New pharmacologic approaches in gastroesophageal reflux disease

This article highlights current and emerging pharmacological treatments for gastroesophageal reflux disease (GERD), opportunities for improving medical treatment, the extent to which improvements may be achieved with current therapy, and where new therapies may be required. These issues are discussed in the context of current thinking on the pathogenesis of GERD and its various manifestations and on the pharmacologic basis of current treatments.     

Esophageal motility,heartburn, and gastroesophageal reflux: Variations in clinical presentation of esophageal dysphagia

Dysphagia is a potentially important symptom, often leading to the finding of an anatomical or motility disorder of the esophagus. Dysphagia and heartburn represent two of the most common symptoms associated with esophageal motility disorders. To explore the relationship of symptomatic esophageal dysphagia and heartburn and their association with primary esophageal motor disorders, we have performed a retrospective assessment of 1035 patient evaluations performed at our gastrointestinal laboratory. A clear statistical association of symptomatic dysphagia and heartburn was established; however, no pattern diagnostic of a specific motility disorder was discernible. A sizable fraction of our patient population with dysphagia demonstrated normal esophageal motility. A significant portion of dyspeptic patients exhibited both normal motility and acid exposure. The differences observed between the incidence of subjective symptoms and objective dysfunction may be explained in part by an altered or increased esophageal sensitivity of these patients.     

Endoluminal fundoplication by a transoral device for the treatment of GERD: A feasibility study

Background A new endoluminal fundoplication (ELF) technique performed transorally using the EsophyX™ device was evaluated for the treatment of gastroesophageal reflux disease (GERD) in a prospective, feasibility clinical trial. Methods Nineteen patients were enrolled into the study. Inclusion criteria were chronic and symptomatic GERD, proton pump inhibitor (PPI) dependence, and the absence of esophageal motility disorder. Two patients were excluded due to esophageal stricture and a 6 cm hiatal hernia. The median duration of GERD symptoms and PPI use in the remaining 17 patients was 10 and 6 years, respectively. The ELF procedure was designed to partially reconstruct the antireflux barrier through the creation of a valve at the gastroesophageal junction. Results The ELF-created valves had a median length of 4 cm (range 3–5 cm) and circumference of 210° (180–270°). Adherence of the valves to the endoscope was tight (n = 14) or moderate (n = 3). Hiatal hernias present in 13 patients (76%) were all reduced. Adverse events were limited to mild or moderate pharyngeal irritation and epigastric pain, which resolved spontaneously. After 12 months, the ELF valves (n = 16) had a median length of 3 cm (1–4 cm) and a circumference of 200° (150–210°). Eighty-one percent of valves retained their tightness. The hiatal hernias present at the baseline remained reduced in 62% of patients. The median GERD-HRQL scores improved by 67% (17–6), and nine patients (53%) improved their scores by ≥50%. Eighty-two percent of patients were satisfied with the outcome of the procedure, 82% remained completely off PPIs, and 63% had normal pH. Conclusion The study demonstrated technical feasibility and safety of the ELF procedure using the EsophyX™ device. The study also demonstrated maintenance of the anatomical integrity of the ELF valves for 12 months and provided preliminary data on ELF efficacy in reducing the symptoms and medication use associated with GERD.     

Psychological distress is not associated with treatment failure in patients with gastroesophageal reflux disease

Objective

Symptoms of anxiety and depression are common in patients with gastroesophageal reflux disease (GERD). We aim to examine the relationship between psychological distress and response to proton pump inhibitors (PPI).

Methods

In this prospective study, GERD patients receiving PPI once or twice daily were divided into 3 groups: responders to PPI once daily (group A, N = 111), non-responders to PPI once daily (group B, N = 78) and non-responders to PPI twice daily (group C, N = 56). All patients completed demographic and clinical questionnaires, Rome III Diagnostic Questionnaire for irritable bowel syndrome, Hospital Anxiety and Depression Scale (HADS), Satisfaction with Life Scale (SWLS) and the Gastroparesis Cardinal Symptom Index (GCSI) questionnaires.

Results

A total of 245 patients (59.3% females, 52 ± 17.2 years) participated in this study. No differences were observed between groups with respect to age, sex, psychiatric medications or pre-existing major depression. Anxiety (HADS—anxiety > 7) was seen in 32%, 31% and 34% of groups A, B and C, respectively (p = ns). Depression (HADS—depression > 7) was present in 30%, 31% and 21% of groups A, B and C, respectively (p = ns). Global satisfaction with life (SWLS > 20) was present in 63% of group C patients, compared to 78% of group A and 78% of group B (p = 0.04, p = 0.05, respectively). GCSI scores (mean ± SD) were 11.1 ± 9.2, 14.07 ± 8.5 and 16.3 ± 10.4, for groups A, B and C, respectively (p = 0.002). GCSI correlated significantly with HADS—anxiety (r = 0.20, p = 0.002) and SWLS (r = − 0.2, p = 0.01).

Conclusion

Lack of response to PPI was associated with lower life satisfaction but not anxiety or depression. Symptoms suggestive of gastroparesis were associated with anxiety and low satisfaction with life in patients with GERD.     

Two-year results of a feasibility study on antireflux transoral incisionless fundoplication using EsophyX

Background  A feasibility study (n = 19) evaluated the safety and initial efficacy of transoral incisionless fundoplication (TIF) for the treatment of gastroesophageal disease (GERD). The results at 1 year (n = 17) indicated that TIF was safe and had a significant effect on reducing GERD symptoms, proton pump inhibitor (PPI) usage, acid exposure, and small hiatal hernia. This study was designed to evaluate the long-term safety and durability of TIF. Methods  Fourteen patients (50% female; median age, 34 years) completed the 2-year follow-up assessment tests. Three patients were excluded from the study after 1 year because two of them underwent retreatment and one was lost to follow-up. Results  At 2 years, no adverse events related to TIF were reported. A ≥50% improvement in GERD-HRQL scores compared with those at baseline on PPIs was sustained by 64% of patients. TIF was effective in eliminating heartburn in 93% of patients and daily PPI therapy in 71% of patients. Significantly (p < 0.05) more patients were able to consume reflux-causing foods and maintain lifestyle activities without GERD symptoms compared with baseline on PPIs. Fundoplications were durable and maintained their geometric dimensions. TIF was effective in eliminating hiatal hernia in 60% of patients and esophagitis in 55% of patients. Global assessment of all outcomes in each patient revealed that 79% of patients experienced complete cure (29%) or remission (50%) of GERD at 2 years after TIF. Conclusion  The results at 2 years supported the long-term safety and durability of TIF and its sustained effect on the elimination of heartburn, esophagitis, ≤2 cm hiatal hernia, and daily dependence on PPIs.     

Comorbidities are Frequent in Patients with Gastroesophageal Reflux Disease in a Tertiary Health Care Hospital

INTRODUCTION

Several aspects of gastroesophageal reflux disease (GERD) have been studied, but the frequency of comorbidities is not yet fully understood.

OBJECTIVES

To study the prevalence of GERD comorbidities in a tertiary care hospital.

METHODS

We prospectively studied 670 consecutive adult patients from the outpatient department of our facility. A diagnosis was established using clinical, endoscopic and/or pHmetry-related findings. Each patient’s medical file was reviewed with respect to the presence of other medical conditions and diagnoses.

RESULTS

Of the 670 patients, 459 (68.6%) were female, and the mean age was 55.94 (17–80 years). We registered 316 patients (47.1%) with the erosive form of GERD and 354 patients (52.9%) with the non-erosive form. A total of 1,664 instances of comorbidities were recorded in 586 patients (87.5%), with the most common being arterial hypertension (21%), hypercholesterolemia (9%), obesity (9%), type II diabetes mellitus (5%) and depression (4%). Two or more comorbidities were present in 437 individuals (64.8%). The occurrence of comorbidities increased with age and was higher in patients with the non-erosive form of GERD.

CONCLUSIONS

In a tertiary referral population, comorbidities were very common, and these may have worsened the already impaired health-related quality of life of these patients. Clinicians caring for GERD patients in this setting must be aware of the likelihood and nature of comorbid disorders and their impact on disease presentation and patient management.     

组织抵抗性异常在非糜烂性反流病烧心机制中的作用

烧心一直以来都被看作是一个酸介导的事件,并作为胃食管反流病的一个可靠指标而存在。但是近来该观点受到质疑。此文通过回顾内脏高敏感性、持续食管收缩和组织抵抗性异常这3个不同的机制, 提出可用组织抵抗性异常来统一解释烧心机制,从而再次证实非糜烂性反流病烧心症状是由酸介导并且以能被制酸剂缓解为特点。