Epidemiological investigation in outpatients with symptomatic gastroesophageal reflux from the Department of Medicine in Zhejiang Province, east China

Background and Aim: To elucidate the epidemiology of gastroesophageal reflux disease (GERD) symptoms in outpatients from the Department of Medicine in 10 hospitals in Zhejiang Province, east China. Methods: A cross‐sectional survey in the cluster random sample was conducted from November 2004 to June 2005 using a validated Chinese version of the reflux disease questionnaire and other items recording the demographic characteristics for GERD symptoms. The statistical analysis was performed with SPSS 13.0 programs. Results: A total of 15 283 outpatients from the Department of Medicine were investigated. The prevalence of GERD symptoms was 7.28% (95% confidence interval [CI], 6.87%, and 7.69%) with the prevalence rate increasing with age (P < 0.001), which was higher in men (7.79%, 95% CI: 7.20%, 8.38%) than in women (6.73%, 95% CI: 6.18%, 7.28%; χ² = 5.81, P < 0.05). The prevalence rate of the gastrointestinal symptoms in GERD symptoms, including epigastric discomfort, nausea, retrosternal pain, belching, globus sensation, loss of appetite, excessive salivation, vomiting, wheezing cough, weight loss, and dysphagia were all higher than the non‐GERD patients (P < 0.0001). In the GERD patients, the prevalence of diseases, such as pharyngolaryngitis, snoring, bronchitis, liver disease, and gallbladder disease were all higher than the non‐GERD patients (P < 0.01). The multiple logistic regression analysis showed that old age, night‐shift work, heavy work burdens, single or divorced people, increase intake of greasy or sweet foods, excessive eating, and constipation were independent risk factors associated with GERD symptoms. Conclusion: GERD has a high prevalence in China and its main associated factors include respiratory, laryngopharyngeal and dental disorders, sex, anthropometrical variables, and social–psychological characteristics.     

Visceral sensitivity in gastroesophageal reflux

Symptomatic gastroesophageal reflux disease (GERD) is characterized by a wide spectrum of symptoms. The variance of GERD symptoms may be due to a decreased threshold for symptom elicitation/perception described as visceral sensitivity. In this study GERD symptoms were scored for presence/frequency. The symptom score was weighted for the presence/frequency of typical reflux symptoms: heartburn, retrosternal pain, and regurgitation. The weighted GERD symptom score was used to assess symptom expansion and the hypothesis of GERD visceral sensitivity. One hundred five subjects with heartburn/retrosternal pain underwent esophageal pH studies. Subjects with abnormal esophageal pH studies reported more GERD-related symptoms, occurring more frequently, compared to subjects with normal esophageal pH studies. Symptom scores correlated with the number of reflux episodes but not with the length of time of mucosal exposure to acid. Therefore, aggregation of symptoms in gastroesophageal reflux is associated with frequent alternation between low and normal pH values in the distal esophagus.     

Detailed esophageal function and morphological analysis shows high prevalence of gastroesophageal reflux disease and Barrett's esophagus in patients with cervical inlet patch

Although the pathogenesis of cervical inlet patch (CIP) is not fully understood, most authors consider it as a congenital abnormality, whereas others surmise it to be related to gastroesophageal reflux disease (GERD). We aimed to evaluate esophageal function and the prevalence of GERD and Barrett's esophagus in patients with CIP. GERD is defined by the presence of erosive esophagitis or an abnormal pH monitoring. Seventy-one consecutive patients with endoscopic and histological evidence of CIP were prospectively evaluated. Esophageal symptom analysis, 24-hour simultaneous biliary reflux and double-channel pH-monitoring, and esophageal manometry were carried out in 65/71 (92%) patients and in 25 matched controls. Six patients were not suitable for testing and were, therefore, excluded. The histological evaluation of the heterotopic islands showed cardia and/or oxyntic mucosa in 64/65 (98%) patients and specialized intestinal metaplasia (SIM) in one patient (2%). The cardia and/or oxyntic mucosa was accompanied by focally appearing pancreatic acinar metaplasia and pancreatic ductal metaplasia in 7/64 (11%) and in 1/64 (2%), superficial mucous glands in 6/64 (9%), and SIM in 2/64 (3%) cases. In total, SIM was present in three patients (5%), and one of them had low-grade dysplasia. At the gastroesophageal junction, 28 (43%) patients had columnar metaplasia, including nine (14%) patients with SIM. Erosive esophagitis was present in 37 (57%) cases. Thirty-two patients (49%) had abnormal acid reflux in the distal and 25 (38%) in the proximal esophagus. Abnormal biliary reflux was present in 25 (38%) cases. On the basis of endoscopic and pH studies, GERD was established in 44/65 (68%) patients. Typical reflux symptoms were common (33/65, 51%). The combined 24-hour biliary and double-channel pH-monitoring detected significantly more significant acidic reflux at both measurement points and significantly longer bile exposure time in the distal esophagus in patients with CIP. Acid secretion in the CIP was detected in three (5%) cases. Esophageal manometry revealed decreased LES pressure and prolonged relaxation with decreased peristaltic wave amplitude, and an increased number of simultaneous contractions in the esophageal body. The detailed evaluation of the esophageal morphology and function in subjects with CIP showed a high prevalence of GERD and Barrett's esophagus. Further studies are needed to evaluate whether combined acidic and biliary reflux is able to promote similar histomorphological changes in the CIP, as it is shown distally in patients with Barrett's esophagus.     

Efficacy and safety of pantoprazole versus ranitidine in the treatment of patients with symptomatic gastroesophageal reflux disease

BACKGROUND/AIM: Gastroesophageal reflux disease (GERD) is a prevalent disease associated with a high symptom burden and a reduced quality of life. This multicenter, randomized, double-blind study compared relief from key GERD symptoms (heartburn, acid eructation, and pain on swallowing) and from other gastrointestinal symptoms (epigastric pain, vomiting, nausea, flatulence, retching, and retrosternal feeling of tightness) and safety profiles of the proton pump inhibitor pantoprazole and the H2 antagonist ranitidine in patients suffering from symptomatic GERD. METHODS: The patients [338 intention-to-treat (ITT) population; 284 per-protocol (PP) population] received 20 mg pantoprazole (once daily in the morning) plus ranitidine placebo (once daily in the evening; ITT n = 167, PP n = 136) or pantoprazole placebo (once daily in the morning) plus 300 mg ranitidine (once daily in the evening; ITT n = 171, PP n = 148) for 28 days. The primary efficacy criterion (ITT and PP populations) was relief from key GERD symptoms (heartburn, acid eructation, and pain on swallowing) after 28 days of treatment. Secondary criteria (PP) included relief from key GERD symptoms on day 14, relief from all gastrointestinal symptoms on days 14 and 28, and relief from key GERD symptoms on days 14 and 28. Safety evaluations included adverse events and laboratory assessments. RESULTS: Significantly more pantoprazole-treated patients were free from key GERD symptoms at day 28 (68.3%, n = 114) as compared with ranitidine-treated patients (43.3%, n = 74; 95% confidence interval for odds ratio 1.84-4.51). Pantoprazole was also significantly more efficacious in controlling all gastrointestinal symptoms of GERD. By day 28, 51.5% (n = 70) of the pantoprazole-treated patients were completely symptom free versus 31.1% (n = 46) of the ranitidine-treated patients (95% confidence interval for odds ratio 1.45-3.83). Both treatments were well tolerated. CONCLUSION: Pantoprazole is significantly superior to ranitidine in the treatment of key and associated gastrointestinal symptoms of GERD and is well tolerated.     

Belching: dyspepsia or gastroesophageal reflux disease?

OBJECTIVES: Eructation (belching) is a common symptom seen in clinical practice. Because either belching or heartburn may result from transient lower esophageal sphincter relaxations, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). In this retrospective study we evaluated the prevalence of belching in dyspepsia and GERD and the relation of belching to acid reflux events documented by pH monitoring. METHODS: We examined the prevalence, frequency, and severity of belching and other GERD symptoms by use of standardized questionnaires in 180 GERD patients (group A) and 78 dyspeptic controls (group B) referred for evaluation at our institution. GERD was defined as either endoscopic esophagitis (or Barrett's esophagus) or positive DeMeester score (>14.2) on pH monitoring or both. Dyspeptic patients had normal endoscopy and pH studies. We also analyzed the relationship of belching to acid reflux events during the 24-h period of pH studies. RESULTS: Of 180 GERD patients, 132 (70%) reported belching during pH monitoring, versus 63 of 78 dyspeptic patients (80%) (p = ns). Similarly, 163 of 180 GERD patients (90%) reported heartburn versus 64 of 78 of dyspeptic patients (82%) (p = ns). Review of symptom questionnaires revealed no significant difference in belching severity between groups. However, heartburn and acid regurgitation were significantly more severe among GERD patients. There was a significantly higher correlation of both heartburn and belching with acid events in patients with GERD compared with patients with dyspepsia. In addition, although both belching and heartburn were significantly improved in patients with GERD, belching scores remained unchanged after proton pump inhibitor (PPI) therapy in patients with dyspepsia. CONCLUSIONS: Belching is as common and as severe in patients with dyspepsia as it is in patients with GERD. Belching and heartburn in GERD patients are more likely correlated with episodes of pathological acid reflux. Because belching cannot be clinically used as a discriminatory symptom, ambulatory pH monitoring should be considered to elucidate the relationship of belching to acid reflux in patients with dyspepsia or GERD.     

Endoscopic reflux esophagitis in patients with upper abdominal pain-predominant dyspepsia

BACKGROUND: Reflux symptom assessment had reliable accuracy in the diagnosis of gastroesophageal reflux disease (GERD). However, patients may recognize heartburn or regurgitation as dyspepsia because of inaccurate understanding or atypical presentation. The aim of the present study was to estimate endoscopic reflux esophagitis in patients with upper abdominal pain as a predominant symptom in the absence of heartburn or regurgitation. METHODS: Two hundred and sixty-three consecutive patients presenting dyspepsia without heartburn or regurgitation were enrolled. Patients with heartburn or regurgitation were excluded using the symptom interviewer method. Dyspepsia was categorized into pain-predominant or dysmotility-predominant groups according to the Rome II proposal. Endoscopic reflux esophagitis was graded using the Los Angeles classification. RESULTS: One hundred and five patients were included in the pain-predominant group and 119 in the dysmotility-predominant group. Reflux esophagitis was found in 18.8% (42/224) of all dyspeptic patients. Grade A esophagitis was noted in 27.6% (29/105) of the pain-predominant group and in 7.6% (9/119) of the dysmotility-predominant group. Grade B was noted in two patients in each group. A total of 29.5% (31/105) and 9.3% (11/119) had reflux esophagitis, respectively (P < 0.001). Comparing patients with or without reflux esophagitis, there was no difference in body mass index, smoking habit, alcohol consumption, or Helicobacter pylori infection status. CONCLUSIONS: A significant proportion of patients presenting dyspepsia, especially pain-predominant dyspepsia, have endoscopic reflux esophagitis. In view of GERD, pain-predominant dyspepsia should be investigated and managed differently from dysmotility-predominant dyspepsia.     

Vonoprazan treatment improves gastrointestinal symptoms in patients with gastroesophageal reflux disease

The effects of vonoprazan, a new potassium-competitive acid blocker, on gastroesophageal reflux disease (GERD) symptom are not fully elucidated. The aim of this study is to determine the effect of vonoprazan on GERD and associated gastrointestinal symptoms. We retrospectively reviewed 88 Helicobacter pylori negative patients with GERD treated with vonoprazan 10 mg daily. Symptoms were evaluated using the Izumo scale, which reflects quality of life related to various abdominal symptoms. The rates of improvement and resolution of GERD symptoms were 86% (76/88) and 57% (50/88), respectively. Improvement and resolution in patients with erosive esophagitis was higher than in those with non-erosive reflux disease (91% vs 83%, p = 0.260 and 71% vs 47%, p = 0.025, respectively). We attempted to identify factors which predict the effects of vonoprazan. Multivariate analysis identified advanced age (≥60-year-old) (odds ratio [OR] 7.281, 95% confidence interval [CI] 2.056–25.776, p = 0.002), obesity (BMI ≥ 24) (OR 3.342, 95%CI 1.124–9.940, p = 0.030) and erosive esophagitis (OR 4.368, 95%CI 1.281–14.895, p = 0.018) as positive predictors of resolution of GERD symptoms. Alcohol use (OR 0.131, 95%CI 0.027–0.632, p = 0.011) and history of H. pylori eradication (OR 0.171, 95%CI 0.041–0.718, p = 0.015) were identified as negative predictors. Vonoprazan also improved epigastric pain (73%), postprandial distress (60%), constipation (58%) and diarrhea (52%) in patients with GERD. In conclusion, vonoprazan 10 mg daily is effective in improving GERD symptoms. Advanced age, obesity, erosive esophagitis, alcohol use and history of H. pylori eradication influence the resolution of GERD symptoms. Treatment with vonoprazan favorably affects gastrointestinal symptoms in patients with GERD.     

反流性疾病问卷表在军人胃食管反流病中的诊断价值

[目的]探讨反流性疾病问卷表(RDQ)在军人胃食管反流病(GERD)中的诊断价值。[方法]采用多阶段、分层、整群随机抽样的方法对驻闽某部军人进行反流性疾病问卷调查,记录被调查者过去4周内烧心、非心源性胸痛、反酸和反流4种症状出现的频率和程度积分,以RDQ评分≥12分作为GERD的诊断标准,计算军人中GERD的患病率,同时分析经电子胃镜检查证实为反流性食管炎(RE)患者的RDQ评分情况。[结果]研究得出军人GERD的患病率为6.77%,经胃镜检查420例中明确诊断为RE 60例(RE组)和内镜检查正常360例(非RE组)的RDQ评分差异有统计学意义(P0.01),说明评分与发生RE之间有较大关联。[结论]RDQ评分量表可以作为初步诊断军人GERD的一个良好的筛选试验。     

Comparison of efficacy of pantoprazole alone versus pantoprazole plus mosapride in therapy of gastroesophageal reflux disease: a randomized trial

The present study aimed to compare the efficacy for the therapy of GERD of pantoprazole alone with a combination of pantoprazole and mosapride. The study was a prospective, randomized trial involving 68 patients suffering heartburn and/or regurgitation at least twice a week for 6 weeks. Sixty-one patients consented to be randomized to receive either pantoprazole 40 mg b.i.d. (n = 33, group A) or pantoprazole 40 mg b.i.d. plus mosapride 5 mg t.d.s. (n = 28, group B) for 8 weeks. Twenty-four-hour esophageal pH-metry and endoscopy were conducted at recruitment and endoscopy was repeated at 8 weeks in all the patients studied. There were no differences in symptomatic responses to therapy between the groups (69.7% vs 89.2%; P = 0.11). The mean symptom score after 8 weeks was significantly lower in group B (3.78 +/- 3.62 vs 1.67 +/- 2.09; P = 0.009). Nonerosive esophagitis was present in 29 patients. In patients with nonerosive GERD there was no significant difference in symptomatic response to either regimen (17/20 in group A and 7/9 in group B responded; P = 0.63). In erosive esophagitis, symptomatic responses occurred more frequently in group B, 18/19 (94.7%), than in group A, 6/13 (46.2%; P = 0.003). However endoscopic healing of esophagitis occurred equally with either regimen (6/11, 54.5% in group A; 12/17, 70.5% in group B; P = 0.44). In nonerosive GERD, the addition of mosapride offers no benefit over pantoprazole alone. A combination of pantoprazole and mosapride is more effective than pantoprazole alone in providing symptomatic relief to patients with erosive GERD.     

ENDOLUMINAL GASTROPLICATION FOR GASTROESOPHAGEAL REFLUX APPEARING AFTER GASTRIC SURGERY

Endoluminal gastroplication (ELGP) is a new endoscopic treatment for gastroesophageal reflux disease (GERD). However, its efficacy has been reported only for primary GERD but not for postoperative GERD. Here we report the first two cases of GERD that appeared after gastric surgery and were successfully treated by ELGP. Both patients developed GERD after gastric surgery. Esophagogastrofiberscopy showed esophagitis and small hiatal hernia. The symptoms failed to disappear after medical therapy and ELGP was performed. ELGP involved the use of the BARD (EndoCinch^TM) endoscopic suturing system, where two to three plications were placed at the esophagogastric junction. Procedure time, start of soft diet and hospital stay were 55 min, the first postoperative day (POD), 5 days and 60 min, 1 POD and 5 days, for patients 1 and 2, respectively. No adverse events were noted apart from mild and transient epigastric pain. The GERD‐related symptoms markedly improved after ELGP. Improvements were also noted in acid exposure time and bile reflux time after the procedure. ELGP is safe and effective for GERD that develops after surgery although this needs to be confirmed in long‐term follow‐up studies. ELGP is potentially suitable for GERD after Billroth‐I distal gastrectomy with lymph node dissection for gastric cancer.     

The clinical characteristics of gastroesophageal reflux disease in patients with laryngeal symptoms who are referred to gastroenterology

The prevalence of gastroesophageal reflux disease (GERD) has increased recently in Asia‐Pacific countries. However, little is known about its prevalence and clinical characteristics in GERD patients with atypical symptoms in Asia. The aim of this study was to investigate the clinical characteristics of GERD in patients who had laryngeal symptoms in Korea. Data were gathered retrospectively from patients who presented with atypical symptoms, such as throat discomfort, globus pharyngeus, hoarseness, and chronic cough. They underwent a 24‐hour ambulatory intraesophageal pH monitoring and filled in a validated reflux questionnaire. Overall, 128 patients (36 men and 92 women) with laryngeal symptoms were included. Of these 128, 43 patients (34%) had erosive esophagitis or pathological reflux from 24‐hour ambulatory pH monitoring, and 24 (19%) had a positive Bernstein test or positive symptom index from 24‐hour pH monitoring. Sixty‐one patients (48%) had no evidence of reflux esophagitis on upper endoscopy and pathological acid reflux on 24‐hour pH monitoring. Fifty‐six patients (44%) had weekly heartburn or regurgitation. Typical symptoms and dyspepsia were significantly more common in patients with GERD who had laryngeal symptoms than non‐GERD. Fifty‐two percent of patients had laryngeal symptoms that were associated with GERD. The presence of typical reflux symptoms and dyspepsia are risk factors for GERD in patients who present with laryngeal symptoms.     

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.     

Changing epidemiology of gastroesophageal reflux disease in the Asian–Pacific region: An overview

Abstract   Gastroesophageal reflux disease (GERD) is a common disease in the West, which now appears to be also increasing in prevalence in the Asian Pacific region. The reasons for this changing epidemiology are two-fold: an increased awareness among doctors and patients, and/or a true increase in the prevalence of the disease. Prevalence rates of reflux esophagitis (RE) of up to 16% and prevalence of GERD symptoms of up to 9% have been reported in the Asian population. However, the frequency of strictures and Barrett's esophagus remain very low. Non-erosive reflux disease (NERD) appears to be the most common form of GERD among Asian patients accounting for 50–70% of cases with GERD. Among Asian patients differences can also be discerned among different ethnic groups. For example, in Malaysia where a multiracial society exists, RE is significantly more common among Indians compared to Chinese and Malays whereas NERD is more frequently seen in the Indian and Malays compared to the Chinese. The reasons for these differences are not known but may indicate both genetic factors and environmental factors peculiar to the particular racial group. GERD has also been increasing in the region demonstrating a time-lag phenomenon compared to the West. Differing predisposition to GERD among different ethnic groups would mean that such an increase would be more prominent among certain racial groups.     

Capsaicin induction of esophageal symptoms in different phenotypes of gastroesophageal reflux disease

"Background: Type 1 vanilloid receptors (TRPV1) have been described on esophageal afferent sensitive neurons. Stimulation of TRPV1 receptors with capsaicin may induce heartburn. Capsaicin is the pungent component of chili and the most extensively studied TRPV1 agonist. Objectives: To investigate the effect of esophageal stimulation with intraesophageal capsaicin administration on induction of esophageal symptoms and on esophageal chemo-sensitization to acid in different gastroesophageal reflux disease (GERD) phenotypes. Methods: Healthy volunteers and patients with GERD (non-erosive [NERD], erosive GERD [EE] and Barrett's esophagus [BE]) were prospectively studied. All subjects were randomized to receive either intraesophageal perfusion capsaicin or saline 0.9%. Thirty minutes after saline or capsaicin infusion an acid perfusion test of HCl was performed. A week later, a crossover phase with capsaicin versus saline was performed. Five symptoms were evaluated every 5 min during the first 30 minutes after capsaicin, saline, and acid perfusion: chest burning, chest pain, heartburn, epigastric burning, and epigastric pain Results: 17 healthy subjects and 31 GERD patients (10 NERD, 11 EE, and 10 BE) were included. Twenty- eight (90%) of GERD and 6 (35%) of healthy subjects had esophageal symptoms after capsaicin perfusion. Mean for the 5 evaluated symptoms induced by capsaicin was significantly higher in the GERD group compared to the control group. The highest symptom severity was in the erosive subgroup. Capsaicin decreased the 5 symptoms induced by acid perfusion in both healthy volunteers and GERD patients. Total score of esophageal symptom severity (produced by acid perfusion) was significantly reduced by capsaicin infusion in the BE group. Conclusions: Capsaicin induces esophageal and gastric symptoms in healthy volunteers and GERD patients. Capsaicin reduces esophageal chemosensitivity to acid, especially in patients with BE. "     

Effect of symptomatic gastroesophageal reflux disease on quality of life of patients with chronic liver disease.

Aim: Reflux esophagitis is becoming increasingly more prevalent in Japan. It has been noted that symptomatic gastroesophageal reflux disease (GERD) and chronic liver disease may adversely affect patients' quality of life. Methods: In the present study, 238 chronic liver disease patients (151 patients with chronic hepatitis and 87 patients with liver cirrhosis) were enrolled. The diagnosis of GERD was made based on the Quality-of-Life and Utility Evaluation Survey Technology questionnaire. Health-related quality of life was evaluated using the Short Forum 36 questionnaire. Results: Symptomatic GERD was present in 31.8% (48/151) of patients with chronic hepatitis and 36.8% (32/87) of patients with liver cirrhosis. Among the chronic hepatitis group, compared to the GERD-negative group, the GERD-positive group had significantly lower scores in six domains, including "rolelimitation due to physical problem", "bodily pain", "general health perception", "vitality", "role limitation due to emotional problem", and "mental health". Among the cirrhotic group, compared to the GERD-negative group, the GERD-positive group had significantly lower scores in the "role limitation due to emotional problem" domain. Significant improvement in the "physical functioning", "bodily pain", and "general health perception" domain scores was noted in chronic hepatitis patients treated with rabeprazole. Conclusion: The QOL of chronic liver disease patients with symptomatic GERD was impaired.     

Belching during gastroscopy and its association with gastroesophageal reflux disease

Belching may result from transient lower esophageal sphincter relaxation; therefore, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). This study was conducted to investigate the frequency of belching during esophagogastroduodenoscopy (EGD) and its association with GERD. A retrospective review was performed on prospectively collected clinical and endoscopic data from 404 subjects who underwent EGD without sedation from December 2012 to May 2013 in a training hospital in Korea. All detectable belching events during endoscopy were counted. Frequency and severity of belching events were compared between the group with and without GERD using an ordinal logistic regression model. There were 145 GERD patients (26 erosive reflux disease and 119 nonerosive reflux disease [NERD]). In the multivariable analysis, GERD was significantly associated with a higher frequency of belching events (odds ratio = 6.59, P < 0.001). Central obesity, female, and younger age were also risk factors for frequent belching during EGD. Subgroup analyses were performed in subjects without erosive reflux disease (n = 378) and NERD (n = 293). NERD was also a predictive factor for frequent belching during EGD (odds ratio = 6.61, P < 0.001), and the frequency of belching was significantly correlated with GERD severity according to the Los Angeles classification (P < 0.05). Frequent belching during EGD was associated with GERD, including NERD. Future research should focus on its adjuvant role in the diagnosis of GERD/NERD and the necessity for applying differentiated endoscopy strategies for GERD patients, leading to less discomfort during EGD in patients at risk for intolerability.     

Influence of cytochrome P450 2C19 genetic polymorphism and dosage of rabeprazole on accuracy of proton-pump inhibitor testing in Chinese patients with gastroesophageal reflux disease

BACKGROUND AND AIM: To evaluate the optimal dosage of rabeprazole for proton-pump inhibitor (PPI) testing of gastroesophageal reflux disease (GERD) and to test the influence of cytochrome P450 (CYP) 2C19 polymorphism in a population with a high prevalence of people who metabolize PPI poorly. METHODS: In this randomized, open-label trial, patients with symptoms suggestive of GERD were randomized to receive a 2-week test with 20- or 40-mg rabeprazole after diagnostic endoscopy. Symptom response was assessed with a four-grade daily record; in addition, DNA from peripheral blood leukocytes was genotyped for CYP2C19 polymorphism with the polymerase chain reaction-restriction fragment length polymorphism technique. RESULTS: Of the 164 patients who completed the study, 69 (42.1%) were endoscopically positive for esophagitis; the remaining 95 (57.9%) were diagnosed with endoscopy-negative reflux disease. Based on the best cut-off value for 50% symptom reduction, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for detecting erosive esophagitis were 68%, 70%, 66%, 72%, and 69%, respectively, for the 20-mg regimen, and 84%, 71%, 64%, 88%, and 76%, respectively, for the 40-mg regimen, a non-significant difference. Regarding the genotype, 60 (39%) patients had two wild-type alleles, 63 (40.9%) had one variant allele, and 31 (20.1%) had two variant CYP2C19 alleles. The presence of a variant allele did not alter the diagnostic efficacy of PPI testing. CONCLUSIONS: Both dose levels of rabeprazole proved efficacious in the diagnosis of GERD. Various measures of test accuracy were unrelated to the status of the CYP2C19 genotype.     

Healing of severe reflux esophagitis with PPI does not improve esophageal dysmotility

Esophageal dysmotility is frequently associated with gastroesophageal reflux disease (GERD). The aim of this study was to investigate the relationship between the severity of reflux esophagitis and esophageal dysmotility and evaluate the effect of prolonged treatment with proton pump inhibitor (lansoprazole 30 mg/day) on esophageal motility in patients with severe reflux esophagitis associated with esophageal motility disorder. Twelve healthy subjects (HS) and 100 patients with reflux disease were involved in the study consisting of two parts: (i) comparison of esophageal motility in HS and patients with non-eroseive reflux disease (NERD), mild esophagitis and severe esophagitis; (ii) effect of 3-6 months lansoprazole therapy on esophageal motility in 23 patients with severe esophagitis, pathologic acid reflux and esophageal peristaltic dysfunction. Results included the following. (i) Esophageal dysmotility was noted in both patients with NERD and erosive GERD. (ii) Severe esophagitis was associated with severe esophageal dysmotility. (iii) Healing of severe esophagitis did not improve esophageal dysmotility. The resting lower esophageal sphincter pressure was 3.9 mmHg (range 1.7-20) before treatment and 4.8 mmHg (range 1.2-18.3) after esophagitis healing (P = 0.23, vs. before treatment), the amplitude of distal esophageal contraction was 28.8 mmHg (range 10.9-80.6) before treatment and 33.3 mmHg (range 10.0-72.5) after esophagitis healing (P = 0.59, vs. before treatment) and the frequency of failed peristalsis was 70% (range 0-100%) before treatment and 70% (range 0-100%) after esophagitis healing (P = 0.78, vs. before treatment). Both esophageal motility disorders and acid reflux play important roles in the mechanism of GERD, especially in severe esophagitis. Esophageal dysmotility is not secondary to acid reflux and esophagitis; it should be a primary motility disorder.     

Epidemiological study of symptomatic gastroesophageal reflux disease in China: Beijing and Shanghai

OBJECTIVE : To explore the 1‐year point prevalences (July–September 1996) of symptomatic gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD) and reflux esophagitis (RE) in the adult population of two Chinese city‐regions (Beijing and Shanghai) and to identify the conditions that predispose patients to GERD. METHODS : Phase I: 5000 residents of the two regions aged between 18 and 70 years were studied via a questionnaire. The study was carried out by cluster sampling from city, suburban and rural areas by using simple random sampling. Symptom scores (Sc) of the intensity and frequency of heartburn, acid reflux and regurgitation within 1 year of the time of study were taken as indices of acid reflux (highest score, Sc = 18) and Sc ≥ 6 indicated the presence of symptomatic GER. Phase II: a small number of patients who were identified as having symptomatic GER in the survey were enrolled in a case– control study using gastroscopy and 24‐h pH monitoring to obtain correct diagnostic rates of GERD and RE. Estimates of the prevalence of GERD and RE were then adjusted according to the rates of correct diagnosis. RESULTS : A total of 4992 subjects completed the survey, 2.5% had heartburn once daily, 8.97% had symptomatic GER (Sc ≥ 6) and the male to female ratio was 1:1.11. Point prevalences for the year for GERD and RE were 5.77 and 1.92%, respectively. Stratified analysis indicated that the prevalence of symptomatic GER in Beijing (10.19%) was higher than that in Shanghai (7.76%) and there was also a higher prevalence of GER in males, manual laborers, people from rural areas and people older than 40 years of age in Beijing as compared with Shanghai. Stepwise logistic analysis indicated that GER had a close relationship with dental, pharyngolaryngeal disorders and respiratory diseases. The conditions that predispose patients to GERD are (OR, odds ratio): age > 40 (OR = 1.01), eating greasy/oily food (OR = 6.56), overeating (OR = 1.99), tiredness (OR = 2.35), emotional stress (OR = 2.22), pregnancy (OR = 6.80) and constipation (OR = 1.65). CONCLUSIONS : Gastroesophageal reflux disease is a common disease in the adult Chinese population and it is more common in Beijing than in Shanghai.     

A novel endoscopic submucosal dissection technique for proton pump inhibitor-refractory gastroesophageal reflux disease

Abstract

Objectives: Although drug treatment is the usual first-line therapy for gastroesophageal reflux disease (GERD), not all patients receive satisfactory relief from drug therapy, alone. We developed an endoscopic fundoplication technique using endoscopic submucosal dissection (ESD); the technique is referred to as ESD for GERD (ESD-G). This study investigated the safety and efficacy of this novel technique in patients with drug-refractory GERD. Patients and methods: ESD-G narrows the hiatal opening through ESD of the esophagogastric junction (EGJ) mucosa. For safety reasons, the range of mucosal resection was limited to half (1/2 or 1/4 +1/4) of the circumference of the EGJ lumen. ESD-G was performed on 13 patients with proton pump inhibitor (PPI)-refractory GERD. GERD symptoms, PPI dose, and 24-h esophageal pH monitoring results were compared before and 6 months after the procedure. Results. In 12 cases, symptoms significantly improved after ESD-G. Five patients demonstrated improved esophagitis, three were able to discontinue PPI therapy, and three were able to reduce their PPI dosage following surgery. The esophageal pH <4 holding time ratio was also decreased after ESD-G. Conclusions. ESD-G may be useful for PPI-refractory GERD patients.