Comparison of gastro-oesophageal reflux disease and heartburn diagnoses in UK primary care

ABSTRACT

Objective: It is unclear how gastro-oesophageal reflux disease (GORD) is diagnosed in primary care. The aim of this study is to compare patients given a diagnosis of GORD with those diagnosed with heartburn.

Research design and methods: Data from the UK General Practice Research Database were extracted for patients newly diagnosed with heartburn (n = 1841) or GORD (n = 5318) in 1996.

Main outcome measures: Patient characteristics, morbidity, healthcare use and prescribed treatments were compared using unconditional logistic regression analysis.

Results: GORD was diagnosed more frequently than heartburn (3.2 vs. 1.1 per 1000 patient-years). A diagnosis of GORD was less likely among females (odds ratio (OR): 0.8; confidence interval (CI): 0.7–0.9), smokers (OR: 0.8; CI: 0.7–0.9) and patients who consulted their physician frequently (OR: 0.8; CI: 0.7–0.9). There was a wide distribution in the ratio of GORD-to-heartburn diagnoses between primary care practices (mean 2.9; range 0–∞). GORD patients were more likely to receive proton pump inhibitors (OR: 2.9; CI: 2.6–3.4), but 24% of GORD patients and 40% of heartburn patients received no acid-suppressive treatment in the month after diagnosis.

Conclusions: Several factors influenced the diagnosis of gastro-oesophageal reflux symptoms by primary care physicians. Further research is needed to aid the diagnosis of GORD in primary care.     

Positive serology for<Emphasis Type="Italic"> Helicobacter pylori</Emphasis> and vomiting in the pregnancy

Introduction. Recently, several investigators have suggested that H. pylori may be a contributory factor in hyperemesis gravidarum. The purpose of this study was to evaluate whether seropositivity for IgG antibodies to H. pylori may also be related to nausea, vomiting, heartburn and epigastric pain in pregnancy. Materials and methods. One hundred and eighty-five women, at term pregnancy, were included in the study. All women completed a questionnaire regarding information on the number of pregnancies and deliveries, weight gain, smoking and gastrointestinal complaints before and during pregnancy. The presence of H. pylori infection was determined by serology. Results. The overall prevalence rate of H. pylori seropositivity was 45.9%. Women positive for H. pylori IgG were older (28.7±4.5 vs. 27.0±4.5, p=0.02), had more prior pregnancies (3.2±2.1 vs. 2.6±1.6, p=0.02) and deliveries (2.6±1.6 vs. 2.0±1.1, p=0.006) and reported vomiting in the first trimester more frequently than H. pylori negative patients (81.2% vs. 65%, p=0.004). On the other hand vomiting in the second trimester was reported more frequently among smokers during pregnancy compared to non-smokers. Conclusions. H. pylori seropositivity is significantly associated with emesis gravidarum but not with gastro-intestinal symptoms later in pregnancy. First trimester vomiting more than doubles the likelihood that the gravida is H. pylori IgG positive.     

Natural history of heartburn: a 10-year population-based study

AIM:To study the natural history and prevalence of heartburn at a 10-year interval,and to study the effect of heartburn on various symptoms and activities.METHODS:A population-based postal study was carried out.Questionnaires were mailed to the same age-and gender-stratified random sample of the Icelandic population(aged 18-75 years) in 1996 and again in 2006.Subjects were classified with heartburn if they reported heartburn in the preceding year and/or week,based on the definition of heartburn.RESULTS:Hear...     

The refluxate: The impact of its magnitude, composition and distribution

The pathogenesis of gastrointestinal reflux disease is multifactoral. Integral to the disease process is the refluxate itself. The characteristics and composition of the refluxate are dependent on several physiological variables. The refluxate may contain varying concentrations of acid, pepsin, gas, or contents of duodenal reflux (such as bile acid and pancreatic enzymes). Characteristics such as volume and proximal extent of the refluxate, and the chemical content of this refluxate can strongly influence the risk of symptom perception. Strong acid (pH<4) and duodeno-gastro-oesophageal reflux are also implicated in the development of mucosal damage in the form of oesophagitis, Barrett's metaplasia and oesophageal adenocarcinoma. The manifestation of disease, however, is not entirely reliant on the refluxate, which must be considered in the context of the genetic, environmental and psychological susceptibility of the individual.     

烧心患者的临床类型及特征分析

目的罗马Ⅲ标准提出了非糜烂性反流病（NERD）和功能性烧心（FH）的诊断标准。根据该标准,结合胃镜、食管pH监测及质子泵抑制剂（PPI）试验,探讨烧心患者临床类型及特征。方法62例连续就诊的烧心患者填写症状问卷后全部行内镜检查,对内镜阴性的患者进行24h食管pH监测,计算症状指数（sI）,随后全部患者完成PPI试验（埃索美拉唑20mg,每天2次,14d）：结果反流性食管炎（RE）16例,NERD和FH分别为39例、7例;NERD又可分3个亚型,pH监测正常的NERD与FH仍存在多项参数的差异：内镜阴性患者中PPI试验阳性组与阴性纽的pH监测值比较差异无统计学意义（x2=2．681,P=0．102）。结论烧心患者可分为RE、NERD和FH三类,NERD和FH是临床特点不同的异质性疾病。     

Management of reflux-related symptoms

Gastro-oesophageal reflux disease develops when the reflux of gastric contents into the oesophagus results in troublesome symptoms and/or complications [1]. Refluxate contains predominantly acid which causes tissue injury at oesophageal and extra-oesophageal sites. It is one of the commonest gastrointestinal diagnosis worlds over. It is associated with chronic symptoms, reduced QOL, significant cost and serious complications. Goals of therapy are to provide symptom relief, heal oesophagitis and prevent long-term complications. Therapeutic measures are directed at reducing the noxiousness of the refluxate; reducing the gastro-oesophageal reflux; enhancing clearance; protecting the mucosa; reducing the mucosal sensitivity and improving healing. Acid suppression with proton pump inhibitors remains the cornerstone of therapy. Recent studies have resulted in better understanding of disease and relative efficacies of various strategies. This has paved way for a better evidence based approach. The therapy however needs to be individualized depending upon the clinical profile, disease severity, the dominant pathophysiological mechanism, cost, availability and individual preferences.     

Prevalence of gastro-oesophageal reflux symptoms and the influence of age and sex

Background: Most previous studies of reflux symptom prevalence are of small sample size. No reliable data concerning age- and sex-stratified prevalence are available. Methods: Among 65,363 adult participants in a public health survey in Nord-Trondelag, Norway, 58,596 (90%) responded concerning occurrence and severity of heartburn or regurgitation during the past 12 months. The prevalence of minor, severe and any reflux symptoms was calculated, including stratification for age and sex. In order to examine whether the relative risk of reflux symptoms between sexes, in different age groups, was affected by other potential risk factors for reflux, confounding effects were tested using multivariate logistic regression. Odds ratios and their 95% confidence intervals were used to estimate relative risks. Results: Total prevalence of reflux symptoms was 31.4%, whereof 26.0% were minor symptoms and 5.4% severe symptoms. The prevalence of symptoms occurring at least weekly was 11.6%. Among women, the prevalence increased gradually from 22.1% in the youngest age category to 37.5% in the oldest, while among men it gradually increased from 25.8% in the youngest age group to peak at 36.0% between the ages of 50 and 60 years, after which it declined to 33.8% after age 70. A higher prevalence among women compared to men in the oldest age groups was not explained by confounding by body mass, tobacco smoking, alcohol consumption, dietary factors, or physical exercise. Conclusions: About every third adult person suffered from reflux symptoms. The prevalence increases linearly with age among women, while among men it peaked between the age of 50 and 70 years and thereafter declined.     

Predictors of heartburn resolution and erosive esophagitis in patients with GERD

ABSTRACT

Objectives: The primary objective was to assess gastroesophageal reflux disease (GERD) symptom resolution rates with esomeprazole by erosive esophagitis (EE) status, and the secondary objective was to evaluate potential predictors of the presence of EE and heartburn resolution.

Background: Patients with GERD who have EE have higher reported symptom resolution rates than those with nonerosive reflux disease (NERD) when treated with proton pump inhibitors (PPIs).

Study: This open-label multicenter study included adults with GERD symptoms. Patients were stratified by EE status after endoscopy and received once-daily esomeprazole 40?mg for 4 weeks. Questionnaires determined symptom response rates, and baseline predictors of EE or heartburn resolution were evaluated. Potential predictors, including years with GERD, history of EE, and time to relief with antacids, were examined.

Results: Heartburn resolution rates at 4 weeks were higher for patients with EE than NERD (69% [124/179] vs. 48% [85/177]; p?<?0.0001). Multivariate models had moderate predictive ability for EE (c-index, 0.76) and poor predictive ability (c-index, 0.57) for heartburn resolution. However, faster heartburn relief with antacid use, particularly within 15?min, was predictive of EE and heartburn resolution.

Conclusions: Patients with EE have higher heartburn resolution rates than patients with NERD after treatment, although recall bias may be possible. Fast relief with antacid use is predictive of EE and heartburn resolution with a PPI and suggests that a history of antacid relief may provide corroborative evidence to empiric PPI therapy in determining whether patients with heartburn have acid reflux disease.

Trial registration: ClinicalTrials.gov identifier: NCT00242736.