups. Results There was no difference between two groups in male/female ratio and morbidity of HH(P＞0.05). In comparison with control group, the frequency of esophagitis graded as LC or LD increased and extra-esophageal symptoms were higher in elderly group (P＜ 0.05), but the lower typical symptoms (heartburn and regurgitation) were seen in the elderly group(P＜0.05). The scores of role physical, bodily pain and role emotional were higher in elderly group than those in control group (P＜0.05). There was no significant differences between two groups in physical function, vitality,social functioning, mental health, and general health. Conclusion The elderly GERD patients often have lower score of typical reflux symptoms (heartburn and regurgitation) and high incidence of severer esophagitis, but their quality of life is not significantly influenced.     

Prevalence of upper respiratory symptoms in patients with symptomatic gastroesophageal reflux disease.

This study evaluated the prevalence of upper respiratory symptoms (URS) among patients with symptomatic gastroesophageal reflux disease (GERD). Seventy-four subjects with heartburn completed a URS questionnaire before dual-probe, 24-h esophageal pH monitoring. The URS questionnaire was also completed by 74 normal volunteers without previous or current symptoms of GERD. Esophageal pH monitoring results were classified as normal, distal, or proximal and distal gastroesophageal reflux using standardized criteria. Mean URS scores (+/- SD) were 8.31 +/- 3.98 in the 52 subjects with GERD and 4.57 +/- 3.57 in the 22 subjects with negative pH probe studies, p = 0.02. Subjects with negative pH probe studies and normal volunteers scored similarly on the URS questionnaire. Reflux episodes/24 h correlated with URS scores, r = 0.47, p = 0.0001. Seventy-five percent of subjects with upper reflux, 68% of subjects with lower reflux, 36% of subjects with normal esophageal pH studies, and 9% of normal volunteers reported laryngeal symptoms for at least 5 d/mo. Sixty-nine percent of subjects with upper reflux, 50% of subjects with lower reflux, 31% of subjects with normal pH studies, and 14% of normal volunteers reported nasal symptoms for at least 5 d/mo. URS are frequent among subjects with GERD. Keywords: rhinitis; upper airway; gastroesophageal reflux     

老年胃食管反流病患者临床特征分析

目的 探讨老年胃食管反流病(GERD)患者的临床特征,为临床诊断、治疗提供帮助.方法 根据GERD蒙特利尔的标准、中国胃食管反流病共识意见等,将GERD患者分为老年组(年龄≥65岁)与中青年组(年龄＜65岁);通过问卷调查,分析2组GERD患者的食管裂孔疝(HH)、食管炎(洛杉矶标准)、临床症状(反流、烧心等)、生活质量.结果 两组性别比差异无统计学意义(P＞0.05).与中青年GERD患者比较:老年患者重度食管炎(LC级+LD级)比例高(P＜0.05);典型反酸、烧心症状轻(P＜0.05),食管外症状发生率高(P＜0.05);但HH发生率差异无统计学意义(P＞0.05).老年患者生理功能、总体健康、活力、社会功能、精神健康、躯体生理健康总评和精神心理健康总评积分与年轻组差异无统计学意义(P＞0.05),仅生理职能、躯体疼痛、情感职能积分较中青年组高(P＜0.05).结论 老年GERD患者典型反流症状(反食、烧心)较少见,易发生重度食管炎,但老年GERD患者生活质量无明显下降.     

Laryngopharyngeal reflux in patients with symptoms of gastroesophageal reflux disease

Laryngopharyngeal reflux (LPR) has been extensively studied in patients with laryngeal signs and symptoms, gastroesophageal reflux being identified in approximately 50%. Few studies have investigated the incidence and significance of LPR in GERD patients. Two-hundred and seventy-six consecutive patients referred with symptoms of gastroesophageal reflux had dual probe 24 h pH, esophageal manometry, GERD and ENT questionnaires. LPR was defined as at least three pharyngeal reflux events less than pH 5.0 with corresponding esophageal reflux, but excluding meal periods. Fourty-two percent of patients were positive for LPR on 24 h pH monitoring and 91.3% corresponded with an abnormal esophageal acid score. Distal esophageal acid exposure was significantly greater (P < 0.001) in patients with LPR but symptoms of GERD and regurgitation scores showed no significant differences between patients with positive and negative LPR on 24 h pH. There was no significant difference between the incidence of LPR in patients with or without laryngeal symptoms. There is a high incidence of LPR in patients with GERD but its significance for laryngeal symptoms is tenuous. Fixed distance dual probe pH monitoring allows documentation of conventional esophageal reflux and LPR.     

Pharmacologic management of gastroesophageal reflux disease

The burden of gastroesophageal reflux disease (GERD) results from its widespread prevalence and the unfavorable impact of its symptoms on well-being and quality of life. Whereas abnormalities of the antireflux barrier (lower esophageal sphincter) are important in the pathophysiology of GERD, pharmacologic therapy for GERD is based on suppression of acid, which is responsible for the majority of the symptoms and for epithelial damage. Proton pump inhibitors (PPIs) are the agents of choice for achieving the goals of medical therapy in GERD, which include symptom relief, improvement in quality of life, and healing and prevention of mucosal injury. As a class, these drugs are extremely safe. The newest PPI, esomeprazole, brings a statistically significant increase in healing of mucosal injury and symptom relief in patients with erosive esophagitis, compared with omeprazole and lansoprazole. This article reviews the role of medical therapy in the short-and long-term management of symptomatic patients with or without erosive esophagitis, including extraesophageal presentations, GERD during pregnancy, and Barrett’s esophagus. Management of refractory patients is addressed.     

The potential impact of contemporary developments in the management of patients with gastroesophageal reflux disease undergoing an initial gastroscopy

BACKGROUND:

Recent developments may alter the approach to patients presenting with gastroesophageal reflux disease (GERD)-like symptoms. A newly proposed Montreal consensus definition of Barrett’s esophagus includes all types of esophageal columnar metaplasia, with or without intestinal-type metaplasia. There is also increasing recognition of eosinophilic esophagitis (EE) in patients with GERD-like symptoms.

OBJECTIVE:

To quantify the impact of these developments on a multiphysician general gastroenterology practice in a tertiary care medical centre.

METHODS:

Medical charts of all patients having an initial gastroscopy for GERD-like symptoms over a one-year period were reviewed retrospectively, and audits of their endoscopic images and esophageal biopsies were performed.

RESULTS:

Of the 353 study participants, typical symptoms of heartburn and acid reflux were present in 87.7% and 23.2%, respectively. Less commonly, patients presented with atypical symptoms (eg, dysphagia in 9.4%). At endoscopy, 26% were found to have erosive esophagitis and 12% had endoscopically suspected esophageal metaplasia. Histological evaluation was available for 65 patients. Ten of the 65 biopsied patients (15%) met traditional criteria for Barrett’s esophagus (ie, exhibiting intestinal-type metaplasia), whereas 49 (75%) fulfilled the newly proposed consensus definition of Barrett’s esophagus. Five patients (7.7%) met the study criteria for EE (more than 20 eosinophils per high-power field), four of whom had not been previously recognized.

CONCLUSIONS:

Among patients presenting with GERD-like symptoms, the prevalence of Barrett’s esophagus may increase markedly if the Montreal definition is adopted. In addition, growing awareness of EE may lead to an increase in the prevalence of this diagnosis. Prospective studies of the management implications of these findings are warranted.     

Pharmacologic management of gastroesophageal reflux disease

Opinion statement The burden of gastroesophageal reflux disease (GERD) results from its widespread prevalence and the unfavorable impact of its symptoms on well-being and quality of life. Whereas abnormalities of the antireflux barrier (lower esophageal sphincter) are important in the pathophysiology of GERD, pharmacologic therapy for GERD is based on suppression of acid, which is responsible for the majority of the symptoms and for epithelial damage. Proton pump inhibitors (PPIs) are the agents of choice for achieving the goals of medical therapy in GERD, which include symptom relief, improvement in quality of life, and healing and prevention of mucosal injury. As a class, these drugs are extremely safe. The newest PPI, esomeprazole, brings a statistically significant increase in healing of mucosal injury and symptom relief in patients with erosive esophagitis, compared with omeprazole and lansoprazole. This article reviews the role of medical therapy in the short- and long-term management of symptomatic patients with or without erosive esophagitis, including extraesophageal presentations, GERD during pregnancy, and Barrett’s esophagus. Management of refractory patients is addressed.     

胃食管反流病患者的临床特征及其影响因素分析

目的分析胃食管反流病(GERD)患者的临床特征以及影响其发生的因素。方法选取深圳市龙岗区横岗人民医院消化内科2011年5月-2013年5月收治的GERD患者146例作为观察组,另选取148例非GERD患者为对照组,探讨其发病的危险因素。结果 GERD患者发生率最高的6项相关症状为反酸、烧心、上腹部不适、吞咽困难、胸痛、胸骨后不适;治疗前观察组Gerd Q得分显著高于对照组(10.63±2.87 vs 4.02±1.81,P0.05),Gerd Q得分自治疗2周后开始与治疗前比较,差异有显著统计学意义(P0.01);后期有消化道外症状的患者(72例)进行消化道外症状(EED)问卷分析,发现观察组自治疗后4周显著改善,差异有显著统计学意义(P0.01);单因素分析显示GERD影响因素包括:年龄、职业、BMI、腰围、辛辣饮食、高盐饮食、H.pylori感染、吸烟、饮酒、便秘。Logistic多元回归分析显示GERD的危险因素由大到小依次为辛辣饮食、年龄、便秘和职业(OR值分别为4.928、3.673、3.452、3.082)。结论 GERD的临床表现以反酸、烧心、上腹部不适等为主,也会表现出EED的症状;养成良好的饮食习惯、保持肠道畅通、戒烟戒酒、注意锻炼和放松等都能够有效预防和减少GERD的发生。     

Laryngeal disorders in patients with gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common medical condition affecting approximately 35-40% of the adult population in the western world. Chronic laryngeal signs and symptoms associated with GERD are often referred to as reflux laryngitis or laryngopharyngeal reflux (LPR). It is estimated that up to 15% of all visits to the otolaryngology offices are because of manifestations of LPR. Injury may occur as a result of one or chronic reflux of gastroduodenal contents directly injuring the laryngeal mucosa. Since less amount of acid is required to make the injury to the larynx as compared to injury to esophagus; it is believed that intermittent exposure to small amount of gastric content can result in laryngitis. The most common presenting symptoms of LPR include hoarseness, sore throat, throat clearing, and chronic cough. The diagnosis of LPR is usually made on the basis of presenting symptoms and associated laryngeal signs including laryngeal edema and erythema. Current recommendation for management of this group of patients is empiric therapy with twice daily proton-pump inhibitors for 2 to 4 months. In majority of those who are unresponsive to such therapy other causes of laryngeal irritation is considered. Surgical fundoplication is most effective in those who are responsive to acid suppressive therapy.     

Saliva transit in patients with gastroesophageal reflux disease

Saliva is an important factor in the neutralization of the acidity of the refluxed material that comes from the stomach to the esophagus. The impairment of saliva transit from oral cavity to distal esophagus may be one of the causes of esophagitis and symptoms in gastroesophageal reflux disease (GERD). With the scintigraphic method, the transit of 2 mL of artificial saliva was measured in 30 patients with GERD and 26 controls. The patients with GERD had symptoms of heartburn and acid regurgitation, a 24‐hour pH monitoring with more than 4.2% of the time with pH below four, 26 with erosive esophagitis, and four with non‐erosive reflux disease. Fourteen had mild dysphagia for solid foods. Twenty‐one patients had normal esophageal manometry, and nine had ineffective esophageal motility. They were 15 men and 15 women, aged 21–61 years, mean 39 years. The control group had 14 men and 12 women, aged 19–61 years, mean 35 years. The subjects swallowed in the sitting and supine position 2 mL of artificial saliva labeled with 18 MBq of ^99mTechnetium phytate. The time of saliva transit was measured from oral cavity to esophageal‐gastric transition, from proximal esophagus to esophageal‐gastric transition, and the transit through proximal, middle, and distal esophageal body. There was no difference between patients and controls in the time for saliva to go from oral cavity to esophageal‐gastric transition, and from proximal esophagus to esophageal‐gastric transition, in the sitting and supine positions. In distal esophagus in the sitting position, the saliva transit duration was shorter in patients with GERD (3.0 ± 0.8 seconds) than in controls (7.6 ± 1.7 seconds, P = 0.03). In conclusion, the saliva transit from oral cavity to the esophageal‐gastric transition in patients with GERD has the same duration than in controls. Saliva transit through the distal esophageal body is faster in patients with GERD than controls.