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.     

Patient satisfaction with medication for gastroesophageal reflux disease: a systematic review

BACKGROUND:

Patient satisfaction is increasingly regarded as an important aspect of measuring treatment success in individuals with gastroesophageal reflux disease (GERD).

OBJECTIVE:

To review how satisfied patients with GERD are with their medication, and to analyze the usefulness of patient satisfaction as a clinical end point by comparing it with symptom improvement.

METHODS:

Systematic searches of the PubMed and EMBASE databases identified clinical trials and patient surveys published between 1966 and 2009.

RESULTS:

Twelve trials reported that 56% to 100% of patients were ‘satisfied’ or ‘very satisfied’ with proton pump inhibitor (PPI) treatment for GERD. Patient satisfaction levels were higher for PPIs than other GERD medications in two trials. The sample-size-weighted average proportion of patients ‘satisfied’ with their PPI after four weeks of treatment in trials was 93% (95% CI 87% to 99%), with 73% (95% CI 62% to 83%) being ‘very satisfied’. In four surveys, the average proportion of patients ‘satisfied’ with their PPI treatment was 82% (95% CI 73% to 90%) and 62% (95% CI 48% to 75%) were ‘very satisfied’. Seven trials found a positive association between patient satisfaction and symptom improvement, and two surveys between satisfaction and improved health-related quality of life. Three trials found that continuous treatment yielded higher rates of satisfaction than on-demand therapy.

CONCLUSIONS:

More than one-half of patients were satisfied with their PPI medication in trials, and more patients were satisfied with PPIs than other medication types. An association between patient satisfaction and symptom resolution was found, suggesting that patient satisfaction is a useful end point for evaluating GERD treatment success.     

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.     

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.     

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.     

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.     

Intestinal metaplasia at the gastroesophageal junction is associated with gastroesophageal reflux but not with Helicobacter pylori infection

Abstract

Objective: Studies of the etiology of intestinal metaplasia (IM) at a normal appearing gastroesophageal junction (GEJ) are conflicting as associations with both H. Pylori (HP) infection and gastroesophageal reflux has been reported. The aim of this study was to investigate whether IM at the GEJ is associated with gastroesophageal reflux or HP infection.

Material and methods: Fifty asymptomatic volunteers and 149 patients with reflux symptoms underwent endoscopy with biopsies obtained from the gastric antrum and the squamocolumnar junction (SCJ). All subjects underwent wireless 48?h pH monitoring with the electrode placed immediately above the SCJ and a fecal antigen test for HP infection. Clinical characteristics and the pattern of reflux were compared in subjects with and without IM.

Results: Three asymptomatic volunteers and 35 patients who had clearly irregular SCJs with short extensions of columnar mucosa were excluded from the study. In the remaining 47 asymptomatic volunteers and 114 patients, variables that reached a significance level of 0.1 or less on univariate analyses were used in a binomial regression analysis to assess their relative importance for the finding of IM. IM at the GEJ was significantly associated with abnormal distal esophageal acid exposure (5.5 (1.2–24.6), p?=?.026), the frequency of reflux episodes/hour (1.5 (1.1–2.2), p?=?.031), and an endoscopic appearance of the SCJ corresponding to ZAP grade I (4.6 (1.4–15.6), p?=?.013). There was no association with HP infection.

Conclusion: The finding of IM at an endoscopically normal-appearing GEJ is associated with gastroesophageal reflux but not with HP infection.     

Endoscopic therapy for gastroesophageal reflux disease: a systematic review

Endoscopic therapy has emerged as an alternative for patients with symptomatic gastroesophageal reflux disease (GERD) who are seeking a non-pharmacologic, non-surgical intervention. To date, there are 3 basic categories of these endoscopic options: radiofrequency ablation, endoscopic suturing and endoscopic injection. Although the pivotal clinical studies to date have consistently demonstrated efficacy for defined endpoints of symptom control, GERD health related quality of life and discontinuance of acid secretory medications, depending on the therapy, there has been less consistent improvement in objective parameters of pH control and lower esophageal sphincter pressure. Although the data for these procedures has been favorable, extrapolation to justify a more widespread clinical use has been limited by the relative lack of controlled sham studies-although these are currently underway for all of the available therapies. Appropriate patient selection for endoscopic GERD therapy is critical and at present these therapies have the best clinical outcome data in patients who are responsive to therapy with a proton pump inhibitor. The risk/benefit profile, long term durability and cost effectiveness should be considered in all patients being considered when evaluating each of the endoscopic therapies for GERD.     

Endoscopic therapy for gastroesophageal reflux disease: a systematic review

The high prevalence of gastroesophageal reflux disease (GERD) in Western societies has accelerated the need for new modalities of treatment. Currently, medical and surgical therapies are widely accepted among patients and physicians. The minimally invasive treatment revolution, however, has stimulated several new endoscopic techniques for GERD. Up to now, the data is limited and further studies are necessary to compare the advantages and disadvantages of the various endoscopic techniques to medical and laparoscopic management of GERD. This systematic review reports the efficacy and durability of various endoscopic therapies for GERD whilst the potential for widespread use of these techniques is also discussed. Despite the limited number of studies and remarkable differences between various trials, strict criteria were used for the pooled data presented and an effort was made to avoid bias by including only studies that used off-antisecretory medication scoring as baseline and intent to treat.     

Relevance of sleep disturbance to the integrity and characteristics of secondary peristalsis in patients with gastroesophageal reflux disease

Objective: Sleep disturbance is common in patients with gastroesophageal reflux disease (GERD). Secondary peristalsis is important for clearance of the refluxate from the esophagus. We aimed to test the hypothesis whether secondary peristalsis is impaired in GERD patients with sleep disturbance.

Methods: Secondary peristalsis was stimulated with slow and rapid air injections into mid-esophagus in 8 age-matched health controls and 41 patients with GERD. Sleep disturbance was assessed by the Pittsburg Sleep Quality Index (PSQI). Objective sleep measures were assessed by ambulatory actigraphy.

Results: The threshold volume for inducing secondary peristalsis during slow air injection was significantly higher in GERD patients with sleep disturbance than healthy controls (14.3?±?1.2 vs. 8.9?±?0.5?mL, p?<?.05). GERD patients with sleep disturbance had higher threshold volume of secondary peristalsis during rapid air injection than GERD patients without sleep disturbance (5.1?±?0.4 vs. 3.9?±?0.2?mL, p?<?.05) and healthy controls (5.1?±?0.4 vs. 3.6?±?0.2?mL, p?<?.05). There was a negative correlation between PSQI score and peristaltic frequency during rapid air injection (r?=??.39, p?=?.01). Secondary peristaltic amplitude during rapid air injection was negatively correlated with wake after sleep onset (r?=??.34, p?=?.04).

Conclusions: Sleep disturbance is associated with secondary peristaltic response to distension-induced esophageal stimulation in patients with GERD. Our study suggests that sleep disturbance per se may adversely influence the effectiveness of esophageal peristalsis and bolus clearance during sleep in patients with GERD.     

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.     

Gastric dysrhythmia in gastroesophageal reflux disease: a systematic review and meta-analysis

Esophagus - Gastroesophageal reflux disease (GERD) is a commonly diagnosed gastrointestinal disorder, with a substantial impact on the quality of life. The underlying pathophysiology of GERD is...     

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.     

Endoscopic therapies for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) accounts for a substantial degree of medical resource utilization and is a common indication for outpatient physician visits. The primary therapy for GERD has been proton pump inhibitors (PPIs). Equally effective and reasonably safe for GERD is surgical therapy, specifically, laparoscopic Nissen fundoplication. Medical therapy is used initially, with surgery reserved for patients with refractory symptoms despite optimal medical management, to avoid the added risks of abdominal surgery. As such, there has been considerable investigation into minimally invasive, endoscopic therapies for patients who respond to PPI, but would prefer to avoid long-term medication use. Here, we discuss the anatomical and physiological barriers that must be overcome by such devices. We further review the data on currently available endoscopic devices. Despite considerable interest and resources in developing an effective endoscopic therapy for GERD, none of the currently available technologies have demonstrated an ability to overcome the pathophysiological hurdles present in most patients with GERD. Furthermore, well-designed trials have not demonstrated adequate clinical efficacy for these endoscopic devices. As such, despite a growing need for an intermediate therapy between PPI and fundoplication, at present there is not adequate evidence to recommend endoscopic therapy for patients with GERD.     

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。     

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.