Chronic cough and hoarseness in patients with severe gastroesophageal reflux disease

Gastroesophageal reflux may be responsible for atypical symptoms such as chronic cough and hoarseness. Our aim was to evaluate and treat patients with severe gastroesophageal reflux and chronic cough or hoarseness with intensive antireflux therapy. Twenty-seven patients with typical heartburn symptoms in addition to significant cough or hoarseness were treated with aggressive antireflux therapy. We recorded the response of each symptom to the antireflux therapy. Two patients were lost to follow-up. Twenty of the 25 (80%) patients showed some improvement in cough or hoarseness, nine (36%) had no atypical symptoms at follow-up. The response of heartburn to therapy was strongly predictive of successful therapy for the atypical symptoms. Cough and hoarseness improved in only two of the five patients with residual heartburn symptoms compared to 18 of 20 patients with no heartburn (P<0.04). Only patients with no heartburn symptoms at follow-up had complete resolution of atypical symptoms. There were no important differences on ambulatory pH monitoring between partial and complete responders. Improvement in atypical reflux symptoms, such as chronic cough and hoarseness, is common with aggressive antireflux therapy. There are no findings on ambulatory esophageal pH monitoring that uniquely identify patients who are likely to respond to antireflux therapy.     

Pharmacologic management and treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common diagnoses in daily practice. Diagnosis can be made on symptom evaluation, on pH-monitoring or on endoscopic findings. In contrast to commonly held opinion there is no strong evidence that lifestyle factors are a dominant factor in the pathophysiology of GERD. The various agents currently used for treatment of GERD include mucoprotective substances, antacids, H(2)-blockers and proton pump inhibitors. This article gives an overview of the pharmacological management of GERD and focuses on the differential therapy of endoscopy-negative GERD, GERD with esophagitis and maintenance therapy.     

Endoscopic grading of gastroesophageal flap valve helps predict proton pump inhibitor response in patients with gastroesophageal reflux disease

Abstract

Objective. Limited information is available on predictors of the response to proton pump inhibitor (PPI) treatment in patients with gastroesophageal reflux disease (GERD). Endoscopic grading of gastroesophageal flap valve (GEFV) is simple and reproducible, and can provide useful information on patients with suspected reflux undergoing an endoscopy. The aim of this study was to prospectively identify predictors, including endoscopic findings such as GEFV, for PPI treatment outcomes in patients with GERD. Material and methods. One hundred and fifty consecutive patients with GERD were enrolled. All patients were treated with pantoprazole 40 mg daily for 8 weeks. Treatment response was defined as greater than 50% reduction in symptom scores between the two symptom assessments (i.e., over 4 or 8 weeks). Univariate and multivariate logistic regression analyses between responders and non-responders were performed to identify variables predicting response to pantoprazole treatment. Results. Of the 150 consecutive patients considered for this study, 31 were excluded based on exclusion criteria and/or refusal to participate, leaving 119 eligible patients. After 4-week pantoprazole treatment, 70 of 119 (58.8%) patients were classified as responders. Patients with obesity and Helicobacter pylori infection demonstrated a higher response rate to 4-week pantoprazole treatment (odds ratio (OR) 5.28, p = 0.008; OR 3.76, p = 0.023, respectively). Patients with abnormal GEFV showed a lower response rate to 4-week treatment (OR 0.17, p = 0.016). After 8-week treatment, 86 of 119 (72.3%) patients were classified as responders. Abnormal GEFV and aspirin intake were associated with a lower response rate to 8-week treatment (OR 0.17, p = 0.021; OR 0.11, p = 0.020, respectively). Conclusions. Abnormal GEFV was a significant independent factor predicting poor response to both 4-week and 8-week pantoprazole treatment. Endoscopic grading of GEFV provides useful information for predicting the response to PPI treatment in patients with GERD.     

Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease

To assess adherence to proton pump inhibitor (PPI) treatment and associated variables in patients with gastroesophageal reflux disease (GERD). Cross‐sectional and prospective comprising 240 consecutive adult patients, diagnosed with GERD for whom continuous use of standard or double dose of omeprazole had been prescribed. Patients were ranked as ne‐GERD (162: 67.5%) or e‐GERD classified according to the Los Angeles classification as A (48:20.0%), B (21:8.6%), C (1:0.5%), D (1:0.5%), and Barrett's esophagus (7:2.9%). The Morisky questionnaire was applied to assess adherence to therapy and a GERD questionnaire to assess symptoms and their impact. Adherence was correlated with demographics, cotherapies, comorbidities, treatment duration, symptoms scores, endoscopic findings, and patient awareness of their disease. 126 patients (52.5%) exhibited high level of adherence and 114 (47.5%) low level. Youngers (P= 0.002) or married (O.R. 2.41, P= 0.03 vs. widowers) patients had lower levels of adherence; symptomatic patients exhibited lower adherence (P= 0.02). All other variables studied had no influence on adherence. Patients with GERD attending a tertiary referral hospital in São Paulo exhibited a high rate of low adherence to the prescribed PPI therapy that may play a role in the therapy failure. Age <60 years, marital status and being symptomatic were risk factors for low adherence.     

Increased esophageal mucosal/submucosal blood flow in patients with gastroesophageal reflux disease: normalization by treatment with a proton pump inhibitor

Background and Aim: Mucosal injury caused by gastroesophageal reflux may result in changes in esophageal mucosal blood flow. Little is known about esophageal mucosal blood flow in patients with gastroesophageal reflux disease (GERD). Here we examined esophageal mucosal blood flow and the effects of treatment in patients with GERD. Methods: The subjects included 41 cases (21 males and 20 females, mean age 64.2 years) in whom endoscopy was warranted in patients complaining of heartburn and/or regurgitation. We also studied six normal control subjects. Patients underwent endoscopy, laser Doppler flow meter measurements, and endoscopic ultrasonography before and after treatment. Results: Esophageal mucosal/submucosal blood flow was increased in patients with GERD compared with the control patients. The thickness of the whole esophageal wall and that of the mucosal and submucosal layers of the esophagus correlated significantly with esophageal mucosal/submucosal blood flow. The increased esophageal mucosal/submucosal blood flow significantly decreased after 4 weeks' treatment with lansoprazole, a proton pump inhibitor. Conclusion: Our results indicated that the pathophysiology or underlying mechanisms of GERD includes increased esophageal mucosal/submucosal blood flow, which correlates with the thickness of the esophageal wall, but is reversible and responds to treatment with lansoprazole. This suggests that proton pump inhibitors can effectively treat GERD and promote histological normalization of the mucosa and submucosa in the lower esophagus.     

Psychological modulation in patients surgically intervened for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) has been related with certain psychological dimensions. The influence of mood, emotional intelligence, and perceived quality of life on clinical symptoms and outcome of antireflux surgery was evaluated in GERD patients with and without hiatal hernia. The study included 61 patients who were diagnosed with GERD between 2003 and 2008: 16 of them without hiatal hernia (group A) and 45 of them with hiatal hernia (group B). All of these patients had undergone laparoscopic antireflux surgery. Patients were clinically examined and evaluated with the following instruments: Short Form (SF)‐36 Health Survey, Gastrointestinal Quality of Life Index, Hospital Anxiety and Depression (HAD) Scale, and Trait Meta‐Mood Scale (TMMS)‐24. Proportions were compared by using the chi‐squared test; averages were compared by using the Student's t‐test (with Bonferroni's correction). In general, our patients intervened for GERD showed results lower than normal or close to the lower limit of normal in the administered tests. Patients in the group without hernia were younger (P < 0.001) and with lower American Society of Anaesthesiologists risk. They showed higher scores in the SF‐36 dimensions: Physical Functioning, Physical Role and Emotional Role, and lower scores in the Social Role (P < 0.001). They showed lower scores in the Emotional dimension of Gastrointestinal Quality of Life Index (P = 0.0068) and worse results in the Hospital Anxiety and Depression subscales of Anxiety (P < 0.001) and Depression (not significant). Men in the group without hernia showed higher scores than men in the group with hernia in the TMMS subscales corresponding to Emotional Clarity and Emotional Repair (P < 0.001). Women in the group with hernia showed higher scores than women in the group without hernia regarding Emotional Clarity (P = 0.0012). GERD patients showed poor results in all the tests, and patients without hiatal hernia compared with patients with hernia showed higher levels of anxiety, which interfered with their social life. Moreover, they showed lower tolerance to stress and higher frustration, fear, and worry. On the basis of such unfavorable phychoemotional results observed with GERD patients (especially those without hernia) in the different tests, we propose that improving our knowledge of the psychological profile of GERD patients – particularly those without hiatal hernia – could help in designing individualized medical and psychological therapies and increase success rates.     

Frequency scale for symptoms of gastroesophageal reflux disease predicts the need for addition of prokinetics to proton pump inhibitor therapy

Background and Aim: Proton pump inhibitor (PPI) monotherapy cannot cure all cases of gastroesophageal reflux disease (GERD), and combination therapy with prokinetics and PPI achieves symptomatic improvement for some GERD patients. Few studies have been performed to predict the need for prokinetics. Methods: Subjects were 163 patients (64 male, mean age 53.1 ± 16.6 years) with GERD symptoms. They were evaluated using the frequency scale for the symptoms of GERD (FSSG), a GERD‐specific questionnaire developed in Japan 1 and endoscopy. They were administered with rabeprazole 10 mg daily. At 12 and 24 weeks of treatment, subjects were offered a choice of four treatment regimens according to their degree of satisfaction (1, no need for further treatment; 2, opt for continued PPI treatment; 3, step‐down to H2RA; 4, dissatisfied with present treatment, so opt for combination treatment with prokinetics, mosapride 5 mg tid). Results: The choice of treatment after 12 weeks of treatment placed 79.1% of subjects in the satisfied group (1, 21; 2, 98; 3, 10). After 24 weeks, 98.2% of subjects were in the satisfied group. Pretreatment FSSG scores were significantly higher in the dissatisfied group (4, 17.4 ± 1.4) than in the satisfied group (1, 12.3 ± 1.3; 2, 12.8 ± 0.8; 3, 10.2 ± 1.8) (P < 0.05). Conclusions: The satisfaction rate with these treatment regimens was 98.2% at 24 weeks, suggesting that combination therapy with prokinetics was effective for patients dissatisfied with PPI monotherapy. The FSSG is a useful predictor of the necessity for combination therapy.     

质子泵抑制剂联合依托必利对胃食管反流病的疗效评价

目的 观察质子泵抑制剂（proton pump inhibitor,PPI）联合盐酸伊托必利（itopride hydrochloride,ITO）对胃食管反流病（gastroesophageal reflux disease,GERD）的疗效,并评价该治疗方案的安全性及耐受性.方法 经内镜、24 h食管pH测定或PPI试验确诊的GERD患者93例,按治疗方案随机分为PPI联合ITO治疗组及PPI单药治疗组,PPI联合ITO治疗组：糜烂性食管炎（EE）16例,非糜烂性反流病（NERD）21例,Barrett食管（BE）14例,共51例;PPI单药治疗组：EE 14例,NERD 16例,BE 12例,共42例.采用前瞻性、随访对照研究,于治疗前、治疗8周后、24周后进行GerdQ评分及内镜检查.结果 8周初始治疗后,两组内的3个亚型患者GerdQ评分均较治疗前明显降低,差异有统计学意义（P＜0.01）,24周后两组内EE及BE患者GerdQ评分较8周时进一步降低,差异有统计学意义（P＜0.05）;治疗8周及24周后两组EE患者食管黏膜愈合率分别为81.3％、71.4％（8周,P=0.00047）及93.8％、85.7％（24周,P=0.00036）,PPI联合ITO治疗组食管黏膜愈合率高于PPI单药治疗组,差异有统计学意义（P＜0.05）.结论 就改善反流相关症状及食管黏膜愈合率而言,PPI联合ITO维持治疗方案优于PPI单药治疗,具有良好的安全性和耐受性.     

Prevalence and clinical picture of gastroesophageal prolapse in gastroesophageal reflux disease

The prevalence of gastroesophageal (GE) mucosal prolapse in patients with gastroesophageal reflux disease (GERD) was investigated as well as the clinical profile and treatment outcome of these patients. Of the patients who were referred to our service between 1980 and 2008, those patients who received a complete diagnostic work-up, and were successively treated and followed up at our center with interviews, radiology studies, endoscopy, and, when indicated, esophageal manometry and pH recording were selected. The prevalence of GE prolapse in GERD patients was 13.5% (70/516) (40 males and 30 females with a median age of 48, interquartile range 38-57). All patients had dysphagia and reflux symptoms, and 98% (69/70) had epigastric or retrosternal pain. Belching decreased the intensity or resolved the pain in 70% (49/70) of the cases, gross esophagitis was documented in 90% (63/70) of the cases, and hiatus hernias were observed in 62% (43/70) of the cases. GE prolapse in GERD patients was accompanied by more severe pain (P < 0.05) usually associated with belching, more severe esophagitis, and dysphagia (P < 0.05). A fundoplication was offered to 100% of the patients and was accepted by 56% (39/70) (median follow up 60 months, interquartile range 54-72), which included two Collis-Nissen techniques for true short esophagus. Patients who did not accept surgery were medically treated (median follow up 60 months, interquartile range 21-72). Persistent pain was reported in 98% (30/31) of medical cases, belching was reported in 45% (14/31), and GERD symptoms and esophagitis were reported in 81% (25/31). After surgery, pain was resolved in 98% (38/39) of the operative cases, and 79% (31/39) of them were free of GERD symptoms and esophagitis. GE prolapse has a relatively low prevalence in GERD patients. It is characterized by epigastric or retrosternal pain, and the need to belch to attenuate or resolve the pain. The pain is allegedly a result of the mechanical consequences of prolapse of the gastric mucosa into the esophagus.     

Evidence-based treatment recommendations for gastroesophageal reflux disease during pregnancy: A review

Gastroesophageal reflux disease (GERD) occurs in approximately two-thirds of all pregnancies. Around 25% of pregnant women experience heartburn daily. Symptomatic GERD usually presents in the first trimester and progresses throughout pregnancy. The treatment goal is to alleviate heartburn and regurgitation without jeopardizing the pregnancy or its outcome. An English language electronic literature search of MEDLINE, EMBASE, and Cochrane Reviews was undertaken to identify randomized controlled trials, observational studies, management recommendations and reviews of GERD and its treatment during pregnancy. The search period was defined by the date of inception of each database. The treatment in a pregnant GERD patient should follow the step-up approach, starting with lifestyle modification as the first step. If heartburn is severe, medication should be started after consultation with a physician (Recommendation Grade C). The preferred choice of antacids is calcium-containing antacids (Recommendation Grade A). If symptoms persist with antacids Sucralfate can be introduced at a 1g oral tablet, 3 times daily (Recommendation Grade C). Followed by histamine-2 receptor antagonist (Recommendation Grade B). Inadequate control while on histamine-2 receptor antagonist and antacid may mandate a step-up to proton pump inhibitors along with antacids as rescue medication for breakthrough GERD (Recommendation Grade C). This article presented the treatment recommendations for pregnant women with typical GERD, based on the best available evidence.     

A prospective study of the prevalence of gastroesophageal reflux disease and confounding factors

Background The prevalence of gastroesophageal reflux disease (GERD) has reportedly risen in recent years. Difficulties associated with endoscopic diagnosis mean it is not easy to determine its precise prevalence. A prospective study of the prevalence of endoscopy-positive GERD (EP-GERD) was conducted at Higuchi Hospital, a general hospital in Northwestern Kyushu, Japan. The study also correlated factors that might affect prevalence (age, sex, and functions of the gastroesophageal junction). Methods From consecutive patients undergoing endoscopic examination at Higuchi Hospital between January 2000 and April 2003, 1234 patients without severe complications were examined for the possible presence of GERD. Patients were stratified by age and sex, and the prevalence in each group ascertained. EP-GERD was defined on the four-level scale of the Los Angeles classification. Endoscopic classification of gastroesophageal flap valve ([GEFV] functional anomalie; using a four-level scale), was done as proposed by Hill et al. in 1996, to assess flap-valve morphology. Six items were evaluated: (1) symptoms and primary diseases; (2) prevalence of development of EP-GERD classified by age and sex; (3) endoscopic morphology of the GEFV as an expression of the functions of the gastroesophageal junction, and its prevalence by age and sex; (4) regression analysis and Spearman's rank correlation of GEFV and EP-GERD grades; (5) prevalence of EP-GERD and GEFV stratified by age and analyzed; and (6) multiple regression analysis of EP-GERD and explanatory variables (age, sex, and GEFV). Results The overall prevalence of EP-GERD was 5.8% (72/1234) and this patient group was dominated by men. Aging had minimal effect on prevalence in men, but the prevalence rose among women as they aged. The age-stratified prevalence of GEFV functional anomalies was similar to the age-stratified prevalence of EP-GERD in both sexes. The correlation between EP-GERD and GEFV functional anomalies was high regardless of sex. Conclusions We postulate that the mechanisms leading to the development of GEFV functional anomalies in men are different from those in women. Future evaluations of EP-GERD should also observe GEFV function.     

Endoluminal gastroplication for the treatment of gastroesophageal reflux disease: a 2-year prospective pilot study from Taiwan

Background and Aim: Endoluminal gastroplication (ELGP) offers a minimally invasive option for the treatment of gastroesophageal reflux disease (GERD) in Western countries. However, long‐term outcomes of ELGP in Asian populations have not been investigated. The aim of this prospective study was to evaluate the long‐term benefits of ELGP in Asian patients with GERD. Methods: Taiwanese patients diagnosed with GERD were enrolled and had the procedure performed with EndoCinch. The assessment included symptom scoring, validated GERD questionnaires, esophagogastroduodenoscopy, esophageal manometry and 24‐h pH monitoring before and after the procedure over a 2‐year period. Results: Twenty‐one consecutive patients were recruited and underwent ELGP. Patients reported improved heartburn symptom score (mean 64.0 vs 21.1, P < 0.001), regurgitation frequency score (mean 2.4 vs 1.3, P < 0.001), and GERD health‐related quality of life (mean 23.1 vs 10.1, P < 0.001) at 24 months. The mean total time of pH < 4 reduced from 121.7 min to 67.1 min (P = 0.008) and mean DeMeester score reduced from 32.9 to 17.6 (P = 0.011) at 3 months. Antisecretory drug discontinuation rate was 81%, 57%, 52% and 48% at 1, 6, 12 and 24 months, respectively. Of the patients who had a favorable initial response to ELGP at 1 month, 41% resumed antisecretory medications at 24 months follow‐up. All adverse events were mild and transient. Conclusions: Endoluminal gastroplication is a safe and modestly effective endotherapy for patients with GERD. It significantly improved symptoms in an Asian population. Approximately one in two patients continues to be off medication at 24 months follow‐up. However, the long‐term efficacy and durability are still to be determined.     

Effect of gluten-free diet on preventing recurrence of gastroesophageal reflux disease-related symptoms in adult celiac patients with nonerosive reflux disease

Background and Aim:  In Celiac Disease (CD) the role of a gluten-free diet (GFD) on gastroesophageal reflux disease–related symptoms (GERD-rs) is unclear. The aim of this study was to establish the recurrence of GERD-rs, in CD patients with nonerosive reflux disease (NERD).
Methods:  From a total of 105 adult CD patients observed, 29 who presented with the NERD form were enrolled in the study. Thirty non-CD patients with NERD were studied as controls. Recurrence of GERD-rs was clinically assessed at 6, 12, 18, and 24 months follow-up (FU) after withdrawal of initial proton-pump inhibitor (PPI) treatment for 8 weeks.
Results:  GERD-rs were resolved in 25 (86.2%) CD patients and in 20 (66.7%) controls after 8 weeks of PPI treatment. In the CD group, recurrence of GERD-rs was found in five cases (20%) at 6 months but in none at 12, 18, and 24 months while in the control group recurrence was found in six of 20 controls (30%), in another six (12/20, 60%), in another three (15/20, 75%), and in another two (17/20, 85%) at 6, 12, 18, and 24 months FU respectively.
Conclusions:  The present study is the first to have evaluated the effect of a GFD in the nonerosive form of GERD in CD patients, by means of clinical long-term follow-up, suggesting that GFD could be a useful approach in reducing GERD symptoms and in the prevention of recurrence.     

黛力新联合质子泵抑制剂治疗胃食管反流病伴咽喉部症状

目的 观察黛力新联合质子泵抑制剂（PPI）治疗胃食管反流病（GERD）咽喉部症状的临床疗效,探讨可能的治疗机制.方法 选取2009年8月-2012年5月门诊确诊GERD,经PPI加促动力药治疗12周后仍有咽喉部症状的患者,用综合性医院焦虑抑郁量表（HADS）进行情绪评定,把其中HADS〉9分患者分为两组,有症状黛力新治疗组,以黛力新＋耐信＋莫沙比利治疗;有症状对照组,以耐信＋莫沙比利治疗;HADS〈9分为无症状黛力新治疗组,以黛力新＋耐信＋莫沙比利治疗.疗程均为4周.三组治疗前后分别作Zung抑郁自评量表和Zung焦虑自评量表评分及临床疗效评分,观察其疗效.结果 HADS≥9分者63例,黛力新治疗组32例,对照组31例;HADS〈9分者35例.有症状黛力新治疗组与无症状黛力新治疗组的疗效相比,差异无统计学意义（P〉0.05）,但高于有症状对照组,且差异有统计学意义（P〈0.05）,有症状黛力新治疗组治疗后SDS和SAS指数均明显下降（P〈0.05）.结论 黛力新联合PPI治疗伴有咽喉部症状的GERD能显著改善患者精神和躯体两方面的症状.     

舒肝解郁胶囊联合西药治疗伴抑郁的胃食管反流病疗效观察

[目的]观察舒肝解郁胶囊联合西药治疗伴抑郁的胃食管反流病(GERD)患者的疗效.[方法]将117例伴抑郁的GERD患者随机分为2组,对照组给予埃索美拉唑和多潘立酮治疗,治疗组在对照组治疗基础上另加用舒肝解郁胶囊.疗程8周.[结果]2组内治疗前与治疗后、2组间治疗后SDS评分比较差异有统计学意义(P＜0.05).治疗组总有效率为92.98％,对照组为73.33％,2组比较差异有统计学意义(P＜0.05).[结论]舒肝解郁胶囊联合埃索美拉唑和多潘立酮治疗伴抑郁的GERD安全、有效.