Giorgia Bodini

Characteristics of reflux episodes and symptom association in patients with erosive esophagitis and nonerosive reflux disease: study using combined impedance-pH off therapy.

OBJECTIVES:We sought to compare reflux and symptom association patterns in patients with nonerosive reflux disease (NERD), erosive esophagitis (EE), and in healthy volunteers (HVs).METHODS:Patients with EE and NERD underwent combined impedance–pH monitoring. Normal values were defined on the basis of previously collected data from 48 HVs. We evaluated distal esophageal acid exposure time (AET), number and type of reflux episodes (acid, nonacid), acid and bolus clearance times, proximal extension of reflux episodes, and symptom association probability (SAP).RESULTS:Distal AET (percentage time, pH<4) was higher (P<0.01) in 58 EE patients (median 7.4%, 25–75th percentile 4.2–9.9%) compared with 168 NERD patients (4.2% (1.2–6.4%)) and 48 HVs (0.7% (0.2–1.4%)). Patients with EE and NERD had a higher (P<0.01) number of acid reflux episodes compared with HVs (51 (37–66) vs. 34 (22–51) vs. 17 (8–31); P<0.05), but a similar number of nonacid reflux episodes (22 (15–39) vs. 23 (15–38) vs. 18 (14–26); P=NS). The percentage of reflux episodes reaching the proximal esophagus was higher (P<0.01) in EE patients (57% (45–73%)) than in NERD patients (45% (36–60%)) and HVs (33% (19–46%)). A positive SAP for heartburn or regurgitation was found in 161 of 168 (96%) NERD and 54 of 58 (93%) EE patients (P=NS).CONCLUSIONS:Acid reflux episodes, volume, and acid clearance are important factors in the pathogenesis of reflux-induced lesions. Nonacid reflux contributes less to esophageal mucosa damage, but is involved in the development of reflux symptoms in both NERD and EE patients.

Adalimumab Is More Effective Than Azathioprine and Mesalamine at Preventing Postoperative Recurrence of Crohn's Disease: A Randomized Controlled Trial

OBJECTIVES:Postsurgical recurrence of Crohns disease (CD) is very frequent and, to date, only infliximab has been shown to be useful in preventing it. The efficacy of adalimumab (ADA) is poorly known. We evaluated whether the administration of ADA after resective intestinal surgery reduces postoperative CD recurrence.METHODS:We randomly assigned 51 patients with CD who had undergone ileocolonic resection to receive after 2 weeks from surgery ADA at the dose of 160/80/40 mg every two weeks, azathioprine (AZA) at 2 mg/kg/day, or mesalamine at 3 g/day, and they were followed up for 2 years. The primary end point was the proportion of patients with endoscopic and clinical recurrence. Secondary end point was the assessment of quality of life by means of a previously validated questionnaire.RESULTS:The rate of endoscopic recurrence was significantly lower in ADA (6.3%) compared with the AZA (64.7%; odds ratio (OR)=0.036 (95% confidence interval (CI) 0.004–0.347)) and mesalamine groups (83.3%; OR=0.013 (95% CI 0.001–0.143)). There was a significantly lower proportion of patients in clinical recurrence in the ADA group (12.5%) compared with the AZA (64.7%; OR=0.078 (95% CI 0.013–0.464)) and mesalamine groups (50%; (OR=0.143 (95% CI 0.025–0.819)). The quality of life was higher in the ADA (202) than in the AZA (90; OR=0.028 (95% CI 0.004–0.196)) and mesalamine groups (98; OR=0.015 (95% CI 0.002–0.134)).CONCLUSIONS:The administration of ADA after intestinal resective surgery was greatly effective in preventing endoscopic and clinical recurrence of CD. Further larger studies are necessary to confirm the therapeutic advantage and to show the economic implications of biologic therapy in this field.

Positive glucose breath testing is more prevalent in patients with IBS-like symptoms compared with controls of similar age and gender distribution.

Background Small intestinal bacterial overgrowth (SIBO) may mimic a functional disorder such as irritable bowel syndrome (IBS) or functional bloating (FB). In this study, we aimed to assess the utility of glucose breath test (GBT) in patients with the above conditions. Methods This study included 200 consecutive patients (130 with IBS and 70 with FB on the basis of Rome III criteria) and 70 controls with similar age and sex distribution. Patients and controls underwent 50 g GBT and a H2 peak of ≥12 ppm was considered diagnostic of SIBO. Positive patients received rifaximin of 1200mg/day for 10 days and underwent a second GBT 1 month after the end of treatment. A symptom questionnaire was completed before and after therapy. Results GBT resulted to be altered in 21 out of 130 IBS patients and in 2 out of 70 FB patients with a significant difference of the former group compared with controls (3 out of 70, P=0.0137). Most IBS patients with a positive GBT complained of diarrhea. GBT showed an increased methane excretion in 26% of patients, who were equally distributed among different bowel pattern subgroups. Previous abdominal surgery was more frequently seen in GBT-positive patients (P=0.008). After antibiotic treatment, eradication of SIBO was achieved in 70% of patients, with a significant improvement of symptoms in eradicated patients compared with the not eradicated ones (P<0.001). Conclusions GBT is useful to identify a subgroup of IBS-like patients, whose symptoms are owing to SIBO. Normalization of GBT after antibiotic therapy is associated with a significant improvement of symptoms. GBT does not offer any advantage in FB patients.

Esophagogastric junction contractility for clinical assessment in patients with GERD: a real added value?

The role of esophagogastric junction contractile integral (EGJ‐CI) as assessed by high‐resolution manometry (HRM) is unclear. We aimed to correlate the EGJ‐CI with impedance‐pH findings in gastro‐esophageal reflux disease (GERD) patients.

Prevention of postoperative recurrence of Crohn's disease by Adalimumab: a case series.

Adalimumab, an anti-TNF-α monoclonal antibody, was found to be effective for the treatment of luminal Crohns disease (CD), but its efficacy for the prevention of postoperative recurrence of CD is still unknown. Here, we present a case series of six patients who underwent resection for an ileocecal stricture caused by CD. Surgery removed the involved ileocolon, and pathology confirmed the presence of a fibrotic stricture. Two weeks after the operation, they were given Adalimumab at the dose of 160/80/40 mg every 2 weeks and were followed up. Since then, they have been disease-free for ≈ 3 years after surgery on clinical, radiological, and endoscopic/histological grounds (Crohns Disease Activity Index ≤ 110 in all occasions). Up to now, they have had no anemia, no increase in inflammatory indices, and no abnormal blood tests. These are the first cases, to our knowledge, in which Adalimumab has been successfully used to prevent the postsurgical recurrence of CD, an event so far considered to be mandatory. Further large placebo-controlled studies are necessary to show the therapeutic advantage and the economic implications of these observations.

Esophageal motility abnormalities in gastroesophageal reflux disease

Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophageal motility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from non-erosive reflux disease to erosive reflux disease and Barretts esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.

The natural history of gastro-esophageal reflux disease: a comprehensive review.

Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barretts esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus.

Esophageal testing: What we have so far

Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry (HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h pH-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and pH monitoring can detect acid and non-acid reflux events. EndoFLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal pH-metry. Future studies are required of these techniques to evaluate their diagnostic accuracy and usefulness, although the available data are promising.

Functional Heartburn Overlaps With Irritable Bowel Syndrome More Often than GERD

Objectives:We aimed to evaluate the prevalence of irritable bowel syndrome (IBS) in patients with typical reflux symptoms as distinguished into gastroesophageal reflux disease (GERD), hypersensitive esophagus (HE), and functional heartburn (FH) by means of endoscopy and multichannel intraluminal impedance (MII)-pH monitoring. The secondary aim was to detect pathophysiological and clinical differences between different sub-groups of patients with heartburn.Methods:Patients underwent a structured interview based on questionnaires for GERD, IBS, anxiety, and depression. Off-therapy upper-gastrointestinal (GI) endoscopy and 24 h MII-pH monitoring were performed in all cases. In patients with IBS, fecal calprotectin was measured and colonoscopy was scheduled for values >100 mg/kg to exclude organic disease. Multivariate logistic regression analysis was performed to identify independent risk factors for FH.Results:Of the 697 consecutive heartburn patients who entered the study, 454 (65%) had reflux-related heartburn (GERD+HE), whereas 243 (35%) had FH. IBS was found in 147/454 (33%) GERD/HE but in 187/243 (77%) FH patients (P<0.001). At multivariate analysis, IBS and anxiety were independent risk factors for FH in comparison with reflux-related heartburn (GERD+HE).Conclusions:IBS overlaps more frequently with FH than with GERD and HE, suggesting common pathways and treatment. HE showed intermediate characteristic between GERD and FH.

Gadolinium accumulation after contrast-enhanced magnetic resonance imaging: Which implications in patients with Crohn's disease?

Crohns disease (CD) is a chronic inflammatory condition of the bowel, characterized by an alternation of remission and relapse phases, leading to a progressive intestinal damage with loss of function. Magnetic resonance enterography has been widely used in the past for the evaluation of fistulizing disease, but its use increased over time, being considered helpful in different moments of disease course. Intravenous injection of Gadolinium-based contrast agents has been demonstrated to be crucial to assess mucosal inflammation, transmural involvement, and extraintestinal disease. Recently, Gadolinium accumulation in human tissues has been increasingly reported, although clinical implications of this event are still unclear. In the present paper, we review the main evidence on the topic, focusing on the potential implications for gastroenterological practice.