The association between gastroesophageal reflux disease and obesity

Nearly all epidemiologic studies have found an association between increasing body mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD). Changes in gastroesophageal anatomy and physiology caused by obesity may explain the association. These include an increased prevalence of esophageal motor disorders, diminished lower esophageal sphincter (LES) pressure, the development of a hiatal hernia, and increased intragastric pressure. Central adiposity may be the most important risk for the development of reflux and related complications such as Barrett's esophagus and esophageal adenocarcinoma. Weight loss, through caloric restriction and behavioral modification, has been studied infrequently as a means of improving reflux. Bariatric surgery and its effects on a number of obesity-related disorders have been studied more extensively. Roux-en-Y gastric bypass (RYGB) has been consistently associated with improvement in the symptoms and findings of GERD. The mechanism of action through which this surgery is successful at improving GERD may be independent of weight loss and needs further examination. Current evidence suggests that laparoscopic adjusted gastric banding should be avoided in these patients as the impact on gastroesophageal reflux disease appears unfavorable.     

Gastroesophageal reflux disease,obesity and laparoscopic sleeve gastrectomy: The burning questions

Obesity is a global health epidemic with considerable economic burden.Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk.Sleeve gastrectomy accounts for almost half of all bariatric surgeries worldwide but concerns regarding its relationship with gastroesophageal reflux disease(GERD)has been a topic of debate.GERD,including erosive esophagitis,is highly prevalent in the obese population.The role of pre-operative endoscopy in bariatric surgery has been controversial.Two schools of thought exist on the matter,one that believes routine upper endoscopy before bariatric surgery is not warranted in the absence of symptoms and another that believes that symptoms are poor predictors of underlying esophageal pathology.This debate is particularly important considering the evidence for the association of laparoscopic sleeve gastrectomy(LSG)with de novo and/or worsening GERD compared to the less popular Roux-en-Y gastric bypass procedure.In this paper,we try to address 3 burning questions regarding the inter-relationship of obesity,GERD,and LSG:(1)What is the prevalence of GERD and erosive esophagitis in obese patients considered for bariatric surgery?(2)Is it necessary to perform an upper endoscopy in obese patients considered for bariatric surgery?And(3)What are the long-term effects of sleeve gastrectomy on GERD and should LSG be done in patients with pre-existing GERD?     

Clinical significance of hiatal hernia

The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted "two-sphincter hypothesis." The gastroesophageal junction is an anatomically complex area with an inherent antireflux barrier function. However, the gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD. Because GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma, a better understanding of this association is warranted. Hiatal hernias can be diagnosed radiographically, endoscopically or manometrically, with each modality having its own limitations, especially in the diagnosis of hiatal hernias less than 2 cm in length. In the future, high resolution manometry should be a promising method for accurately assessing the association between hiatal hernias and GERD. The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition. Surgery should be considered for those patients with refractory symptoms and for those who develop complications, such as recurrent bleeding, ulcerations or strictures.     

Role of endoscopy in the bariatric surgery of patients

Obesity is an increasingly serious health problem in nearly all Western countries.It represents an important risk factor for several gastrointestinal diseases,such as gastroesophageal reflux disease,erosive esophagitis,hiatal hernia,Barrett’s esophagus,esophageal adenocarcinoma,Helicobacter pylori infection,colorectal polyps and cancer,non-alcoholic fatty liver disease,cirrhosis,and hepatocellular carcinoma.Surgery is the most effective treatment to date,resulting in sustainable and significant weight loss,along with the resolution of metabolic comorbidities in up to 80%of cases.Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery.There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings,such as large hiatal hernia or Barrett’s esophagus,are detected preoperatively.The value of a routine endoscopy before bariatric surgery in asymptomatic patients(screening esophagogastroduodenoscopy)remains controversial.The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms,the management of complications,and the evaluation of weight loss failure.It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting.The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.     

Gastroesophageal reflux disease and morbid obesity: To sleeve or not to sleeve?

Laparoscopic sleeve gastrectomy(LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease(GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h p H monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve(both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Rouxen-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX? Reflux Management System procedure and the Stretta? procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of p H monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5~(th) International Consensus Conference on sleeve gastrectomy.     

Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease

OBJECTIVE: Although reflux esophagitis is a multifactorial disease, the relative importance of these pathogenetic factors has not been clearly established. In this study, regression analysis was used to model the major determinants of esophagitis in patients with symptomatic gastroesophageal reflux disease (GERD). METHODS: Sixty-six GERD patients and 16 asymptomatic controls were evaluated. All patients underwent upper endoscopy, esophageal manometry, and 24-h pH monitoring. Esophagrams were performed in 38 of the GERD patients and all controls. Stepwise regression was performed using esophagitis severity as the dependent variable. Logistic regression was performed grouping subjects as controls, nonerosive GERD, or erosive esophagitis. RESULTS: Hiatal hernia size, lower esophageal sphincter pressure, esophageal acid exposure, and number of reflux episodes >5 min significantly correlated with esophagitis severity. Stepwise regression identified hiatal hernia size (p = 0.0001) and lower esophageal sphincter pressure (p = 0.0024) as significant predictors of esophagitis. Logistic regression also identified hiatal hernia size (chi2 = 17.07, p < 0.0001) and lower esophageal sphincter pressure (chi2 = 5.97, p = 0.0146) as significant predictors of erosive esophagitis. CONCLUSION: Esophagitis severity is best predicted by hiatal hernia size and lower esophageal sphincter pressure. Of these, hiatal hernia size is the strongest predictor.     

Obesity and GERD: Pathophysiology and Effect of Bariatric Surgery

Epidemiologic, endoscopic, and pathophysiologic studies document the relationship between obesity and gastroesophageal reflux disease (GERD). Increased body mass index and accumulation of visceral fat are associated with a two- to threefold increased risk of developing reflux symptoms and esophageal lesions. Given this association, many studies were designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity. Among bariatric procedures, gastric sleeve and banded gastroplasty were shown to have no effect or even worsen reflux symptoms in the postoperative setting. Gastric banding improves reflux symptoms and findings (endoscopic and pH-measured distal esophageal acid exposure) in many patients, but is associated with de novo reflux symptoms or lesions in a considerable proportion of patients. To date, Roux-en-Y gastric bypass is the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms in patients undergoing direct gastric bypass and among those converted from restrictive bariatric procedures to gastric bypass.     

Epidemiology and clinical characteristics of GERD in the Japanese population

We reviewed articles on the epidemiology and clinical characteristics of gastroesophageal reflux disease (GERD) in Japan to clarify these features of GERD in this country. Although the definition of GERD depends on the individual study, the prevalence of GERD has been increasing since the end of the 1990s. The reasons for the increase in the prevalence of GERD may be due to increases in gastric acid secretion, a decrease in the Helicobacter pylori infection rate, more attention being paid to GERD, and advances in the concept of GERD. More than half of GERD patients had non-erosive reflux disease, and the majority (87%) of erosive esophagitis was mild type, such as Los Angeles classification grade A and grade B. There were several identified risk factors, such as older age, obesity, and hiatal hernia. In particular, mild gastric atrophy and absence of H. pylori infection influence the characteristics of GERD in the Japanese population. We also discuss GERD in the elderly; asymptomatic GERD; the natural history of GERD; and associations between GERD and peptic ulcer disease and H. pylori eradication. We examined the prevalence of GERD in patients with specific diseases, and found a higher prevalence of GERD, compared with that in the general population, in patients with diabetes mellitus, those with obstructive sleep apnea syndrome, and those with bronchial asthma. We provide a comprehensive review of GERD in the Japanese population and raise several clinical issues.     

Effects of environment and lifestyle on gastroesophageal reflux disease

BACKGROUND: Gastroesophageal reflux disease (GERD) is comprised of a spectrum of related disorders, including hiatal hernia, reflux disease with its associated symptoms, erosive esophagitis, peptic stricture, Barrett's esophagus, and esophageal adenocarcinoma. Besides multiple pathophysiological associations among these disorders, they are also characterized by their comorbid occurrence in identical patients and by their similar epidemiologic behavior. The occurrence of GERD is shaped by marked temporal and geographic variations, suggesting the influence of environmental risk factors in the etiology of these diseases. VARIATIONS BY TIME, GEOGRAPHY, AND RACE: Between 1975 and 2005, the incidence of GERD and esophageal adenocarcinoma increased fivefold in most Western countries. The incidence of GERD also appears to be rising in the most developed countries of Asia. All severe forms of GERD, such as erosive esophagitis, peptic stricture, Barrett's metaplasia, and esophageal adenocarcinoma, are more common among whites than other ethnic groups. AFFLUENCE AND OBESITY AS RISK FACTORS: Barrett's esophagus and esophageal adenocarcinoma tend to occur slightly more often in subjects with higher income. Overweight and obesity contribute to the development of hiatal hernia, increase intra-abdominal pressure, and promote gastroesophageal reflux. Weight gain increases reflux symptoms, whereas weight loss decreases such symptoms. Other risk factors, such as smoking, alcohol, dietary fat, or drugs, play only a minor role in shaping the epidemiologic patterns of GERD. PROTECTION THROUGH HELICOBACTER PYLORI: On a population level, a high prevalence of H. pylori infection is likely to reduce levels of acid secretion and protect some carriers of the infection against reflux disease and its associated complications. Several studies have confirmed a lesser prevalence of H. pylori among subjects with than without GERD. Until recently, populations in Africa and Asia may have been protected against the development of GERD and esophageal adenocarcinoma by their higher prevalence of H. pylori infection. CONCLUSION: The study of environmental risk factors may provide an opportunity to better understand GERD and develop a means of its prevention.     

Laparoscopic sleeve gastrectomy and gastroesophageal reflux

Bariatric surgery is the only effective procedure that provides long-term sustained weight loss. Sleeve gastrectomy (SG) has emerged over the last few years to be an ideal bariatric procedure because it has several advantages compared to more complex bariatric procedures, including avoiding an intestinal bypass. However, several published follow-up studies report an increased rate of gastroesophageal reflux (GERD) after a SG. GERD is described as either de novo or as being caused by aggravation of preexisting symptoms. However, the literature on this topic is ambivalent despite the potentially increased rate of GERDs that may occur after this common bariatric procedure. This article reviews the mechanisms responsible for GERD in obese subjects as well as the results after a SG with respect to GERD. Future directions for clinical research are discussed along with the current surgical options for morbidly obese patients with GERD and undergoing bariatric surgery.     

Gastro-oesophageal reflux disease in obesity: pathophysiological and therapeutic considerations

Gastro‐oesophageal reflux disease (GERD) is common in obese patients. Apart from the physical discomfort and the economic burden, GERD may increase morbidity and mortality through its association with oesophageal carcinoma. The pathophysiology of GERD differs between obese and lean subjects. First, obese subjects are more sensitive to the presence of acid in the oesophagus. Second, hiatal hernia, capable of promoting GERD by several mechanisms, is more prevalent among the obese. Third, obese subjects have increased intra‐abdominal pressure that displaces the lower oesophageal sphincter and increases the gastro‐oesophageal gradient. Finally, vagal abnormalities associated with obesity may cause a higher output of bile and pancreatic enzymes, which makes the refluxate more toxic to the oesophageal mucosa. The altered body composition associated with obesity affects the pharmacokinetics of drugs. There are no data regarding the efficacy of any of the drugs used for GERD treatment. The dosages of cimetidine and ranitidine should be calculated according to the patient’s ideal body weight, not their actual weight. Of the operative procedures used for weight loss, Roux‐en‐Y gastric bypass was found to be most effective for GERD, while gastric banding was associated with a high prevalence of reflux. This review outlines the pathophysiology and the treatment of GERD in obesity with emphasis on the therapeutic considerations in this population of patients.     

Recent advances in the surgical treatment of achalasia and gastroesophageal reflux disease

Achalasia and gastroesophageal reflux disease (GERD) represent diverse physiologic disorders both of which result from lower esophageal sphincter (LES) dysfunction. Fortunately, both diseases are benign and amenable to surgically corrective therapies. Achalasia is characterized by destruction of the smooth muscle ganglion cells of the myenteric plexus (Auerbach) resulting in motor dysfunction, incomplete LES relaxation, and progressive esophageal dilation. GERD is frequently characterized by hypotonia or shortening of the LES. Local anatomical derangements such as a hiatal hernia (eg, sliding type I hernia) can predispose to GERD. Other predisposing factors for GERD include obesity, smoking, alcohol, and pregnancy. Transient LES relaxation is the most significant factor in the development of GERD. Transient LES relaxations last from 10 to 45 seconds and are not related to swallowing. The diagnostic workup of achalasia and GERD may include barium esophagram, upper gastrointestinal endoscopy, pH monitoring, and esophageal manometry. The different medical treatment options for achalasia comprise pharmacologic treatment, botulinum toxin, and balloon dilation. Surgical interventions include Heller myotomy, which is usually combined with a partial fundoplication. GERD is managed by treating the predisposing factors, using medications (ie, anatacids or proton pump inhibitors) and surgery (ie, fundoplication). Recently, endoluminal therapy has been employed in the treatment of GERD with promising short-term results.     

胃食管反流病的危险因素以及相关疾病的研究概况

胃食管反流病（GERD）是西方国家比较常见的疾病,近年亚洲国家的发病率呈上升趋势,其发病机制复杂。与GERD发生相关的分子机制主要包括IL-1β、IL-8、E-钙黏蛋白、PAR-2、COL3A1等,遗传因素、肥胖、生活方式、精神心理因素、药物、人口因素、食管裂孔疝等可能是GERD的危险因素。此外,GERD可导致多种食管外相关疾病和食管腺癌。本文就此作一综述。     

Gastroesophageal reflux disease in children: What’s new right now?

Gastroesophageal reflux (GER) in children is very common and refers to the involuntary passage of gastric contents into the esophagus. This is often physiological and managed conservatively. In contrast, GER disease (GERD) is a less common pathologic process causing troublesome symptoms, which may need medical management. Apart from abnormal transient relaxations of the lower esophageal sphincter, other factors that play a role in the pathogenesis of GERD include defects in esophageal mucosal defense, impaired esophageal and gastric motility and clearance, as well as anatomical defects of the lower esophageal reflux barrier such as hiatal hernia. The clinical manifestations of GERD in young children are varied and nonspecific prompting the necessity for careful diagnostic evaluation. Management should be targeted to the underlying aetiopathogenesis and to limit complications of GERD. The following review focuses on up-to-date information regarding of the pathogenesis, diagnostic evaluation and management of GERD in children.     

Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia

BACKGROUND & AIMS: This study aimed to determine if hiatal hernia influences vulnerability to reflux and transient lower esophageal sphincter relaxation (tLESR) during gastric distention in patients with gastroesophageal reflux disease (GERD). METHODS: Eight normal subjects and 15 patients with GERD were studied. A metal clip attached to the squamocolumnar junction (SCJ) was beneath the hiatus in all control subjects. Eight GERD patients with >/=1-cm SCJ-hiatus separation were considered hernia patients, and 7 with <1-cm separation were considered nonhernia patients. Manometry and esophageal pH were recorded for 30 minutes, after which the stomach was loaded with acid dextrose and the recording continued for 2 hours with intragastric air infusion of 15 mL/min. RESULTS: Baseline reflux was comparable among groups. Gastric distention increased the frequency of reflux by the tLESR mechanism in all groups. Controls and nonhernia patients had median increases of 4.0 and 4.5 in tLESR frequency, respectively, and hernia patients had a median increase of 9.5/h. tLESR frequency was highly correlated with the SCJ-hiatus separation (r = 0.76; P < 0.001). CONCLUSIONS: Gastric air infusion was a potent stimulus for tLESR and reflux. The resultant tLESR frequency was directly proportional to the separation between the SCJ and hiatus, suggesting that the perturbed anatomy associated with hiatal hernia predisposed to eliciting tLESRs in patients with GERD.     

Extra-esophageal gastroesophageal reflux disease and asthma: understanding this interplay

Gastroesophageal reflux disease (GERD) is a condition that develops when there is reflux of stomach contents, which typically manifests as heartburn and regurgitation. These esophageal symptoms are well recognized; however, there are extra-esophageal manifestations of GERD, which include asthma, chronic cough, laryngitis and sinusitis. With the rising incidence of asthma, there is increasing interest in identifying how GERD impacts asthma development and therapy. Due to the poor sensitivity of endoscopy and pH monitoring, empiric therapy with proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. If unresponsive, diagnostic testing with pH monitoring off therapy and/or impedance/pH monitoring on therapy, may be reasonable in order to assess for baseline presence of reflux with the former and exclude continued acid or weakly acid reflux with the latter tests. PPI-unresponsive asthmatics, without overt regurgitation, usually have either no reflux or causes other than GERD. In this group, PPI therapy should be discontinued. In those with GERD as a contributing factor acid suppressive therapy should be continued as well as optimally treating other etiologies requiring concomitant treatment. Surgical fundoplication is rarely needed but in those with a large hiatal hernia, moderate-to-severe reflux by pH monitoring surgery might be helpful in eliminating the need for high-dose acid suppressive therapy.     

Surgical Management of Gastroesophageal Reflux Disease in Obesity

Bariatric surgery is ubiquitous today. In the obese patient with comorbid gastroesophageal reflux disease (GERD), it is increasingly being used as an alternative to fundoplication because it not only has an effect on GERD but also on other comorbid illnesses. Traditional GERD surgery is designed to augment the mechanical barriers against reflux, decrease acid production in the stomach, improve gastric emptying, or divert bile from the stomach. Roux-en-Y gastric bypass addresses these issues in addition to resulting in profound weight loss in patients. Banding may have a positive influence in patients' GERD, though to a lesser extent. The duodenal switch provides excellent control for patients with alkaline reflux. A revision of the 1991 National Institutes of Health guidelines for determining bariatric surgical candidates is overdue, and it may be feasible to consider expanding the body mass index and comorbidity requirements to reflect the benefits offered by these techniques for GERD patients.     

Manometric Study of Hiatal Hernia and Its Correlation with Esophageal Peristalsis

The pathogenesis of gastroesophageal refluxdisease (GERD) is considered multifactorial, butalterations of the esophagogastric junction (EGJ) andhiatal hernia play a prominent role. The correlationsbetween hiatal hernia and the other pathogeneticfactors are as yet unclear, and they need to beinvestigated by a methodological approach based on newanatomic and functional criteria. Our aim was to study,by stationary manometry, the relationships betweensmall reducible hiatal hernia, identified by endoscopy,and esophageal peristalsis, in patients with and withoutGERD. According to the absence or presence of esophagitis (E), and the absence or presenceof hiatal hernia (H), 58 subjects were divided into fourgroups: controls 10; H 14; E 10; and HE 24. Stationarymanometry was performed by the rapid pull-through (RPT) technique, with catheter water perfused,to study the lower esophageal high pressure zone [loweresophageal sphincter (LES) and diaphragmatic crura] andthe parameters of esophageal peristalsis. In patients with hiatal hernia, the variouscombinations of peak and/or deflection of manometricline pressure identified five EGJ profiles, only one ofwhich reveals (by one-peak profile due to superimposed LES and diaphragmatic crura) the reducibilityof the hernia. The frequency of the five profiles wascalculated in the HE and H groups: a two-peak profilewas significantly more prevalent in these patients, although less so in the group with esophagitis.In E patients the distal amplitude and the distalpropagation of esophageal waves were significantly lowerthan in the other three groups (P < 0.05 vs controls and group HE; P < 0.01 vs group H).Furthermore, the distal amplitude was significantlyhigher in the group H than in the HE (P < 0.01). Ourresults show a better definition of hiatal hernia morphology, via the RPT technique, disclosingfive pressure profiles. In addition, a significant linkwas found between small reducible hiatal hernia withoutGERD and wave amplitude of the distal esophagus. The amplification of peristaltic clearing maybe considered the initial protective process againstacid reflux; the breakdown of this mechanism may triggerthe pathological sequence of GERD.     

Evaluation of gastric emptying by electrogastrography and ultrasonography in gastroesophageal reflux disease

Background: It has been suggested that transient lower esophageal sphincter relaxation is involved in the occurrence of gastroesophageal reflux disease (GERD) and that decreased gastric emptying is an exacerbating factor of transient LES relaxation. In addition, the gastric emptying function is considered to be closely related to gastric motility. Methods: Gastric activity was evaluated by electrogastrography (EGG) in 22 patients with endoscopically positive reflux esophagitis (15 with mild esophagitis of Los Angeles grade A or B and seven with severe esophagitis of Los Angeles grade C or D) and 20 normal individuals. The gastric emptying function was also evaluated by abdominal ultrasonography. The sampling cycle of EGG was 1 s, and the measured frequency was 2.1–6.0 cycle/min (c.p.m.). The mean amplitude of EGG was compared by EGG spectral analysis among brady‐gastria cases with a contraction frequency of less than 2.4 c.p.m., normo‐gastria cases with a contraction frequency of 2.4–3.6 c.p.m., and tachy‐gastria cases with a contraction frequency exceeding 3.6 c.p.m. Results: In the patients with GERD, both the frequency of 3‐c.p.m. waves and peak frequency were reduced, and the gastric emptying function examined by ultrasonography had deteriorated, in comparison with normal individuals. Of those with GERD, the ultrasonographic gastric emptying function was significantly reduced in all patients with severe esophagitis compared with those with mild esophagitis, but the differences of the frequency of 3‐c.p.m. waves, the peak frequency, were not significant. Also, no significant difference was observed in the frequency of 3‐c.p.m. waves or the ultrasonographic gastric emptying function between the 16 patients with hiatal hernia and the six patients with no hiatal hernia. However, the mean amplitude in brady‐gastria and tachy‐gastria was significantly increased in the patients with hiatal hernia compared to those without hiatal hernia. Conclusions: Reduced gastric motility was suggested to be involved in the development of reflux esophagitis, and the presence of hiatal hernia was considered to have some effect on gastric motility.     

Screening pre-bariatric surgery patients for esophageal disease with esophageal capsule endoscopy

AIM:To determine if esophageal capsule endoscopy(ECE)is an adequate diagnostic alternative to esophagogastroduodenoscopy(EGD)in pre-bariatric surgery patients.METHODS:We conducted a prospective pilot study to assess the diagnostic accuracy of ECE(PillCam ESO2,Given Imaging)vs conventional EGD in pre-bariatric surgery patients.Patients who were scheduled for bariatric surgery and referred for pre-operative EGD were prospectively enrolled.All patients underwent ECE followed by standard EGD.Two experienced gastroenterologists blinded to the patient’s history and the findings of the EGD reviewed the ECE and documented their findings.The gold standard was the findings on EGD.RESULTS:Ten patients with an average body mass index of 50 kg/m2were enrolled and completed the study.ECE identified 11 of 14(79%)positive esophageal/gastroesophageal junction(GEJ)findings and 14of 17(82%)combined esophageal and gastric findings identified on EGD.Fisher’s exact test was used to compare the findings and no significant difference was found between ECE and EGD(P=0.64 for esophageal/GEJ and P=0.66 for combined esophageal and gastric findings respectively).Of the positive esophageal/GEJ findings,ECE failed to identify the following:hiatal hernia in two patients,mild esophagitis in two patients,and mild Schatzki ring in two patients.ECE was able to identify the entire esophagus in 100%,gastric cardia in0%,gastric body in 100%,gastric antrum in 70%,pylorus in 60%,and duodenum in 0%.CONCLUSION:There were no significant differences in the likelihood of identifying a positive finding using ECE compared with EGD in preoperative evaluation of bariatric patients.