Isaac B. Malagon

Non‐erosive reflux disease (NERD) — acid reflux and symptom patterns

Background: Recent reports suggest that patients with non‐erosive reflux disease (NERD) treated with anti‐reflux medications show lower symptom improvement rates than patients with erosive oesophagitis treated with the same medications.

Failure of oesophageal acid control in candidates for Barrett's oesophagus reversal on a very high dose of proton pump inhibitor

Normalization of oesophageal acid exposure using high dose proton pump inhibitors in patients who are candidates for ablation therapy has been suggested to be essential for successful Barretts reversal. However, the success rate for achieving pH normalization has not been determined.

Omeprazole 40 mg once a day is equally effective as lansoprazole 30 mg twice a day in symptom control of patients with gastro‐oesophageal reflux disease (GERD) who are resistant to conventional‐dose lansoprazole therapy—a prospective, randomized, multi‐centre study

Comparative studies of omeprazole and lansoprazole are scarce and even scarcer are comparisons of higher doses. Most of the comparative studies have assessed the effect of the two proton pump inhibitors (PPIs) on gastric acid secretion or gastric pH. Few studies have compared clinical end‐points such as oesophageal healing and symptom control.

Feasibility and tolerability of transnasal/per-oral placement of the wireless pH capsule vs. traditional 24-h oesophageal pH monitoring--a randomized trial.

Background : The wireless pH is a new technique to monitor oesophageal acid exposure.

The Effect of Auditory Stress on Perception of Intraesophageal Acid in Patients With Gastroesophageal Reflux Disease

BACKGROUND & AIMS Most patients with gastroesophageal reflux disease (GERD) report that stress exacerbates their symptoms, yet mechanisms underlying this association remain unknown. We sought to determine the effect of an acute laboratory stressor on perceptual and emotional responses to intraesophageal acid perfusion in healthy controls and patients with GERD. METHODS Forty-six patients with heartburn and 10 healthy controls underwent upper endoscopy and, if negative, pH monitoring. Assessment of psychologic factors and health-related quality of life was done by a questionnaire. Perceptual and emotional responses to intraesophageal acid at baseline, during auditory stress, and during an auditory control condition were determined using a randomized crossover design. Plasma levels of norepinephrine, adrenocorticotropic hormone, and cortisol were assessed. RESULTS Twenty-nine subjects were identified as nonerosive reflux disease and 17 as erosive esophagitis. Quality of life, psychologic profile, and personality assessment variables were similar among the 2 patient groups and the controls. There was a significant reduction in mean lag time to initial symptom perception and an increase in mean intensity rating and mean acid perfusion sensitivity score in the 2 patient groups during the stress period, which was not seen during the control condition. Healthy controls demonstrated lack of a significant change in all parameters of stimulus response functions to acid, regardless of condition. CONCLUSIONS Acute auditory stress can exacerbate heartburn symptoms in GERD patients by enhancing perceptual response to intraesophageal acid exposure. This greater perceptual response is associated with greater emotional responses to the stressor.

Functional Heartburn Patients Demonstrate Traits of Functional Bowel Disorder but Lack a Uniform Increase of Chemoreceptor Sensitivity to Acid

BACKGROUND:Functional heartburn (FH) patients have a profound impact on the response to anti-reflux therapy of the nonerosive reflux disease (NERD) group as compared to the response of the erosive esophagitis group. Thus far, there is paucity of information about their physiological and clinical characteristics that may separate them from the other NERD patients.AIM:To compare physiological and clinical characteristics of patients with FH to their counterparts within the NERD group (NERD-positive [NERD+]).METHODS:Subjects with typical heartburn symptoms, at least twice a week, were evaluated by an upper endoscopy. Only those with normal esophageal mucosa were recruited into the study and underwent pH testing to assess esophageal acid exposure. The patients were divided into those with normal pH test (FH) and those with abnormal pH test (NERD+). The groups were compared for demographics, gastroesophageal reflux disease symptom characteristics, psychological profile, and reported quality of life. Additionally, the two patient groups were compared for stimulus response functions to acid, autonomic function response, and rate of Helicobacter pylori infection.RESULTS:Fifty-two patients included 30 with FH and the rest with NERD+. There was no statistical difference in demographics, frequency of hiatal hernia and H. pylori infection between the two groups. Patients with FH had a significantly longer history of heartburn and reported more episodes of chest pain than NERD+ patients (M—7.5 yr and M—once a week vsM—3.5 yr and M—once a month, respectively, p < 0.05). Patients with FH scored significantly higher in the somatization domain than patients with NERD+ (M—60 vs 52.5, p < 0.05), but had similar reported quality of life. Patients with NERD+ demonstrated a significantly shorter time to symptom perception and higher intensity rating (p < 0.05). Only patients with FH demonstrated a statistically significant increase in heart rate and skin conductance after acid perfusion, as compared to those with NERD+ (p < 0.05).CONCLUSION:Patients with FH demonstrate increased reports of chest pain and somatization, an alteration in autonomic function but lack a uniform increase in chemoreceptor sensitivity to acid as compared to those with NERD+. This suggests that while FH patients harbor clinical traits of a functional bowel disorder, hypersensitivity to acid is not a general phenomenon.

Comparison of esophageal acid exposure distribution along the esophagus among the different gastroesophageal reflux disease (GERD) groups.

BACKGROUND:Patients with nonerosive reflux disease (NERD) have the lowest esophageal acid exposure profile compared with the other gastroesophageal reflux disease (GERD) groups.AIM:To compare lower esophageal acid exposure recordings 1 cm above the lower esophageal sphincter (LES) with those 6 cm above the LES as well as to determine the characteristics of esophageal acid exposure along the esophagus among the different GERD groups.METHODS:Patients with classic heartburn symptoms were enrolled into the study. Patients were evaluated by a demographics questionnaire and the validated GERD Symptom Checklist. Upper endoscopy was performed to evaluate the presence of esophageal erosions and Barretts esophagus (BE). Ambulatory pH testing was performed using a commercially available 4-sensor pH probe with sensors located 5 cm apart. The distal sensor was placed 1 cm above the LES.RESULTS:Sixty-four patients completed the study. Of those, 21 patients had NERD, 20 had erosive esophagitis (EE), and 23 had BE. All patient groups demonstrated greater esophageal acid exposure 1 cm above the LES than 6 cm above the LES. In NERD and EE, this phenomenon was primarily a result of a higher mean percentage of upright time with pH <4. Unlike patients with EE and BE, those with NERD had very little variation in esophageal acid exposure throughout the esophagus (total and supine).CONCLUSIONS:ALL GERD groups demonstrated significant greater esophageal acid exposure at the very distal portion of the esophagus, primarily as a result of short upright reflux events. Unlike erosive esophagitis and BE, NERD patients demonstrate a more homogenous acid distribution along the esophagus.

Comparisons of the distribution of oesophageal acid exposure throughout the sleep period among the different gastro‐oesophageal reflux disease groups

Background  Nocturnal gastro‐oesophageal reflux diseases (GERD) can lead to oesophageal mucosal injury and extra‐oesophageal complications.

Assessment of 24-h oesophageal pH monitoring should be divided to awake and asleep rather than upright and supine time periods*

Abstract  Oesophageal acid exposure analysis is divided to upright and supine, based on the assumption that the supine–awake period is similar to the supine–asleep period. To determine if the principal acid‐reflux characteristics of supine–awake are closer to supine–asleep or upright period. Patients with heartburn underwent an upper endoscopy and pH testing. The patients were instructed to carefully document their upright, supine–awake and supine–asleep periods. A total of 64 patients were enrolled into this study (M/F 35/29; mean age 52.4 ± 13.3). The mean percentage total time pH <4, frequency of acid‐reflux events (per h) and number of sensed reflux events was not different between upright and the supine–awake period (P = ns). In contrast, the mean percentage total time pH <4, frequency of acid‐reflux events and number of sensed reflux events was significantly higher in both upright and supine–awake periods vs supine–asleep (4.3 ± 6.9, 1.86 ± 2.7 and 0.01 ± 0.05, P < 0.0001, respectively). The principal characteristics of the acid‐reflux events in the supine–awake period are closer to the upright period than to the supine–asleep period.

Increased oesophageal acid exposure at the beginning of the recumbent period is primarily a recumbent‐awake phenomenon

Background  A significant increase in oesophageal acid exposure during early recumbent period has been demonstrated.