Is there a changing trend in surgical management of gastroesophageal reflux disease in children？

Gastroesophageal reflux disease (GORD) is a pathological process in infants manifesting as poor weight gain, signs of esophagitis, persistent respiratory symptoms and changes in neurobehaviour. It is currently estimated that approximately one in every 350 children will experience severe symptomatic gastroesophageal reflux necessitating surgical treatment. Surgery for GORD is currently one of the common major operations performed in infants and children. Most of the studies found favour laparoscopic approach which has surpassed open antireflux surgery as the gold standard of surgical management for GORD.However, it must be interpreted with caution due to the limitation of the studies, especially the small number of subject included in these studies. This review reports the changing trends in the surgical treatment of GORD inchildren.     

Is ineffective esophageal motility gastropharyngeal reflux disease？

AIM： TO evaluate the association between IEM and gastropharyngeal reflux disease （GPRD） in patients who underwent ambulatory 24-h dual-probe pH monitoring for the evaluation of supraesophageal symptoms.
METHODS： A total of 632 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h dual-pH monitoring due to supraesophageal symptoms （e.g. globus, hoarseness, or cough） were enrolled. Of them, we selected the patients who had normal esophageal motility and IEM. The endoscopy and ambulatory pH monitoring findings were compared between the two groups.
RESULTS;： A total of 264 patients with normal esophageal motility and 195 patients with the diagnosis of IEM were included in this study. There was no difference in the frequency of reflux esophagitis and hiatal hernia between the two groups. All the variables showing gastroesophageal reflux and gastropharyngeal reflux were not different between the two groups. The frequency of GERD and GPRD, as defined by ambulatory pH monitoring, was not different between the two groups.
CONCLUSION： There was no association between IEM and GPRD as well as between IEM and GERD. IEM alone cannot be considered as a definitive marker for reflux disease.     

Esophageal epithelial surface in patients with gastroesophageal reflux disease： An electron microscopic study

A/M： To investigate the intercellular spaces between the most superficially located esophageal epithelial cells in patients with gastroesophageal reflux disease （GERD）.
METHODS： Eighteen patients with erosive esophagitis, 10 patients with non-erosive reflux disease （NERD）, and 18 normal asymptomatic volunteers were enrolled. Biopsy specimens were obtained from the lower esophageal mucosa without ulcer or erosion. Scanning electron microscopy was employed to investigate the tightness of the superficial cellular attachment.
RESULTS： The intercellular space between the most superficially located epithelial cells in patients with erosive esophagitis or NERD was not different from that in asymptomatic healthy individuals.
CONCLUSION： Widened luminal intercellular spaces of esophageal superficial epithelium are not responsible for the induction of reflux symptoms in patients with GERD.     

Gastro esophageal reflux disease is associated with absence from work： Results from a prospective cohort study

AIM: To study the association of gastro-esophageal reflux disease (GERD) with the absence from work and to estimate the extent of loss in gross domestic product due to inability to work. METHODS: Analysis was based on the prospectively gathered data of a large European cohort study involving 6 215 symptomatic GERD patients (ProGERD). Among these patients, 2 871 were initially employed. The calculation of the loss of gross domestic product was based on the assumption that the prevalence of GERD was about 15% in Germany. According to the German Federal Statistical Office, the mean gross wage of employees was 150 (?)/d in 2002. RESULTS: The data of 2 078 employed patients who were prospectively followed up for over 2 years were analyzed. At study entry, the patients reported a mean of 1.8 d per year of inability to work. During the prospective follow-up under routine clinical care, the proportion of patients reporting days with inability to work decreased from 14% to 6% and the mean number of days per year with inability to work decreased to 0.9 d. Assuming a prevalence of troublesome GERD of 15% in the employed German population, the loss of gross domestic product amounted to 668 million (?)/year in Germany. CONCLUSION: GERD causes a relevant impairment on the national economics by absence from work. The presented data demonstrate the importance of GERD, not only for patients and health insurance companies, but also for the community at large.     

Esophageal cell proliferation in gastroesophageal reflux disease： Clinical-morphological data before and after pantoprazole

AIM： To evaluate esophageal mucosal defense mechanisms at an epithelial level to establish if pantoprazole treatment can induce ultrastructural healing and improvement in the proliferation activity of the esophageal epithelium in gastroesophageal reflux disease （GERD）. METHODS： This was a single-blinded study for pH- monitoring, and histological, ultrastructural and MIB1 immunostaining evaluation. Fifty eight patients with GERD were enrolled and underwent 24 h pH-monitoring and endoscopy. Patients were treated for 12 and 24 mo with pantoprazole. Esophageal specimens were taken for histological and ultrastructural evaluation, before and after the treatment. RESULTS： With transmission electron microscopy, all patients with GERD showed ultrastructural signs of damage with dilation of intercellular spaces （DIS）. After 3 mo of therapy the mean DIS values showed a significant reduction and the mean MIB1-LI values of GERD showed an increase in cell proliferation. A further 3 mo of therapy significantly increased cell proliferation only in the erosive esophagitis （ERD） group. CONCLUSION： Three months of pantoprazole therapy induced ultrastructural healing of mucosal damage in 89% and 93% of ERD and non-erosion patients, respectively. Moreover, long-term pantoprazole treatment may be helpful in increasing the capability for esophageal cell proliferation in GERD, particularly in ERD patients.     

Is obesity associated with gastropharyngeal reflux disease？

AIM： To examine the association between obesity and gastropharyngeal reflux disease （GPRD） as well as gastroesophageal reflux disease （GERD）
METHODS： We conducted a cross-sectional study of consecutive patients undergoing ambulatory 24-h dualprobe pH monitoring from July 2003 to December 2006. The association between body mass index （BMI） and parameters about gastroesophageal or gastropharyngeal reflux was examined in univariate and multivariate analyses.
RESULTS： A total of 769 patients （307 men and 462 women; mean age 50.7 years） were finally enrolled. Most variables showing gastroesophageal reflux was higher in the obese patients than the patients with normal BMI. There was no difference in all the variables showing gastropharyngeal reflux according to the BMI. After adjustment for age, sex, alcohol intake and smoking, obese patients demonstrated an about 2-fold increase in risk of GERD compared with patients with normal BMI （OR, 1.9; 95 CI, 1.3-2.9）, but overweight patients did not demonstrate increased risk of GERD （OR, 1.2; 95 CI, 0.8-1.7）. Both obese patients and overweight patients did not demonstrated increased risk of GPRD compared with patients with normal BMI （OR, 1.1; 95 CI, 0.8-1.7; and OR, 0.9; 95 CI, 0.6-1.3, respectively）.
CONCLUSION： Obesity is not associated with GPRD reflux while it is associated with GERD.     

Tongue-like Barrett＇s esophagus is associated with gastroesophageal reflux disease

AIM： To test this hypothesis of barrett esophagus （BE） classified into two types and to further determine if there was any correlation between the shape of endoscopically suspected esophageal metaplasia （ESEM）, prevalence of reflux esophagitis （RE） and heartburn. METHODS： A total of 6504 Japanese who underwent endoscopy for their annual stomach check-up were enrolled in this study. BE was detected without histological confirmation that is ESEM. We originally classified cases of ESEM into 3 types based on its shape： Tongue-like （T type）, Dome-like （D type） and Wave-like （W type） ESEM. The respective subjects were prospectively asked to complete questionnaires concerning the symptoms of heartburn, dysphagia, and abdominal pain for a one-month period. RESULTS： ESEM was observed in 10.3% of 6504 subjects （ESEM 〈 1 cm, 9.4%; 1cm≤ESEM 〈 3 cm, 1.7%; ESEM≥3 cm, 0.5%）. The frequency of ESEM was significantly higher in males compared with female subjects. Statistical analysis showed that the prevalence of heartburn and RE were significantly higher in the T type ESEM than in the W type ESEM （P 〈 0.05）. CONCLUSION： The T type ESEM was strongly associated with reflux symptoms and RE whereas the W type ESEM was not associated with GERD.     

Interleukin‐8 expression in the esophageal mucosa of patients with gastroesophageal reflux disease

Background: It has been reported that inflammatory cell infiltration can be detected in patients with endoscopically negative gastroesophageal reflux disease (GERD) as well as those with erosive reflux esophagitis. In this study, we examined the expression of mRNA for interleukin (IL)‐8, a potent chemokine for neutrophils, in the esophageal mucosa of patients with GERD and compared the results with their endoscopic findings and symptoms. Methods: Biopsy samples were obtained from 80 patients. Endoscopic diagnosis was performed according to the Los Angeles classification. Patients with typical symptoms such as heartburn despite normal endoscopic findings were classified as the non‐erosive GERD group. Total cellular RNA was extracted from the biopsy samples and IL‐8 mRNA was quantified by real‐time polymerase chain reaction (PCR). Localization of IL‐8 protein in the esophageal mucosa was done by immunostaining. Results: Expression of IL‐8 mRNA was correlated with the endoscopic grade of esophagitis or with inflammatory cell infiltration, but not with the symptoms of the patients. Expression of IL‐8 mRNA was also detected in all patients with non‐erosive GERD. The level of IL‐8 expression in non‐erosive GERD was low compared with that in erosive GERD, but was higher than that in normal controls. IL‐8 immunostaining was found in the basal layers of the esophageal mucosa. Administration of lansoprazole, a proton‐pump inhibitor, decreased both IL‐8 mRNA and protein levels in the esophageal mucosa. Conclusion: These results suggest that IL‐8 in the esophageal mucosa may be involved in the pathogenesis of esophageal inflammation, including non‐erosive GERD.     

Is analysis of lower esophageal sphincter vector volumes of valuein diagnosing gastroesophageal reflux disease？

AIM: With successful surgical treatment of gastroesophageal reflux disease (GERD), there is interest in understanding the anti-reflux barrier and its mechanisms of failure. To date, the potential use of vector volumes to predict the DeMeester score has not been adequately explored. METHODS: 627 patients in the referral database received esophageal manometry and ambulatory 24-hour pH monitoring. Study data included LES resting pressure (LESP), overall LES length (OL) and abdominal length (AL), total vector volume (TVV) and intrabdominal vector volume (IVV). RESULTS: In cases where LESP, TVV or IVV were all below normal, there was an 81.4 % probability of a positive DeMeester score. In cases where all three were normal, there was an 86.9 % probability that the DeMeester score would be negative. Receiver-operating characteristics (ROC) for LESP, TVV and IVV were nearly identical and indicated no useful cut-off values. Logistic regression demonstrated that LESP and IVV had the strongest association with a positive DeMeester score; however, the regression formula was only 76.1 % accurate. CONCLUSION: While the indices based on TVV, IVV and LESP are more sensitive and specific, respectively, than any single measurement, the measurement of vector volumes does not add significantly to the diagnosis of GERD.     

24-hour esophageal pH-monitoring in children suspected of gastroesophageal reflux disease： Analysis of intraesophageal pH monitoring values recorded in distal and proximal channel at diagnosis

AIM To assess values of 24-h esophageal pH-monitoring parameters with dual-channel probe (distal and proximal channel) in children suspected of gastroesophageal reflux disease (GERD).METHODS 264 children suspected of gastroesophageal reflux (GER) were enrolled in a study (mean age χ = 20.78 ± 17.23 mo). The outcomes of this study,immunoallerrgological tests and positive result of oral food challenge test with a potentially noxious nutrient,enabled to qualify children into particular study groups.RESULTS 32 (12.1%) infants (group 1) had physiological GER diagnosed. Pathological acid GER was confirmed in 138 (52.3%) children. Primary GER was diagnosed in 76 (28.8%) children (group 2) and GER secondary to allergy to cow milk protein and/or other food (CMA/FA) in 62 (23.5%) children (group 3). 32(12.1%) of them had CMA/FA (group 4-reference group),and in remaining 62 (23.5%) children neither GER nor CMA/FA was confirmed (group 5). Mean values of pH monitoring parameters measured in distal and proximal channel were analyzed in individual groups. This analysis showed statistically significant differentiation of mean values in the case of number of episodes of acid GER,episodes of acid GER lasting ＞ 5 min, duration of the longest episode of acid GER in both channels, acid GER index total and supine in proximal channel. Statistically significant differences of mean values among examined groups, especially between group 2 and 3 in the case of total acid GER index (only distal channel) were confirmed.CONCLUSION 24-h esophageal pH monitoring confirmed pathological acid GER in 52.3% of children with typical and atypical symptoms of GERD. The similar pH-monitoring values obtained in group 2 and 3 confirm the necessity of implementation of differential diagnosis for primary vs secondary cause of GER.     

Asthma and gastroesophageal reflux disease： Effect of long-term pantoprazole therapy

AIM: To define the prevalence of gastroesophageal reflux disease (GERD) in mild persistent asthma and to value the effect of pantoprazole therapy on asthmatic symptoms. METHODS: Seven of thirty-four asthmatic patients without GERD served as the non-GERD control group. Twenty-seven of thirty-four asthmatic patients had GERD (7/27 also had erosive esophagitis, sixteen of them presented GERD symptoms. An upper gastrointestinal endoscopy was performed in all the subjects to obtain five biopsy specimens from the lower 5 cm of the esophagus. Patients were considered to have GERD when they had a dilation of intercellular space (DIS)>0.74 urn at transmission electron microscopy. Patients with GERD were treated with pantoprazole, 80 mg/day. Forced expiratory volume in one second (FEV1) was performed at entry and after 6 mo of treatment. Asthmatic symptoms were recorded. The required frequency of inhaling rapid acting β2-agonists was self-recorded in the patients' diaries. RESULTS: Seven symptomatic patients presented erosive esophagitis. Among the 18 asymptomatic patients, 11 presented DIS, while all symptomatic patients showed ultrastructural esophageal damage. Seven asymptomatic patients did not present DIS. At entry the mean of FEV1 was 1.91 L in symptomatic GERD patients and 1.88 L in asymptomatic GERD patients. After the treatment, 25 patients had a complete recovery of DIS and reflux symptoms. Twenty-three patients presented a regression of asthmatic symptoms with normalization of FEV1. Four patients reported a significant improvement of symptoms and their FEV1 was over 80%. CONCLUSION: GERD is a highly prevalent condition in asthma patients. Treatment with pantoprazole (80 mg/day) determines their improvement and complete regression.     

Severity of gastroesophageal reflux disease influences daytime somnolence： A clinical study of 134 patients underwent upper panendoscopy

AIM: To asses the relationship between severity of gastroesophageal refluxe disease and Epworth sleepiness scale as an indicator of daytime somnolence. METHODS: One hundred and thirty-four patients underwent an upper panendoscopy as indicated by the typical reflux symptoms and were also investigated with regard to somnolence. Sleepiness was evaluated by Epworth Sleepiness Scale, which was compared to the severity of endoscopic findings (Savary-Miller/modified by Siewert). Patients with psychiatric disorders or being on sedato-hypnotics as well as shift workers were excluded from the study. The relationship between the severity of the reflux disease and daytime somnolence was analyzed with the help of multivariate regression analysis. RESULTS: A positive tendency was found between the severity of the reflux disease and the corresponding Epworth Sleepiness Scale. In the case of the more severe type-Savary-Miller Ⅲ- at least a mild hypersomnia was found. For this group daytime somnolence was significantly higher than in the case of the non-erosive type of Gastroesophageal Reflux Disease representing the mildest stage of reflux disease. CONCLUSION: The severity of Gastroesophageal Reflux Disease influences daytime somnolence.     

Overlap of reflux and eosinophilic esophagitis in two patients requiring different therapies：A review of the literature

Eosinophilic esophagitis （EE） and gastroesophageal reflux disease （GERD） have overlapping clinical, manometric, endoscopic and histopathologic features. The diagnosis of EE is nowadays based upon the presence of 15 or more eosinophils per high power field （eo/HPF） in esophageal biopsies. We report the cases of two young males suffering from dysphagia and recurrent food impaction with reflux esophagitis and more than 20 eo/HPF in upper-mid esophagus biopsies, both of which became asymptomatic on proton pump inhibitor （PPI） therapy. The first patient also achieved a histologic response, while EE remained in the other patient after effective PPI treatment, as shown by 24-h esophageal pH monitoring. Topical steroid therapy combined with PPI led to complete remission in this latter patient. GERD and EE may be undistinguishable, even by histology, so diagnosis of EE should only be established after a careful correlation of clinical, endoscopic and pathologic data obtained under vigorous acid suppression. These diagnostic difficulties are maximal when both diseases overlap. Limited data are available about this topic, and the interaction between EE and GERD is a matter of debate. In this setting, upper-mid esophagus step biopsies and esophageal pH monitoring of patients on PPI therapy are pivotal to evaluate the role of each disease. A PPI trial is mandatory in patients with a histopathologic diagnosis of EE; in those unresponsive to PPI treatment, EE should be suggested. However, a clinical response to PPI may not rule out quiescent EE, as shown in this report.     

Barrett＇s esophagus and its correlation with gastroesophageal reflux in Chinese

AIM- To study the prevalence of Barrett‘s esophagus in Chinese and its correlation with gastroesophageal reflux. METHODS: This study was carded out in a large prospective series of 391 patients who had undergone upper endoscopy. The patients were divided into 3 groups according to the position of squamocolumnar junction (SC3). Reflux esophagitis (RE) and its degree were recorded. Intestinal metaplasia (IM) in biopsy specimen was typed according to histochemistry and HE and alcian blue (pH2.5) staining separately. Results correlating with clinical, endoscopic, and pathological data were analysed. RESULTS: The prevalence of IM endoscopically appearing Long-segment Barrett‘s Esophagus (LSBE) was 26.53%, Short-segment Barrett‘s Esophagus (SSBE) was 33.85% and gastroesophageal junction (GEJ) was 34.00%. IM increased with age of above 40 years old and no difference was found between male and female. Twelve were diagnosed as dysplasia (7 low -grade, 5 high-grade), 16 were diagnosed as cardiac adenocarcinoma and 1 as esophageal adenocarcinoma. The more far away the SCJ moved upward above GEJ, the higher the prevalence and the more severe the RE were. CONCLUSION: There was no difference of the prevalence of IM in different places of SCJ, and IM increased with age of above 40 years old. It is important to pay attention to dysplasia in the distal esophagus and gastro-esophageal junction, and adenocarcinoma is more common in cardia than in esophagus. BE is a consequence of gastroesophageal reflux disease.     

Epidemiology of gastroesophageal reflux disease： A general population-based study in Xi＇an of Northwest China

AIM: Gastroesophageal reflux disease (GERD) is a common disorder in the Western population, but detailed population-based data in China are limited. The aim of this study was to understand the epidemiology of symptomatic gastroesophageal reflux (SGER) in adults of Xi‘an, a northwestern city of China, and to explore the potential risk factors of GERD. METHODS: Symptoms suggestive of GERD, functional dyspepsia (FD), irritable bowel syndrome (IBS), upper respiratory diseases and some potential risk factors were investigated in a face-to-face manner in a region-stratified random samples of 2 789 residents aged 18-70 years in Xi‘an by using a standardized questionnaire. METHODS: With a response rate of 91.8%, the prevalence of SGER was 16.98% (95% CI, 14.2-18.92) in Xi‘an adults, and no gender-related difference was observed (P<0.05). SGER was more common among subjects aged 30-70 years than in those aged 18-29 years (P<0.01). The prevalence of SGER in rural, urban and suburban subjects was 21.07%, 17.44% and 12.12%, respectively, and there was a significant difference between rural, urban and suburban regions (P<0.05). Compared with subjects without SGER, the prevalence of symptoms suggestive of FD and IBS, pneumonia, asthma, bronchitis, laryngitis, pharyngitis, chronic cough, wheeze, globus sensation, oral ulcer and snore was significantly increased in subjects with SGER (P<0.01). Heavy smoking (OR=5.76; CI, 3.70-6.67), heavy alcohol use (OR=2.85; CI, 1.67-4.49), peplJc ulcer (OR=5.76; CI, 3.99-8.32), cerebral palsy (OR=3.97; CI, 1.97-8.00), abdominal operation (OR=2.69; CI, 1.75-4.13), obesity(OR=2.16; CI, 1.47-3.16), excessive food intake (OR= 1.43;CI, 1.17-1.15), sweet food (OR=1.23; CI, 0.89-1.54), and consumption of coffee (OR= 1.23; CI, 0.17-2.00) were independently associated with SGER. The episodes of GERD were commonly precipitated by dietary factors (66.05%), followed by body posture (26.54%), ill temper (23.72%), fatigue (22.32%) and stress (10.93%). CONCLUSION: GERD is common in Xi‘an‘s adult population with a mild or moderate degree. The etiology and pathogenesis of GERD are probably associated with FD, IBS, and some respiratory, laryngopharyngeal and odontostological diseases or symptoms. Some lifestyles, diseases and dietary factors are the risk factors of GERD.     

Is the severity of obstructive sleep apnea or the magnitude of respiratory effort associated with gastroesophageal reflux？

TO THE EDITOR In a recent issue of World Journal of Gastroenterology, Demeter et al, reported that in patients having both gastro-esophageal reflux disease (GERD) and obstructive sleep apnea (OSA), there was a positive correlation between     

Microproteinuria in patients with inflammatory bowel disease： Is it associated with the disease activity or the treatment with 5-aminosalicylic acid？

AIM: To investigate whether microproteinuria in patients with inflammatory bowel disease (IBD) is associated with the disease activity or the treatment with 5-aminosalicylic acid (5-ASA). METHODS: We prospectively studied microproteinuria in 86 consecutive patients with IBD, 61 with ulcerative colitis (UC) and 25 with Crohn's disease (CD), before as well as 2 and 6 months after their inclusion in the study. Forty-six patients received 5-ASA for a period of 28.8 months (range 1-168 mo). Microalbuminuria (mALB) and urine levels of the renal tubular proteins beta2-microglobulin (beta2mGLB) and beta-N-acetyl-D-glucosamidase (beta-NAG) as well as the creatinine clearance were determined in a 12-h overnight urine collection. Tumor necrosis factor-alpha (TNF-alpha) serum levels were also measured. RESULTS: A total of 277 measurements (194 in UC patients and 83 in CD patients) were performed. The prevalence of abnormal microproteinuria in UC and CD patients was 12.9% and 6.0% for mALB, 22.7% and 27.7% for beta2mGLB, and 11.3% and 8.4% for beta-NAG, respectively. mALB was not associated with IBD activity. Beta2mGLB and beta-NAG urine levels were correlated to UC activity (UCAI: P<0.01; UCEI: P<0.005). mALB in UC patients and beta-NAG urine levels in CD patients were related to TNF-alpha serum levels. An association was noticed between microproteinuria and smoking habit. Treatment with 5-ASA was not correlated to the severity of microproteinuria or to the changes of creatinine clearance. CONCLUSION: Microproteinuria is mainly associated with UC and its activity but not affected by 5-ASA.     

Relationship of gastric Helicobacter pyloriinfection to Barrett＇s esophagus and gastro-esophageal reflux disease in Chinese

AIM:To evaluate the relationship of Helicobacter pylori infection to reflux esophagitis (RE), Barrett‘s esophagus (BE)and gastric intestinal metaplasia (IM).METHODS:RE,BE and gastric IM were determined by upper endoscopy. Patients were divided into 2 groups; those with squamocolumnar junction (SCJ) beyond gastroesophageal junction (GEJ)≥3cm (group A), and those with SCJ beyond GE.1 &lt;3cm (group B). Biopsy specimens were obtainedend escopically from just below the SCJ, gastric antrum along the greater and lesser curvature. Pathological changes and Hpylorr infection were determined by HE staining, Alcian blue staining and Giemsa staining.RESULTS:The prevalence of Hpyloriinfection was 46.93%.There was no difference in the prevalence between males and females.The prevalence of Hpyloriinfection decreased stepwise significantly from RE grade I to Ⅲ.There was no difference in the prevalence between the two groups, and between long-segment and short-segment BE. In distal stomach, prevalence of Hpyloriinfection was significantly higher in patients with IM than those without IM.CONCLUSION: There is a protective role of Hpyloriinfectuion to GERD. There may be no relationship between Hpylori infection of stomach and BE. Hpyloriinfection is associated with the development of IN in the distal stomach.