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.     

Gastric emptying in infants with gastroesophageal reflux

It is well established that liquid emptying occurs in the absence of motor activity of the stomach. In contrast, solid-phase emptying is controlled in part by antral peristalsis and is, therefore, a more precise indicator of gastric motility. We developed a semisolid, radionuclide gastric emptying test using rice cereal and technetium-99m-sulfur colloid to assess antral physiology in infants with vomiting. Computer-programmed mathematical models were used to determine the shape of a line that best fit our emptying data points. Linear, simple exponential [f = 2-(t/t1/2)], and power exponential [f = 2(t/t1/2)beta] patterns of emptying were calculated, where f is the fraction of the meal remaining in the stomach at time t, and t1/2 is the time when 50% of the meal has emptied and is a determinant of the shape of the curve. In infants with simple regurgitation (chalasia) and those with vomiting and failure to gain weight, we made statistical comparisons between gastric emptying patterns after analysis of the mean percentage of retained radionuclide at 120 min, calculated t1/2, and area under the curve. The coefficient of determination, R2, was calculated as an index of whether a curve provided goodness of fit to the data. Differences between groups of patients were statistically significant for all parameters of each mathematical model. However, higher coefficients of determination were noted in the power exponential model. The data suggest that the power exponential mathematical model provides the best analysis of the gastric emptying patterns for infants with chalasia and those with vomiting and failure to gain weight.(ABSTRACT TRUNCATED AT 250 WORDS)     

胃食管反流病与幽门螺杆菌及胃排空关系的研究

目的探讨幽门螺杆菌(H.pylori)与胃食管反流病(GERD)的关系,以及H.pylori对GERD患者胃动力的影响。方法按中华医学会的GERD诊断标准,确诊GERD患者200例,进行胃镜、胃排空时间及H.pylori检查,依据洛杉矶分级将反流性食管炎(RE)分为A、B、C、D四级,200例无消化道症状的健康体检者作为对照组,进行H.pylori检查。结果 GERD组的感染率明显低于对照组(P<0.05),反流性食管炎(RE)的炎症程度与H.pylori的感染率呈负相关,GERD患者中H.pylori阳性组和H.pylori阴性组间胃排空情况无统计学差异(P>0.05)。结论 H.pylori可能对GERD有潜在的保护作用;RE炎症程度越重,H.pylori感染率越低;H.pylori不影响GERD患者的胃动力。     

胃食管反流病的胃排空率与感知研究

目的 探讨胃食管反流病（gastroseophageal reflux diease,GERD)患者的胃排空率,对饱胀、饥饿感知敏感性,及胃排空速度对感知的影响。方法 临床诊断的15例GERD病人和17例对照者采用核素法测定胃液体、固体排空功能,并记录试餐前后饱胀、饥饿计分。结果 GERD组平均胃液体和固体半排空时间显著长于对照组。GERD组在空腹时有较高的饱胀计分和较低的饥饿计分,随着胃排空延迟,餐后GERD组饱胀计分下降和饥饿计分上升较对照组缓慢,结论 GERD病人存在胃液体,固体排空延迟;对饱胀、饥饿感知敏感性增加,胃排空病速度影响对饱胀、饥饿的感知。     

Impaired gastric motility and its relationship to reflux symptoms in patients with nonerosive gastroesophageal reflux disease

Background  More than half of patients with refluxrelated symptoms have no endoscopic evidence of mucosal breaks. These patients are considered to have nonerosive gastroesophageal reflux disease (NERD). The pathogenesis of NERD may be multifactorial, but the role played by gastric motility in symptom generation in patients with NERD has not been examined. In this study, we elucidate gastric motility in patients with NERD and the efficacy of a prokinetic agent in the treatment of NERD. Methods  Gastric motility was evaluated with electrogastrography (EGG) and by measurement of gastric emptying using the acetaminophen method in 26 patients with NERD and in 11 matched healthy controls. NERD patients were treated with a prokinetic agent (mosapride 15 mg, orally three times daily) for a period of 4 weeks, after which gastric motility was measured again. Results  Compared with the healthy controls, the NERD patients showed a significantly lower percentage of normogastria, a lower power ratio in EGG, and delayed gastric emptying. Ten patients had normal gastric motor function (group A), and 16 showed abnormalities of either gastric myoelectrical activity or gastric emptying (group B). After treatment with mosapride, gastric motility improved significantly in both groups of patients compared with pretreatment values. The subjective assessment by the patient after the treatment was improved in 20.0% of group A versus 62.5% of group B patients (P < 0.05). Conclusions  Gastric hypomotility appears to be an important factor in reflux symptom generation in some NERD patients.     

Gastric emptying and duodeno-gastro-oesophageal reflux in gastro-oesophageal reflux disease

BACKGROUND: Previous studies present conflicting results regarding relationship between gastric emptying and gastro-oesophageal reflux disease. Reflux of duodenal content to oesophagus is generally considered to be associated with more severe disease. AIM: To assess presence of a gastric emptying disorder in persons with reflux of duodenal contents to oesophagus and to identify any correlation with gastric emptying and oesophageal motility. METHODOLOGY: A total of 15 subjects with (B+) and 15 subjects without (B-) bile reflux to oesophagus determined by 24-hour bilirubin monitoring were studied with scintigraphic solid gastric emptying and 24-hour oesophageal manometry. RESULTS: There was no difference in lag phase [median 23.7 (range 10.8-44.0) vs 24.6 (8.1-40.1) min], half emptying time [74.6 (48.0-93.6) vs 82.8 (54.4-153.9) min] or emptying rate [0.89 (0.59-1.34) vs 0.83 (0.36-1. 15)%/min] for B- and B+ subjects, respectively. In addition, there was no difference in emptying rate of gastric fundus between B- and B+ subjects. Subjects with bile reflux had less effective oesophageal contractions of oesophageal body [9.4(3.3-37)%] compared to subjects without bile reflux [32(19-47)%, p = 0.002]. However, there was no correlation between oesophageal motility and gastric emptying. CONCLUSION: Results suggest that a gastric emptying disorder is a less likely contributing cause of bile reflux to the oesophagus, but bile reflux is associated with less effective oesophageal motility.     

Prevention of gastroduodenal content reflux and delayed gastric emptying after esophagectomy: gastric tube reconstruction with duodenal diversion plus Roux‐en‐Y anastomosis

Reflux of gastroduodenal contents and delayed gastric emptying are the most common and serious problems after esophagectomy with gastric reconstruction. However, attempts to reduce the above symptoms, surgically as well as non‐surgically, had no or limited effect. To address this issue, we performed retrosternal gastric reconstruction with duodenal diversion plus Roux‐en‐Y anastomosis (RY) in eight patients with thoracic esophageal cancer and compared the outcomes with control patients who underwent standard reconstruction. The procedure is simple, safe, and not associated with any postoperative complications. The pancreatic amylase concentrations in the gastric juice samples on postoperative day 2 were slightly lower in the non‐RY group than in the RY group (1884 ± 2152 vs. 25,790 ± 23,542 IU/mL, respectively, P= 0.07). Postoperative endoscopic examination showed neither reflux esophagitis nor residual gastric content in the RY group. Quality of life assessed by the Dysfunction After Upper Gastrointestinal Surgery‐32 questionnaire postoperatively was significantly better in the RY group than in the non‐RY group for ‘decreased physical activity,’‘symptoms of reflux,’‘nausea and vomiting,’ and ‘pain.’ The results of this pilot study suggest that gastric reconstruction with duodenal diversion plus RY seems effective in improving both the reflux and delayed gastric emptying. The benefits of this procedure need to be further assessed in a large‐scale, randomized controlled trial.     

The proton pump inhibitor test and the diagnosis of gastroesophageal reflux disease

There continues to be significant controversy related to diagnostic testing for gastroesophageal reflux disease (GERD). Symptoms of GERD may be associated with physiologic esophageal acid exposure measured by intraesophageal pH monitoring or pH-impedance monitoring, and a significant percentage of patients with abnormal esophageal acid (or weak acid) exposure have no or minimal clinical symptoms of reflux. On the other hand, endoscopic lesions are only present in a minority of GERD patients. In clinical practice, presumptive diagnosis of GERD is reasonably assumed by the substantial reduction or elimination of suspected reflux symptoms during the therapeutic trial of acid reduction therapy, the so-called proton pump inhibitor (PPI) test. We aimed to assess the optimal cutoff value and duration of this test in GERD patients with and without esophagitis. We conducted a prospective study of 544 patients, endoscopically investigated and treated for 2 weeks with PPIs at double dose, and for an additional 3 months at standard dose. The status of the patient at the end of the study was used as an independent diagnostic standard. We found esophagitis present in 55.8% and absent in 44.2% of patients (corresponding to a diagnosis of nonerosive reflux disease [NERD]). The test was positive in 89.7–97.8% of the patients according to the cutoff or duration of the test used. The sensitivity of the PPI test was excellent, ranging from 95.5 to 98.8%, whereas the specificity was poor, not exceeding 36.3%. Erosive esophagitis patients responded more favorably to the PPI test and subsequent PPI therapy compared with NERD patients. In conclusion, the PPI test is a sensitive but less specific test. Its optimal duration is 1 week, and the optimal cutoff value is a decrease of heartburn score of more than 75%. NERD patients respond less satisfactorily to PPIs, even when functional heartburn patients are excluded and only ‘true’ NERD patients are considered.     

Relationship between acceleration of gastric emptying and oesophageal acid exposure in patients with endoscopy-negative gastro-oesophageal reflux disease

Objective. A delay in gastric emptying has been reported in patients with gastro-oesophageal reflux disease (GORD), but its role in increasing the number of reflux episodes is still debated. The aim of this study was to assess the relationship between acceleration of gastric emptying and gastro-oesophageal reflux in patients with endoscopy-negative GORD and pathological oesophageal acid exposure. Material and methods. Twelve patients (7 M, age range 24–65 years) underwent 6-h postprandial (2.1 MJ meal) combined gastric emptying by real-time ultrasonography and intra-oesophageal pH monitoring after cisapride (20 mg b.i.d.) and placebo for 3 days, on two separate occasions at least 7 days apart in double-blind randomized order. Gastric emptying after placebo was also measured in 12 healthy volunteers (7 M, age range 25–54 years). Results. In the patients’ group, the area under the emptying time curve was greater (p<0.01), and half and total emptying times prolonged (p<0.01) compared to the healthy subjects, 115 min (mean)±6 (SEM) versus 86±6 and 232 min±16 versus 160±7, respectively. Cisapride accelerated both half- and total gastric emptying (p<0.02): ?22 min (mean); ?10 to ?34 (95% CI) and ?48 min; ?10 to ?85, respectively, decreased both percentage of time at pH?p<0.01) and number of reflux episodes (p<0.05). However, no relationship was found between changes in gastric emptying and in the reflux variables by linear regression analysis (R²<0.005). Conclusion. The emptying rate of the whole stomach is not a major determinant of gastro-oesophageal reflux.     

Changes in liquid emptying in migraine patients: diagnosed with liquid phase gastric emptying scintigraphy

Gastric stasis is suspected mostly to be encountered during acute migraine attack. The aim of this study is to evaluate the liquid phase gastric emptying and motility in migraine patients in ictal and interictal periods in comparison to normal subjects with gastric emptying scintigraphy. Seven women with migraine and age, sex matched controls who applied to the Neurology Department from May 2009 to May 2010 were compared. Gastric emptying study with a standard liquid was performed one time in the non-migraineur group and two times in the migraineur group. Non-migraineur controls and migraineurs were compared. The mean T1/2 was longer in ictal period in migraineurs. The T1/2 of migraineurs interictally and the control groups were similar. The T1/2 of migraineurs ictally and migraineurs interictally were also compared. We also considered the percentage of the radioactive material remaining in the stomach. There were no significant differences between non-migraineurs and migraineurs interictally. However, increased amount of radioactive material remaining in the stomach was observed in migraineurs ictally. We concluded that the liquid emptying was delayed in spontaneous migraine attacks in migraine without aura, however in the interictal period the emptying of liquids did not differ between migraineurs and non-migraineurs.     

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.     

Endoscopic management of refractory gastroesophageal reflux disease

Objective: Despite the therapeutic and surgical interventions for the management of gastroesophageal reflux disease (GERD), yet the high cost and the post-operative complications had led to a significant socioeconomic burden. The aim was to evaluate the safety and efficacy of endoscopic band ligation (EBL) in the management of refractory GERD.

Methods: A total of 150 patients with refractory GERD were assigned to an EBL group (banding was done at four quadrants just at the gastroesophageal junction (GEJ) (n?=?75) or to a control group (optimized dose of PPI, n?=?75). Follow-up for both groups by upper GI endoscopy to evaluate the site of the Z line from the incisors, the width of the GEJ and the coaptation of GEJ around the endoscope on retroflection. PH monitoring was performed every 3 months with GERD- QoL assessment monthly for 1 year.

Results: In EBL group; 58 patients (77.3%) needed 1 session, 17 patients (22.7%) needed 2 sessions. 4 rubber bands were utilized in 44 patients (58.7%), 3 rubber bands in 31 patients (41.3%). Follow-up for 1 year revealed a highly significant improvement of the GERD- QoL score, the site of Z line with significant reduction of reflux episodes and symptom index when compared to the medical treatment group. In EBL group; there were no major adverse events including bleeding, post band ulcers, stenosis at one year follow up.

Conclusion: The current study provides a novel endoscopic intervention to treat refractory GERD, which is safe, cost-effective, with no major adverse effects at one year follow up.     

Z-line alterations and gastroesophageal reflux: an endoscopic population-based prospective cohort study

Abstract

Background and study aims: Barrett's esophagus is a premalignant condition in the distal esophagus associated with esophageal adenocarcinoma. Since gastroesophageal reflux is known to be of etiological importance in both Barrett's esophagus and esophageal adenocarcinoma, we aimed to study which endoscopic alterations at the Z-line can be attributed to a previous history of reflux symptoms.

Patients and methods: From 1988, a population cohort in Sweden has been prospectively studied regarding gastrointestinal symptoms, using a validated questionnaire. In 2012, the population was invited to undergo a gastroscopy and participate in the present study. In order to determine which endoscopic alterations that can be attributed to a previous history of gastroesophageal reflux, three different endoscopic definitions of columnar-lined esophagus (CLE) were used: (1) ZAP I, An irregular Z-line with a suspicion of tongue-like protrusions; (2) ZAP II/III, Distinct, obvious tongues of metaplastic columnar epithelium; (3) CLE ≥1?cm, The Prague C/M-classification with a minimum length of 1?cm.

Results: A total of 165 community subjects were included in the study. Of these, 40 had CLE?≥?1?cm, 99 had ZAP I, and 26 had ZAP II/III. ZAP II/III was associated with an over threefold risk of previous GER symptoms (OR: 3.60, CI: 1.49–8.70). No association was found between gastroesophageal reflux and ZAP I (OR: 2.06, CI: 0.85–5.00), or CLE ≥1?cm (OR: 1.64, CI: 0.77–3.49).

Conclusions: In a general community, the only endoscopic alteration to the Z-line definitely linked to longstanding GER symptoms was the presence of obvious tongues of metaplastic columnar epithelium (ZAP II/III).     

胃食管反流性疾病不同疗法的总体评价(附112例临床分析)

目的 了解胃食管反流性疾病对患者生活质量的影响,评价两种“三联疗法”对胃食管反流性疾病的疗效及生活质量,经济投入的影响。方法 通过丽水市6所市、县级人民医院收集同期经胃镜确诊的反流性食管病例,采用问卷调查方式,了解受试者的一般情况,胃食管反流症状和疾病前后生活质量,经济投入改变情况,分别给予质子泵抑制剂+促动力剂+黏膜保护剂(方案甲),及H_2受体阻滞剂+促动力剂+黏膜保护剂(方案乙)8周治疗。记录治疗后患者生活质量(QOL)表和经济投入量表。探讨两种“三联疗法”的疗效,生活质量改变情况和经济投入关系。结果①共收集112例GERD病例,男女比24:1,平均年龄47.9+13.8岁,两组患者的临床资料具有可比性(P>0.05);②甲方案总有效率92.98%,乙方案总有效率80％。甲方案疗效优于乙方案。③GERD严重影响QOL,优质QOL由发病前63.7％降至13.7％,甲方案治疗后可恢复优质QOL至84％,乙方案为63％。两种方案经济投入无显著差异(P=0.085)。④疗效和生活质量改善有显著相关性。结论“三联疗法”治疗胃食管反流性疾病疗效高,并可显著改善患者的生活质量。以兰索拉唑促动力剂+黏膜保护剂三联组更为明显。此三联疗法是经济、高效和有效提高生活质量的疗法,值得推广。     

Short-term treatment of gastroesophageal reflux disease

OBJECTIVE: To investigate the efficacy of acid suppressant drugs in the empirical treatment of gastroesophageal reflux disease (GERD) and in the treatment of endoscopy-negative reflux disease (ENRD). DESIGN: medline, embase, and the Cochrane Controlled Trials Register were searched. Bibliographies were reviewed. SETTING: Studies were eligible that compared the short-term use of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) with each other or with placebo in adults with GERD who were enrolled irrespective of endoscopic findings (empirical cases) or in whom endoscopy showed no signs of esophagitis (endoscopy-negative cases). MEASUREMENTS: Of 1,408 studies, only 13 could be included for meta-analysis. Data on 3,433 patients empirically treated for GERD and 2,520 patients treated for ENRD were extracted. The primary endpoint was relief of heartburn. MAIN RESULTS: In the empirical treatment of GERD, the summary relative risk (sRR) for symptom relief from H2RAs versus placebo was 0.77 (95% confidence interval [95% CI], 0.60 to 0.99). RR in the only placebo-controlled PPI trial was 0.35 (95% CI, 0.26 to 0.46). The sRR for standard dose PPIs versus H2RAs was 0.55 (95% CI, 0.44 to 0.68). In treatment of ENRD, both PPIs (sRR, 0.64; 95% CI, 0.52 to 0.79) and H2RAs (sRR, 0.78; 95% CI, 0.62 to 0.97) were superior to placebo, and PPIs were superior to H2RAs (sRR, 0.81; 95% CI, 0.70 to 0.95). CONCLUSIONS: Acid suppressant therapy (with a PPI or an H2RA) is more effective than placebo for short-term relief of heartburn in patients with persistent symptoms who are treated empirically for GERD and in those in whom esophagitis was excluded after endoscopy. The benefit of PPIs compared with H2RAs is more pronounced in patients treated empirically.     

Systematic review: questionnaires for assessment of gastroesophageal reflux disease

Numerous questionnaires with a wide variety of characteristics have been developed for the assessment of gastroesophageal reflux disease (GERD). Four well‐defined dimensions are noticeable in these GERD questionnaires, which are symptoms, response to treatment, diagnosis, and burden on the quality of life of GERD patients. The aim of this review is to develop a complete overview of all available questionnaires, categorized per dimension of the assessment of GERD. A systematic search of the literature up to January 2013 using the Pubmed database and the Embase database, and search of references and conference abstract books were conducted. A total number of 65 questionnaires were extracted and evaluated. Thirty‐nine questionnaires were found applicable for the assessment of GERD symptoms, three of which are generic gastrointestinal questionnaires. For the assessment of response to treatment, 14 questionnaires were considered applicable. Seven questionnaires with diagnostic purposes were found. In the assessment of quality of life in GERD patients, 18 questionnaires were found and evaluated. Twenty questionnaires were found to be used for more than one assessment dimension, and eight questionnaires were found for GERD assessment in infants and/or children. A wide variety of GERD questionnaires is available, of which the majority is used for assessment of GERD symptoms. Questionnaires differ in aspects such as design, validation and translations. Also, numerous multidimensional questionnaires are available, of which the Reflux Disease Questionnaire is widely applicable. We provided an overview of GERD questionnaires to aid investigators and clinicians in their search for the most appropriate questionnaire for their specific purposes.     

Laryngeal cancer and gastroesophageal reflux disease: a case-control study

Purpose

Gastroesophageal reflux disease (GERD) is common in patients with laryngeal cancer. However, the role of GERD in laryngeal cancer remains controversial because of poor matching and selection of inappropriate control groups in prior studies. We aimed to better understand this relationship by conducting a matched case-control study.

Methods

This study was based in a single tertiary care center over a 2-year period. Cases included all patients with a diagnosis of new laryngeal cancer presenting to the otolaryngology clinics. Two controls, derived from the internal medicine clinics, were matched to the cases on an individual basis for age (within 1 year), gender, ethnicity, and time of first visit to the institution (within 1 month). Data were extracted by chart review. Conditional logistic regression was used to assess the relationship between laryngeal cancer and GERD, tobacco, and alcohol consumption.

Results

A total of 96 cases were matched to 192 controls. On univariable analysis, the significant risk factors were current smoking, odds ratio (OR) 5.46 (95% confidence interval [CI], 2.59-11.50); alcohol, OR 1.97 (CI, 1.19-3.26); and GERD, OR 1.79 (CI, 1.03-3.11). On multivariable analysis, only smoking and GERD continued to be significantly associated with laryngeal cancer, OR 6.08 (CI, 2.82-13.10) and OR 2.11 (CI, 1.16-3.85), respectively.

Conclusions

Smoking and GERD are significant risk factors for laryngeal cancer and may have an independent incremental risk for laryngeal carcinogenesis.