Donald O. Castell

Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.

Symptomatic gastroesophageal reflux: incidence and precipitating factors.

The incidence and precipitating factors associated with symptomatic gastroesophageal reflux were evaluated by a questionnaire in 446 hospitalized and 558 nonhospitalized subjects. Of 385 control subjects 7% experienced heartburn daily, 14% noted heartburn weekly, and 15% experienced it once a month, giving a total of 36% of subjects having heartburn at least monthly. Daily heartburn occurred at a significantly greater (P<0.05) rate for 246 medical inpatients (14%) and for 121 patients seen in outpatient gastroenterological clinic (15%). Pregnant women seen in uncomplicated obstetrical clinic had symptoms of significantly greater (P<0.01) incidence: daily (25%) and at least once monthly (52%). Age, sex, or hospitalization did not significantly affect incidence. Fried foods, “spicy” foods, and alcohol were the most common precipitating factors.The incidence and precipitating factors associated with symptomatic gastroesophageal reflux were evaluated by a questionnaire in 446 hospitalized and 558 nonhospitalized subjects. Of 385 control subjects 7% experienced heartburn daily, 14% noted heartburn weekly, and 15% experienced it once a month, giving a total of 36% of subjects having heartburn at least monthly. Daily heartburn occurred at a significantly greater (P<0.05) rate for 246 medical inpatients (14%) and for 121 patients seen in outpatient gastroenterological clinic (15%). Pregnant women seen in uncomplicated obstetrical clinic had symptoms of significantly greater (P<0.01) incidence: daily (25%) and at least once monthly (52%). Age, sex, or hospitalization did not significantly affect incidence. Fried foods, “spicy” foods, and alcohol were the most common precipitating factors.

Gastro-oesophageal reflux monitoring: review and consensus report on detection and definitions of acid, non-acid, and gas reflux

To date, most concepts on the frequency of gastro-oesophageal reflux episodes and the efficiency of the antireflux barrier have been based on inferences derived from measurement of oesophageal pH. The development of intraluminal impedance monitoring has highlighted the fact that pH monitoring does not detect all gastro-oesophageal reflux events when little or no acid is present in the refluxate, even if special pH tracing analysis criteria are used. In November 2002, a workshop took place at which 11 specialists in the field of gastro-oesophageal reflux disease discussed and criticised all currently available techniques for measurement of reflux. Here, a summary of their conclusions and recommendations of how to achieve the best results from the various techniques now available for reflux measurement is presented.

Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy. A multicentre study using combined ambulatory impedance-pH monitoring

Background and aims: Empiric proton pump inhibitor (PPI) trials have become increasingly popular leading to gastroenterologists frequently evaluating gastro-oesophageal reflux disease (GORD) patients only after they have “failed” PPI therapy. Combined multichannel intraluminal impedance and pH (MII-pH) monitoring has the ability to detect gastro-oesophageal reflux (GOR) episodes independent of their pH and evaluate the relationship between symptoms and all types of GOR. Using this technique, we aimed to characterise the frequency of acid and non-acid reflux (NAR) and their relationship to typical and atypical GOR symptoms in patients on PPI therapy. Methods: Patients with persistent GORD symptoms referred to three centres underwent 24 hour combined MII-pH monitoring while taking PPIs at least twice daily. Reflux episodes were detected by impedance channels located 3, 5, 7, 9, 15, and 17 cm above the lower oesophageal sphincter (LOS) and classified into acid or non-acid based on pH data from 5 cm above the LOS. A positive symptom index (SI) was declared if at least half of each specific symptom events were preceded by reflux episodes within five minutes. Results: A total of 168 patients (103 (61%) females and 65 (39%) males; mean age 53 (range 18–85) years) underwent combined MII-pH monitoring while taking PPIs at least twice daily. One hundred and forty four (86%) patients recorded symptoms during the study day and 24 (15%) patients had no symptoms during testing. Sixty nine (48%) symptomatic patients had a positive SI for at least one symptom (16 (11%) with acid reflux and 53 (37%) with NAR) and 75 (52%) had a negative SI. A total of 171 (57%) typical GORD symptoms were recorded, 19 (11%) had a positive SI for acid reflux, 52 (31%) for NAR, and 100 (58%) had a negative SI. One hundred and thirty one (43%) atypical symptoms were recorded, four (3%) had a positive SI for acid reflux, 25 (19%) had a positive SI for NAR, and 102 (78%) had a negative SI. Conclusion: Combined MII-pH identifies the relation of reflux of all types to persistent symptoms and the importance of NAR in patients taking PPIs.

Esophageal Manometry in 95 Healthy Adult Volunteers Variability of Pressures with Age and Frequency of "Abnormal" Contractions

Although esophageal manometry is widely used in clinical practice, the normal range of esophageal contraction parameters is poorly defined. Therefore, 95 healthy volunteers (mean age: 43 years; range 22–79 years) were studied with a low-compliance infusion system and 4.5-mm-diameter catheter. All subjects were given 10 wet swallows (5 cc H2O) and 38 subjects also were given 10 dry swallows. Results: Amplitude, but not duration, was greater (P<0.05) after wet compared to dry swallows. Both distal mean contractile amplitude and duration of wet swallows significantly increased with age and peaked in the fifties. Double-peaked waves frequently occurred after both wet (11.3%) and dry (18.1%) swallows, but triple-peaked waves were rare (<1%). Nonperistaltic contractions were more common (P<0.001) after dry compared to wet swallows (18.1% vs 4.1%). This difference resulted from frequent simultaneous contractions after dry swallows (12.6% vs 0.4%). Conclusions: (1) Distal esophageal contractile amplitude and duration after wet swallows increases with age. (2) Triple-peaked waves and wet-swallow-induced simultaneous contractions should suggest an esophageal motility disorder. Double-peaked waves are a common variant of normal. (3) Dry swallows have little use in the current evaluation of esophageal peristalsis.

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The Practice Parameters Committee of the American College of Gastroenterology.

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.

Twenty-four hour ambulatory simultaneous impedance and pH monitoring: a multicenter report of normal values from 60 healthy volunteers.

OBJECTIVES:Impedance monitoring is a new diagnostic method for gastroesophageal reflux disease (GERD) where multiple impedance electrode pairs are placed on a standard pH catheter. It detects reflux of a liquid and/or gas bolus into the esophagus, as well as its distribution, composition, and clearing. The aim of this collaborative study is to define normal values for 24-h ambulatory simultaneous impedance and pH monitoring (24-h Imp-pH), and compare bolus parameters by impedance monitoring to changes in [H+] measured by pH monitoring.METHODS:Sixty normal volunteers without GER symptoms underwent 24-h Imp-pH with impedance measured at six sites (centered at 3, 5, 7, 9, 15, and 17 cm above lower esophageal sphincter) and pH 5 cm above the LES. Reflux detected by impedance was characterized by the pH probe as either acid, weakly acidic, nonacid, or superimposed acid reflux. Proximal reflux was defined as reflux that reached the impedance site 15 cm above the LES.RESULTS:Reflux frequency was common upright (median-27, 25th and 75th quartile-16, 42), but rare recumbent (median-1; 0, 4). A median of 34% (14%, 49%) of upright reflux reached the proximal esophagus. There was a similar number of mixed composition (liquid + gas; 49%) and liquid-only reflux (51%). Acid reflux was two-fold more common than weakly acidic reflux (p < 0.001). Superimposed acid reflux and nonacid reflux were rare. Acid neutralization to pH 4 took twice as long as volume clearance measured by impedance.CONCLUSIONS:Combining impedance and pH monitoring improves the detection and characterization of GER. This study characterizes the frequency, duration, and extent of reflux in health and provides normal values for 24-h Imp-pH for future comparison with GERD patients.

Esomeprazole (40 mg) compared with lansoprazole (30 mg) in the treatment of erosive esophagitis

OBJECTIVES: Esomeprazole, the S isomer of omeprazole, has been shown to have higher healing rates of erosive esophagitis than omeprazole. This study compared esomeprazole with lansoprazole for the healing of erosive esophagitis and resolution of heartburn.METHODS:This United States multicenter, randomized, double blind, parallel group trial was performed in 5241 adult patients (intent-to-treat population) with endoscopically documented erosive esophagitis, which was graded by severity at baseline (Los Angeles classification). Patients received 40 mg of esomeprazole (n = 2624) or 30 mg of lansoprazole (n = 2617) once daily before breakfast for up to 8 wk. The primary efficacy endpoint was healing of erosive esophagitis at week 8. Secondary assessments included proportion of patients healed at week 4, resolution of investigator-recorded heartburn, time to first and time to sustained resolution of patient diary-recorded heartburn, and proportion of heartburn-free days and nights.RESULTS:Esomeprazole (40 mg) demonstrated significantly higher healing rates (92.6%, 95% CI = 91.5–93.6%) than lansoprazole (30 mg) (88.8%, 95% CI = 87.5–90.0%) at week 8 (p = 0.0001, life-table estimates, intent-to-treat analysis). A significant difference in healing rates favoring esomeprazole was also observed at week 4. The difference in healing rates between esomeprazole and lansoprazole increased as baseline severity of erosive esophagitis increased. Sustained resolution of heartburn occurred faster and in more patients treated with esomeprazole. Sustained resolution of nocturnal heartburn also occurred faster with esomeprazole. Both treatments were well tolerated.CONCLUSIONS:Esomeprazole (40 mg) is more effective than lansoprazole (30 mg) in healing erosive esophagitis and resolving heartburn. Healing rates are consistently high with esomeprazole, irrespective of baseline disease severity.

Abnormal sensory perception in patients with esophageal chest pain

Many cases of recurrent noncardiac chest pain are considered to be of esophageal origin. The mechanism of this pain is poorly understood and only rarely appears related to abnormal esophageal contractions observed during manometry. We studied the response to intraesophageal balloon distention in 30 patients with noncardiac chest pain (mean age 52 yr) and 30 controls (mean age 41 yr). A polyvinyl balloon (length 30 mm; maximum diameter after 10-ml distention, 25 mm) was positioned 10 cm above the lower esophageal sphincter and inflated with progressively larger volumes of air (each increase = 1 ml). Chest pain was correlated with balloon volumes and pressures, esophageal contractions 5 cm above the balloon, and electrocardiogram changes. Results were as follows: 18 of 30 (60%) patients and 6 of 30 (20%) controls (p less than 0.005) experienced chest pain. Electrocardiogram changes of ischemia were not seen. Neither balloon pressures nor esophageal contractions above the balloon differed significantly during pain in the controls or patients. As assessed by pressure-volume curves, esophageal tone was also similar in all subjects regardless of pain production. Patients were more sensitive to smaller volumes of balloon distention; 15 of 18 patients had chest pain at less than or equal to 8 ml volume while controls only noted chest pain at greater than or equal to 9 ml volume. We therefore arrived at the following conclusions: esophageal balloon distention may provide a nonpharmacologic provocative test for esophageal chest pain; and the mechanism of chest pain in these patients may be related to lower pain threshold to balloon distention, which is independent of esophageal contractions.

Gastroesophageal Reflux: Pathogenesis, Diagnosis, and Therapy

In recent years, considerable new information has become available on the pathogenesis, diagnosis and therapy of gastroesophageal reflux. Gastric contents, mucosal resistance, esophageal acid clearance, and gastric emptying are now recognized, along with incompetency of the lower esophageal sphincter, as contributing factors to gastroesophageal reflux disease. The potential tests for reflux are reviewed and the diagnostic accuracy of each is evaluated. A diagnostic approach to the patient with reflux symptoms is outlined that considers the sensitivity and specificity of these various tests as well as their availability to the generalist and gastrointestinal specialist. Finally, an overview of the current therapy for reflux disease summarizes the controlled studies in the medical literature.