Gastro-oesophageal reflux disease (GERD) is a common disorder with consequences for the patient's health-related quality of life (HRQoL). In Germany, few data are available on the impact of GERD on work-related productivity.
To study the impact of GERD on work productivity despite proton pump inhibitor (PPI) therapy and the association between productivity and symptom duration, severity, and HRQoL.
Retrospective data from randomly selected patients with chronic GERD symptoms, treated by office-based general practitioners or general internists with routine clinical care, were analyzed together with information from self-administered instruments assessing work productivity (WPAI-GERD), symptoms (RDQ), and HRQoL (QOLRAD).
Reduced productivity was reported by 152 of 249 patients (61.0%), although 89.5% of them were treated with PPI. The reduction in work productivity was 18.5% in all patients and 30.3% in those with reduced productivity. Patients with impaired productivity showed a significantly lower HRQoL and more-severe symptoms of reflux disease. In all patients, the mean sick leave attributable to reflux symptoms was 0.6 hours in the previous seven days and 1.4 work days in the previous three months.
GERD has a substantial impact on work productivity in Germany, even in patients receiving routine clinical care and PPI therapy.
Gastro-oesophageal reflux; Sick leave; Medical economics; Proton Pump Inhibitors
AIM: To assess the management and outcome of nonerosive gastro-esophageal reflux disease (NERD) patients who were identified retrospectively, after a 5-year follow-up.
METHODS: We included patients with gastro-esophageal reflux disease (GERD) symptoms who had a negative endoscopy result and pathological 24-h esophageal pH-monitoring while off therapy. We interviewed them after an average period of 5 years (range 3.5-7 years) by means of a structured questionnaire to assess presence of GERD symptoms, related therapy, updated endoscopic data and other features. We assessed predictors of esophagitis development by means of univariate and multivariate statistical analysis.
RESULTS: 260 patients (137 women) were included. Predominant GERD symptoms were heartburn and regurgitation in 103/260 (40%). 70% received a maintenance treatment, which was proton pump inhibitor (PPI) in 55% of cases. An average number of 1.5 symptomatic relapses per patient/year of follow-up were observed. A progression to erosive gastro-esophageal reflux disease (ERD) was found in 58/193 (30.0%) of patients undergoing repeat endoscopy; 72% of these were Los Angeles grade A-B.
CONCLUSION: This study shows that progression to ERD occurs in about 5% of NERD cases per year, despite therapy. Only two factors consistently and independently influence progression: smoking and absence of PPI therapy.
Esophagus; Nonerosive gastro-esophageal reflux disease; Gastro-esophageal reflux disease; Epidemiology; Acidity
Gastro-esophageal reflux disease (GERD) is one of the most prevalent chronic diseases. Although proton pump inhibitors (PPIs) represent the mainstay of treatment both for healing erosive esophagitis and for symptom relief, several studies have shown that up to 40% of GERD patients reported either partial or complete lack of response of their symptoms to a standard PPI dose once daily. Several mechanisms have been proposed as involved in PPIs resistance, including ineffective control of gastric acid secretion, esophageal hypersensitivity, ultrastructural and functional changes in the esophageal epithelium. The diagnostic evaluation of a refractory GERD patients should include an accurate clinical evaluation, upper endoscopy, esophageal manometry and ambulatory pH-impedance monitoring, which allows to discriminate non-erosive reflux disease patients from those presenting esophageal hypersensitivity or functional heartburn. Treatment has been primarily based on doubling the PPI dose or switching to another PPI. Patients with proven disease, not responding to PPI twice daily, are eligible for anti-reflux surgery.
Gastro-esophageal reflux disease; Proton pump inhibitor; Ambulatory pH-impedance monitoring; Esophageal hypersensitivity; Gastro-esophageal reflux disease treatment
Critical needs for treatment trials in gastroesophageal reflux disease (GERD) include assessing response to treatment, evaluating symptom severity, and translation of symptom questionnaires into multiple languages. We evaluated the previously validated Reflux Disease Questionnaire (RDQ) for internal consistency, reliability, responsiveness to change during treatment and the concordance between RDQ and specialty physician assessment of symptom severity, after translation into Swedish and Norwegian.
Performance of the RDQ after translation into Swedish and Norwegian was evaluated in 439 patients with presumed GERD in a randomized, double-blind trial of active treatment with a proton pump inhibitor.
The responsiveness was excellent across three RDQ indicators. Mean change scores in patients on active treatment were large, also reflected in effect sizes that ranged from a low of 1.05 (dyspepsia) to a high of 2.05 (heartburn) and standardized response means 0.99 (dyspepsia) and 1.52 (heartburn). A good positive correlation between physician severity ratings and RDQ scale scores was seen. The internal consistency reliability using alpha coefficients of the scales, regardless of language, ranged from 0.67 to 0.89.
The results provide strong evidence that the RDQ is amenable to translation and represents a viable instrument for assessing response to treatment, and symptom severity.
The impact of gastroesophageal reflux disease (GERD) on the daily lives of patients managed in primary care is not well known. We report the burden of GERD in a large population of patients managed in primary care, in terms of symptoms and impact on patients' daily lives.
RANGE (Retrospective ANalysis of GERD) was an observational study that was conducted at 134 primary care sites across six European countries. All adult subjects who had consulted their primary care physician (PCP) during a 4-month identification period were screened retrospectively and those consulting at least once for GERD-related reasons were identified. From this population, a random sample of patients was selected to enter the study and attended a follow-up appointment, during which the Reflux Disease Questionnaire (RDQ), the GERD Impact Scale (GIS) and an extra-esophageal symptoms questionnaire were self-administered. Based on medical records, data were collected on demographics, history of GERD, its diagnostic work-up and therapy.
Over the 4-month identification period, 373,610 subjects consulted their PCP and 12,815 (3.4%) did so for GERD-related reasons. From 2678 patients interviewed (approximately 75% of whom reported taking medication for GERD symptoms), symptom recurrence following a period of remission was the most common reason for consultation (35%). At the follow-up visit, with regard to RDQ items (score range 0–5, where high score = worse status), mean Heartburn dimension scores ranged from 0.8 (Sweden) to 1.2 (UK) and mean Regurgitation dimension scores ranged from 1.0 (Norway) to 1.4 (Germany). Mean overall GIS scores (range 1–4, where low score = worse status) ranged from 3.3 (Germany) to 3.5 (Spain). With regard to extra-esophageal symptoms, sleep disturbance was common in all countries in terms of both frequency and intensity.
In this large European observational study, GERD was associated with a substantial impact on the daily lives of affected individuals managed in the primary care setting.
In the MUSE classification of gastroesophageal reflux disease (GERD), esophagitis is assessed by the presence of metaplasia, ulcer, stricture, or erosion, each being graded as absent, mild or severe. Daily reflux symptoms affect about 4 to 7 percent of the population; erosive esophagitis occurs in about 2 percent; the prevalence rate of Barrett's metaplasia is 0.4 percent; and esophageal adenocarcinoma leads to two deaths per million living population. In persons with GERD symptoms, about 20 percent are found to have erosive esophagitis, while ulcers or strictures are found in less than 5 percent of all patients with erosive esophagitis. No clear-cut temporal progression exists between successive grades of disease severity, as the most severe grade of GERD is reached at the onset of the disease. Mild forms of GERD tend to be more common in women than men, while severe GERD characterized by erosive esophagitis, esophageal ulcer, stricture or Barrett's metaplasia are far more common in men than women. All forms of GERD affect Caucasians more often than African Americans or Native Americans. The prevalence of GERD is high among developed countries in North America and Europe and relatively low in developing countries in Africa and Asia. During the past three decades, hospital discharges and mortality rates of gastric cancer, gastric ulcer and duodenal ulcer have declined, while those of esophageal adenocarcinoma and GERD have markedly risen. These opposing time trends suggest that corpus gastritis secondary to Helicobacter pylori infection protects against GERD. This hypothesis is consistent with the geographic and ethnic distributions of GERD. Case-control studies also indicate that cases with erosive esophagitis are less likely to harbor active or chronic corpus gastritis than controls without esophagitis.
Persons with gastroesophageal reflux disease (GERD) frequently search online for information about causes and treatment options. The GerdQ self-assessment questionnaire can be used for diagnosis of GERD and follow-up of symptoms.
To assess whether it is feasible (1) to study the prevalence and impact of GERD in persons visiting a GERD information website, and (2) to identify partial responsiveness to proton pump inhibitor (PPI) therapy using the GerdQ.
All visitors (aged 18–79 years) to a GERD information website between November 2008 and May 2011 were invited to complete the GerdQ online. The GerdQ questionnaire consists of 6 questions (score per question: 0–3). In respondents who did not use PPIs, we used the questionnaire to identify those with GERD (total score ≥8) and assess the influence of these symptoms on their daily life, divided into low (total score <3 on impact questions) and high impact (total score ≥3 on impact questions). In PPI users, we used the GerdQ to quantify partial responsiveness by any report of heartburn, regurgitation, sleep disturbance, or over-the-counter medication use for more than 1 day in the preceding week. We subsequently asked GerdQ respondents scoring ≥8 to complete the disease-specific Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire.
A total of 131,286 visitors completed the GerdQ, of whom 80.23% (n = 105,329) did not use a PPI. Of these, we identified 67,379 respondents (63.97%) to have GERD (n = 32,935; 48.88% high impact). We invited 14,028 non-PPI users to complete the QOLRAD questionnaire, of whom 1231 (8.78%) completed the questionnaire. Mean total QOLRAD scores were 5.14 (SEM 0.04) for those with high-impact GERD and 5.77 (SEM 0.04) for those with low-impact GERD (P < .001). In PPI users, 22,826 of 25,957 respondents (87.94%) reported partial responsiveness. We invited 6238 PPI users to complete the QOLRAD questionnaire, of whom 599 (9.60%) completed the disease-specific quality-of-life questionnaire. Mean total QOLRAD scores were 4.62 (SEM 0.05) for partial responders and 5.88 (SEM 0.14) for adequate responders (P < .001).
The GerdQ identified GERD in many website respondents and measured partial responsiveness in the majority of PPI users. Both non-PPI users with GERD and PPI users with partial responsiveness were associated with a decreased health-related quality of life. We have shown the feasibility of GERD patient identification online.
Gastroesophageal reflux; proton pump inhibitor; Internet; open access questionnaire; partial responsiveness
AIM: To investigate usefulness of adherence to gastro-esophageal reflux disease (GERD) guideline established by the Spanish Association of Gastroenterology.
METHODS: Prospective, observational and multicentre study of 301 patients with typical symptoms of GERD who should be managed in accordance with guidelines and were attended by gastroenterologists in daily practice. Patients (aged > 18 years) were eligible for inclusion if they had typical symptoms of GERD (heartburn and/or acid regurgitation) as the major complaint in the presence or absence of accompanying atypical symptoms, such as dyspeptic symptoms and/or supraesophageal symptoms. Diagnostic and therapeutic decisions should be made based on specific recommendations of the Spanish clinical practice guideline for GERD which is a widely disseminated and well known instrument among Spanish in digestive disease specialists.
RESULTS: Endoscopy was indicated in 123 (41%) patients: 50 with alarm symptoms, 32 with age > 50 years without alarm symptom. Seventy-two patients (58.5%) had esophagitis (grade A, 23, grade B, 28, grade C, 18, grade D, 3). In the presence of alarm symptoms, endoscopy was indicated consistently with recommendations in 98% of cases. However, in the absence of alarm symptoms, endoscopy was indicated in 33% of patients > 50 years (not recommended by the guideline). Adherence for proton pump inhibitors (PPIs) therapy was 80%, but doses prescribed were lower (half) in 5% of cases and higher (double) in 15%. Adherence regarding duration of PPI therapy was 69%; duration was shorter than recommended in 1% (4 wk in esophagitis grades C-D) or longer in 30% (8 wk in esophagitis grades A-B or in patients without endoscopy). Treatment response was higher when PPI doses were consistent with guidelines, although differences were not significant (95% vs 85%).
CONCLUSION: GERD guideline compliance was quite good although endoscopy was over indicated in patients > 50 years without alarm symptoms; PPIs were prescribed at higher doses and longer duration.
Gastro-esophageal reflux disease; Clinical practice guidelines; Adherence to guidelines; Treatment of gastro-esophageal reflux disease
Though gastroesophageal reflux disease (GERD) has been a prevalent disease in Western countries, the incidence of GERD has only just started to increase in Japan.
The aim of this study was to determine which lifestyle factors may be associated with GERD in Japan.
A total of 2,853 participants who took part in a health examination program between July 2004 and March 2005 were enrolled. GERD symptoms were assessed using the Japanese version of the Carlsson-Dent self-administered questionnaire (QUEST). The GERD group consisted of participants with a QUEST score ≥6 and/or endoscopic findings. The GERD group was divided into asymptomatic ERD (erosive reflux disease with no symptoms), symptomatic ERD (erosive reflux disease with symptoms) and NERD (non-erosive reflux disease) groups. Associated factors for these diseases were analyzed by logistic regression analysis.
GERD was diagnosed in 667 (23.4%) participants. Among the subjects placed in the GERD group, asymptomatic ERD, symptomatic ERD and NERD were diagnosed in 232 (8.1%), 91 (3.2%) and 344 (12.1%) participants, respectively. Factors associated with GERD included a high BMI (body mass index), hiatus hernia, fewer hours of sleep, lack of exercise, and drinking green tea.
Relationships between lifestyle, gender and GERD were investigated in the present study. Both lifestyle improvements and consideration of gender differences can be used to help prevent GERD development.
Gastroesophageal reflux disease (GERD); Japanese; Lifestyle; Gender
The confluence between the increased prevalence of gastro-esophageal reflux disease (GERD) and of obesity has generated great interest in the association between these two conditions. Several studies have addressed the potential relationship between GERD and obesity, but the exact mechanism by which obesity causes reflux disease still remains to be clearly defined. A commonly suggested pathogenetic pathway is the increased abdominal pressure which relaxes the lower esophageal sphincter, thus exposing the esophageal mucosal to gastric content. Apart from the mechanical pressure, visceral fat is metabolically active and it has been strongly associated with serum levels of adipo-cytokines including interleukin-6 and tumor necrosis factor α, which may play a role in GERD or consequent carcinogenesis. This summary is aimed to explore the potential mechanisms responsible for the association between GERD and obesity, and to better understand the possible role of weight loss as a therapeutic approach for GERD.
Body mass index; Visceral obesity; Gastro-esophageal reflux; Gastro-esophageal reflux disease complication
Esophageal adenocarcinoma (EAC) is a devastating disease that has risen in incidence over the past several decades. Barrett's esophagus (BE) is an associated premalignant lesion. Current preventative efforts rely on endoscopic screening of individuals with gastroesophageal reflux disease (GERD) symptoms and surveillance endoscopy for those with BE. However, some recent studies have found a high prevalence of BE in patients without GERD, and others have found little or no association with GERD. We hypothesized that studies of higher-quality design show weaker associations of GERD with BE, and that GERD is only weakly associated with short-segment Barrett's esophagus (SSBE).
We performed a systematic literature search in multiple online electronic databases regardless of language. Eligible studies required visualization of columnar mucosa and histological confirmation of intestinal metaplasia, and GERD symptoms ascertained by questionnaire or interview. The highest-quality sampling design was defined a priori by both cases and controls identified among unselected research volunteers (“research design”) rather than by patients selected for endoscopy for clinical indications (“clinical design”), which introduces selection and ascertainment bias. A priori, heterogeneity was defined by Cochrane's Q P < 0.20 and the inconsistency index (I2; 25% low, 50% moderate, and 75% high). Heterogeneity of results can reflect significant differences in study design or effect modification by strata of outcomes.
Systematic review identified 13,392 citations. Evaluation identified 108 potentially relevant journal articles, of which 26 met eligibility. Of these, 14 studies identified cases of BE and controls based on clinical indication (“clinical design”), and 6 used the “research design.” The remaining six studies identified cases of BE from patients undergoing endoscopy for clinical indication and controls among patients without known BE (“cases clinical/controls research”). The summary odds ratio (OR) for the association of GERD with BE from all studies was 2.90 (95% confidence interval (CI), 1.86–4.54), but the results were very heterogeneous (P = 0.0001; I2 = 89%). When stratified by BE length and sampling design, the studies with clinical design showed substantial, but heterogeneous, associations with SSBE (OR, 2.38; 95% CI, 1.21–4.70; P = 0.02; I2 = 62%), and stronger and homogeneous association with long-segment BE (LSBE; fixed effects OR, 2.96; 95% CI, 1.69–5.19; P = 0.25; I2 = 25%). In the research study design, stratifying by length of BE resolved the heterogeneity and showed a strong association between GERD and LSBE (fixed effects OR, 4.92; 95% CI, 2.01–12.0; P = 0.30; I2 = 19%) and no association with SSBE (fixed effects OR, 1.15; 95% CI, 0.763–1.73; P = 0.84; I2 = 0%). Funnel plots showed potential evidence for bias against dissemination of small negative studies.
In the highest-quality studies, GERD symptoms are not associated with SSBE, but increased the odds of LSBE by fivefold. GERD symptoms can serve as a reliable predictor of LSBE, but not SSBE. If SSBE is considered worthy of identification, then current screening practices do not select patients at risk for endoscopy, and alternative methods of selection for screening need to be developed.
Gastro-esophageal reflux disease (GERD) in otherwise healthy older children and adolescents is commonly encountered in pediatric clinics and poses a complex treatment problem involving changes of diets and lifestyle. After an initial history taking and a physical examination, typical symptoms of GERD in older children and adolescenct are initially treated with the trials of acid suppressants. With an increase of severe cases, more and more GERD children have been evaluated with endoscopy, which helps to delineate an erosive esophagitis from a non-erosive reflux disease as they are presumed to have different pathogenesis. For the pediatric patients without a significant underlying disease, a reflux esophagitis can be treated adequately with acid suppressants. Recently, the rapid increase of children who are taking anti-reflux medication has brought up a serious alarm among pediatricians. Some at risk pediatric patients with recurrent and/or chronic GERD have been linked to adulthood GERD. In this paper, pediatric GERD with and without erosive esophagitis was reviewed along with treatment options and issues specifically for the otherwise healthy older children and adolescents in the primary clinics or the secondary hospitals.
Gastroesophageal reflux; Child; Adolescents
The current epidemics of obesity and gastroesophageal reflux disease (GERD)–related disorders, including symptoms, esophageal erosions, Barrett’s esophagus (BE), and esophageal adenocarcinoma, have generated much interest in studying the association between these two conditions. Results of multiple case-control and cohort studies indicate that obesity satisfies several criteria for a causal association with GERD and some of its complications, including a generally consistent association with GERD symptoms, erosive esophagitis, and esophageal adenocarcinoma. An increase in GERD symptoms has been shown to occur in individuals who gain weight but continue to have a body mass index (BMI) in the normal range, contributing to the epidemiological evidence for a possible dose-response relationship between increasing BMI and increasing GERD. However, data are less clear on the relationship between BE and obesity, with more recent investigations showing little association. However, when considered separately, abdominal obesity seems to explain a considerable part of the association with GERD, including BE. Overall, epidemiological data show that maintaining a normal BMI may reduce the likelihood of developing GERD and its potential complications.
Many individuals with gastroesophageal reflux disease (GERD) never visit their general practitioner. Therefore, prospective data about GERD and its natural history in the general population are scarce. The aims of this study were to assess symptoms over time and consultation reasons in an Internet population with GERD.
Visitors (18–79 years) to a GERD information website who completed the GerdQ self-assessment questionnaire were invited to participate. Follow-up GerdQ questionnaires were sent after 4, 12 and 24 weeks, and those who had a total GerdQ score ≥ 8 and responded to at least the baseline and 4-week questionnaires (within 2–7 weeks) were included in the analyses. Outcome in proton pump inhibitor (PPI) and non-PPI users was classified as symptom improvement, symptom persistence/stable symptoms, or symptom relapse according to GerdQ scores.
A total of 403 non-PPI users (mean age 48 years, 40% male) and 304 PPI users (mean age 51 years, 41% male) were included. After 24 weeks, symptom improvement was present in 66% of non-PPI users (45/68) and 8% of PPI users (6/73), while persisting symptoms were reported by 24% (16/68) and 89% (65/73) respectively (baseline symptoms did not influence outcome at 24 weeks). Fifty-five percent of PPI users (116/210) and 37% of non-PPI users (76/207) who intended to visit a healthcare practitioner, performed one or more healthcare visits in the interim. Most frequently reported reason for consultation was persistence of symptoms.
GERD symptoms were persistent in the majority of PPI users during our 24-week follow-up, while almost two thirds of non-PPI users reported symptom improvement. Online follow-up of an Internet population with GERD is feasible.
The internet; GERD; PPI; Healthcare visit; GerdQ
Gastroesophageal reflux disease (GERD) is common in patients with many chronic diseases, but has not been well recognized in rheumatoid arthritis (RA). We investigated the prevalence of GERD symptoms in 278 outpatients with RA and their association with such clinical factors as age, sex, height, weight, body mass index, medications drugs, and functional status evaluated by the Modified Health Assessment Questionnaire (MHAQ). GERD symptoms were evaluated by Frequency Scale for the Symptoms of GERD (FSSG). The mean FSSG score for all patients was 5.6, and 82 patients were considered to have GERD symptoms (FSSG score ≥8), thus the overall prevalence of GERD symptoms was 29.5%. MHAQ score and height were significantly higher and lower, respectively, and prednisolone usage was significantly more in the patients with GERD symptoms than those without. These three clinical factors were also significantly associated with GERD symptoms by univariate logistic regression. Multivariate logistic regression analysis demonstrated that MHAQ was the only clinical factor related to GERD symptoms. In conclusion, the prevalence of GERD symptoms in RA patients was high and strongly associated with decreased functional status, suggesting that physicians should pay attention to GERD symptoms in RA management, especially for patients with low functional status.
rheumatoid arthritis; gastroesophageal reflux disease; Frequency Scale for the Symptoms of GERD; Modified Health Assessment Questionnaire; quality of life
Weight gain is an important risk factor for gastroesophageal reflux disease (GERD); however, whether weight loss can lead to resolution of GERD symptoms is not clear. Our aim was to measure the impact of weight loss on GERD symptoms.
Design and Methods
In a prospective cohort study at a tertiary referral center, overweight/obese subjects (BMI 25-39.9 kg/m2) were enrolled in a structured weight loss program. Weight loss strategies included dietary modifications, increased physical activity and behavioral changes. At baseline and at 6 months, BMI and waist circumference were measured and all participants completed a validated reflux disease questionnaire.
A total of 332 adult subjects, mean age 46 years and 66% women were prospectively enrolled. At baseline, the mean body weight, BMI, and waist circumference were 101 (±18) kg, 35 (±5) kg/m2 and 103 (±13) cm. At 6 months, majority of the subjects (97%) lost weight (average weight loss: 13 ± 7.7 kg) and as compared with baseline, there was a significant decrease in the overall prevalence of GERD (15 vs. 37%; P < 0.01) and the mean GERD symptom score (1.8 vs. 5.5; P < 0.01). Overall, 81% of the subjects had reduction in GERD symptom scores; 65% had complete resolution and 15% had partial resolution of reflux symptoms. There was a significant correlation between % body weight loss and reduction in GERD symptom scores (r = 0.17, P < 0.05).
In conclusion, the overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects. A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of these subjects.
Patients with type II diabetes mellitus (DM) were known to have higher prevalence of gastroesophageal reflux disease (GERD). Recent studies have shown that neuropathy has positive role on the development of GERD in type II DM, although its pathogenesis has not been fully understood yet. The aim of this study was to investigate whether neuropathy really contribute to the development of GERD and typical GERD symptoms in patients with type II DM in Korea.
One hundred and nineteen patients with type II DM who had given informed consents were enrolled. All patients underwent electromyography to check the presence of peripheral neuropathy, face-to-face interview to evaluate their typical GERD symptoms and esophagogastroduodenoscopy to look for the presence of erosive esophagitis. Ninety-five patients were finally included for this study and they were divided according to the presence or absence of the peripheral neuropathy.
The mean age of 95 patients was 59.3 ± 9.1 years and the mean disease duration of DM was 9.3 ± 5.9 years. Typical GERD symptoms were similarly found in both groups with and without peripheral neuropathy (23.6% vs 22.8%, P = 0.921). Erosive esophagitis was more prevalent in patients with neuropathy than in those without neuropathy (31.5% vs 10.5%, P = 0.022).
In patients with type II DM, peripheral neuropathy is an independent risk factor for the erosive esophagitis. However, peripheral neuropathy did not contribute to the presence of the typical GERD symptoms.
Diabetes mellitus, Type 2; Erosive esophagitis; Gastroesophageal reflux disease; Neuropathy
Obesity and gastroesophageal reflux disease (GERD) are increasingly important health problems. Previous studies of the relationship between obesity and GERD focus on indirect manifestations of GERD. Little is known about the association between obesity and objectively measured esophageal acid exposure. The aim of this study is to quantify the relationship between body mass index (BMI) and 24-h esophageal pH measurements and the status of the lower esophageal sphincter (LES) in patients with reflux symptoms.
Data of 1,659 patients (50% male, mean age 51 ± 14) referred for assessment of GERD symptoms between 1998 and 2008 were analyzed. These subjects underwent 24-h pH monitoring off medication and esophageal manometry. The relationship of BMI to 24-h esophageal pH measurements and LES status was studied using linear regression and multiple regression analysis. The difference of each acid exposure component was also assessed among four BMI subgroups (underweight, normal weight, overweight, and obese) using analysis of variance and covariance.
Increasing BMI was positively correlated with increasing esophageal acid exposure (adjusted R2 = 0.13 for the composite pH score). The prevalence of a defective LES was higher in patients with higher BMI (p < 0.0001). Compared to patients with normal weight, obese patients are more than twice as likely to have a mechanically defective LES [OR = 2.12(1.63–2.75)].
An increase in body mass index is associated with an increase in esophageal acid exposure, whether BMI was examined as a continuous or as a categorical variable; 13% of the variation in esophageal acid exposure may be attributable to variation in BMI.
Obesity; Gastroesophageal reflux disease (GERD); BMI; Comorbidity; Ambulatory pH monitoring; Lower esophageal sphincter (LES)
To evaluate the effectiveness of pantoprazole magnesium (pantoprazole-Mg) 40 mg in the relief of esophageal and extra-esophageal symptoms of gastroesophageal reflux disease (GERD), particularly night-time symptoms.
Patients (aged 18-50 years) with 3-month history of heartburn and/or acid regurgitation plus at least one other symptom in the last week were enrolled in a nationwide, prospective and observational study in Mexico. Patients received pantoprazole-Mg 40 mg once daily during 4 weeks. Symptoms were assessed through a physician-administered structured interview and the patient-completed ReQuest in Practice™ questionnaire. Night-time GERD was defined as arousal from sleep during the night due to GERD-associated symptoms.
Out of 4,343 patients included at basal visit, 3,665 were considered for the effectiveness per protocol analysis. At baseline, patients had a median of 8 GERD related symptoms. Patients with night-time GERD symptoms (42.7%) were more likely to have extra-esophageal symptoms (P < 0.001) than other GERD patients. Pantoprazole-Mg 40 mg once daily for 4 weeks improved a broad range of GERD-associated symptoms from baseline (80% reduction on physicians assessments; 68-77% reduction on ReQuest in Practice™ dimensions), including both day- and night-time GERD symptoms; improvements were the greatest for extra-esophageal symptoms in patients with night-time symptoms. Pantoprazole-Mg was well tolerated.
Pantoprazole-Mg 40 mg significantly improved a broad range of esophageal and extra-esophageal GERD related symptoms including sleep disturbances, as well as well-being, in patients with daytime or night-time GERD, making it a good option for patients with GERD, especially when extra-esophageal and night-time symptoms are present.
Gastroesophageal; Night-time symptoms; Pantoprazole; Proton pump inhibitors
Wireless pH studies can offer prolonged pH monitoring, which may potentially facilitate the diagnosis and management of patients with gastroesophageal reflux disease (GERD). The aim of the present study was to evaluate the detection rate of abnormal esophageal acid exposure using prolonged pH monitoring in patients with suspected or refractory GERD symptoms.
Patients undergoing prolonged ambulatory pH studies for the evaluation of GERD-related symptoms were assessed. Patients with a known diagnosis of GERD were tested on medical therapy, while patients with suspected GERD were tested off therapy. The wireless pH capsules were placed during upper endoscopy 6 cm above the squamocolumnar junction.
One hundred ninety-one patients underwent a total of 198 pH studies. Fifty ambulatory pH studies (25%) were excluded from the analysis: 27 patients (14%) had insufficient data capture (less than 18 h on at least one day of monitoring), 15 patients had premature capsule release (7%), seven were repeat studies (3.5%) and one had intolerable pain requiring capsule removal (0.5%). There were 115 patients undergoing pH studies who were off medication, and 33 patients were on therapy. For the two groups of patients, results were as follows: 32 (28%) and 22 (67%) patients with normal studies on both days; 58 (50%) and five (15%) patients with abnormal studies on both days; 18 (16%) and three (9%) patients with abnormal studies on day 1 only; and seven (6%) and three (9%) patients with abnormal studies on day 2 only, respectively.
Prolonged 48 h pH monitoring can detect more abnormal esophageal acid exposure but is associated with a significant rate of incomplete studies.
Ambulatory pH monitoring; Endoscopy; Gastroesophageal reflux disease; Treatment
Gastroesophageal reflux disease (GERD) is a growing problem in the pediatric population and recent advances in diagnostics and therapeutics have improved their management, particularly the use of esophago-gastroduodenoscopy (EGD). Most of the current knowledge is derived from studies in adults; however there are distinct features between infant onset and adult onset GERD. Children are not just little adults and attention must be given to the stages of growth and development and how these stages impact the disease management. Although there is a lack of a gold standard test to diagnose GERD in children, EGD with biopsy is essential to assess the type and severity of tissue damage. To date, the role of endoscopy in adults and children has been to assess the extent of esophagitis and detect metaplastic changes complicating GERD; however the current knowledge points another role for the EGD with biopsy that is to rule out other potential causes of esophagitis in patients with GERD symptoms such as eosinophilic esophagitis. This review highlights special considerations about the role of EGD in the management of children with GERD.
Endoscopy; Gastroesophageal reflux; Esophagitis; Infants; Children
Gastroesophageal reflux disease (GERD) is caused by abnormal reflux of gastric contents into the esophagus. GERD can be divided into two groups, erosive esophagitis and non-erosive reflux disease (NERD). The aim of this study was to compare the clinical characteristics of patients with erosive esophagitis to those with NERD. All participating patients underwent an upper endoscopy during a voluntary health check-up. The NERD group consisted of 500 subjects with classic GERD symptoms in the absence of esophageal mucosal injury during upper endoscopy. The erosive esophagitis group consisted of 292 subjects with superficial esophageal erosions with or without typical symptoms of GERD. Among GERD patients, male gender, high body mass index, high obesity degree, high waist-to-hip ratio, high triglycerides, alcohol intake, smoking and the presence of a hiatal hernia were positively related to the development of erosive esophagitis compared to NERD. In multivariated analysis, male gender, waist-to-hip ratio and the presence of a hiatal hernia were the significant risk factors of erosive esophagitis. We suggest that erosive esophagitis was more closely related to abdominal obesity.
Erosive Esophagitis; Non-erosive Reflux Disease
To evaluate the prevalence and possible contributing factors to postprandial bloating in patients having chronic gastroesophageal reflux disease (GERD) before and after laparoscopic Nissen fundoplication.
A prospective cohort study.
A tertiary care teaching hospital.
Five hundred and seventy-eight patients with proven GERD.
Laparoscopic Nissen fundoplication.
Symptom severity scores for postprandial bloating and dysphagia, esophageal motility and 24-hour pH measurement before and at 6 months, 2 years and 5 years after laparoscopic Nissen fundoplication.
Of the 598 patients, 436 (73%) reported some postprandial bloating before the procedure. The symptom score for bloating significantly improved after surgery (p < 0.0001). There were no significant differences in the lower esophageal sphincter basal pressures or 24-hour pH scores between those who reported improvement or worsening of their postprandial bloating. At 6 months after surgery, 54% of patients experienced postprandial bloating; of these, 49% reported improvement, 21% reported worsening and 30% reported no change in bloating symptoms compared with the preoperative state. Of the patients who reported worsening of postprandial bloating 6 months after surgery, 86 were reassessed 2 years after surgery and 71% reported improvement of this symptom over this time interval.
Bloating is a common symptom in patients who suffer from chronic GERD. Laparoscopic Nissen fundoplication lessens the severity of this symptom in most patients. In a small subgroup of patients, antireflux surgery may exacerbate the bloating, but this improves over time.
Precise mechanisms of atrial fibrillation (AF) are uncertain, but their association with esophageal disorders has been recently proposed. The association between gastroesophageal reflux disease (GERD), the most common gastroesophageal disorder, and AF remains undetermined. We therefore aimed to investigate the association between GERD and later development of AF.
Methods and Results
Patients with GERD were identified from the 1,000,000-person cohort dataset sampled from the Taiwan National Health Insurance database. The study cohort comprised 29,688 newly diagnosed adult GERD patients; 29,597 randomly selected age-, gender-, comobidity-matched subjects comprised the comparison cohort. Cox proportional hazard regressions were performed as a means of comparing the AF-free survival rate for the two cohorts. During a maximum three years of follow-up, a total of 351 patients experienced AF, including 184 (0.62%) patients in the GERD cohort and 167 (0.56%) in the control group. The log-rank test showed that patients with GERD had significantly higher incidence of AF than those without GERD (p = 0.024). After Cox proportional hazard regression model analysis, GERD was independently associated with the increased risk of AF (hazard ratio, 1.31; 95% confidence interval, 1.06–1.61, p = 0.013).
GERD was independently associated with an increased risk of future AF in a nationwide population-based cohort.
The value of gastroesophageal reflux disease (GERD) indicators (acid exposure time (AET), symptom association probability (SAP), and symptom index (SI)) in predicting therapeutic success in noncardiac chest pain (NCCP) has not been systematically evaluated in outcome studies.
We retrospectively identified 98 subjects with NCCP (age 51.8±1.2 years, 75 women, mean duration of symptoms 7.3±0.4 years) who underwent pH monitoring off antireflux therapy. Distal esophageal AET (abnormal if ≥4.0%), SAP (measured as Ghillibert probability estimate, abnormal if P < 0.05), and SI (abnormal if ≥50%) were calculated; symptom severity and change after therapy were assessed on a 10-point Likert scale. Subjects were interviewed 2.8±0.9 years after the pH study to determine the degree of symptom change (high-degree response (HDR), with definite, sustained symptom improvement) after antireflux therapy. Regression analysis was used to determine the independent predictors of HDR.
GERD indicators were present in 61 subjects (62.2%); 52 subjects (53.1%) had abnormal AET, 26 (26.5%) had positive SAP, and 25 (25.5%) had positive SI. With therapy, mean symptom scores improved from 6.3±0.3 at the time of the pH study to 2.9±0.3 at the time of interview (P < 0.001). A total of 58 subjects (59.2%) achieved HDR, and another 29.6% had moderate symptom improvement. On univariate analysis, HDR was associated with positive SAP (P = 0.003) and elevated AET (P = 0.015) but not with demographics, SI, or esophageal motor pattern. In regression analysis containing demographics, GERD indicators, psychiatric comorbidity, and esophageal motor pattern, positive SAP was retained as a significant predictor of HDR (P = 0.003); elevated AET trended toward significance (P = 0.055). Frequency of HDR was highest when subjects had all three GERD parameters abnormal (93.3% HDR) or both elevated AET and positive SAP (88.2% HDR, P < 0.001 compared with only one or no GERD parameter abnormal).
Positive statistical tests of symptom association predict the therapeutic success of GERD management in NCCP. When used hierarchically, response to antireflux therapy is best predicted when GERD parameters are all abnormal and poorest when parameters are normal. These results support the importance of GERD, the relevance of symptom association testing during ambulatory pH monitoring, and the value of intensive antireflux therapy in NCCP.