Ram Dickman

The effect of a therapeutic trial of high-dose rabeprazole on symptom response of patients with non-cardiac chest pain: a randomized, double-blind, placebo-controlled, crossover trial

Background : Empirical trial with high‐dose omeprazole has been shown to be a sensitive tool for diagnosing patients with gastro‐oesophageal reflux disease‐related non‐cardiac chest pain.

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.

Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn.

Background  The current standard of care in proton pump inhibitor failure is to double the proton pump inhibitor dose, despite limited therapeutic gain.

Prevalence of upper gastrointestinal tract findings in patients with noncardiac chest pain versus those with gastroesophageal reflux disease (GERD)-related symptoms: results from a national endoscopic database.

BACKGROUND:Available data on the prevalence of esophageal and upper gut findings in patients with noncardiac chest pain (NCCP) are scarce and limited to one centers experience.AIM:To determine the prevalence of esophageal and upper gut mucosal findings in patients undergoing upper endoscopy for NCCP only versus those with gastroesophageal reflux disease (GERD) symptoms only, using the national Clinical Outcomes Research Initiative (CORI) database.METHODS:During the study period, the CORI database received endoscopic reports from a network of 76 community, university, and Veteran Administration Health Care System (VAHCS)/military practice sites. All adult patients who underwent an upper endoscopy for NCCP only or GERD-related symptoms only were identified. Demographic characteristics and prevalence of endoscopic findings were compared between the two groups.RESULTS:A total of 3,688 consecutive patients undergoing an upper endoscopy for NCCP and 32,981 for GERD were identified. Normal upper endoscopy was noted in 44.1% of NCCP patients versus 38.8% of those with GERD (P < 0.0001). Of the NCCP group, 28.6% had a hiatal hernia (HH), 19.4% erosive esophagitis (EE), 4.4% Barretts esophagus (BE), and 3.6% stricture/stenosis. However, HH, EE, and BE were significantly more common in the GERD group as compared with the NCCP group (44.8%, 27.8%, and 9.1%, respectively, P < 0.0001). In univariate analysis of patients with NCCP, male gender was a risk factor for BE (OR 1.86, 95% CI 1.35–2.55, P = 0.0001) and being nonwhite was protective (OR 0.43, 95% CI 0.22–0.86, P = 0.02). In this group, male gender was also a risk factor for EE (OR 1.31, 95% CI 1.11–1.54, P = 0.001) and age ≥65 yr was protective (OR 0.73, 95% CI 0.6–0.89, P = 0.002). The NCCP group had a significantly higher prevalence of peptic ulcer in the upper gastrointestinal tract as compared with the GERD group (2.0% vs 1.5%, P = 0.01).CONCLUSIONS:In this endoscopic prevalence study, most of the endoscopic findings in NCCP were GERD related, but less common as compared with GERD patients.

Non‐cardiac chest pain: an update

Abstract  Non‐cardiac chest pain (NCCP) is very common, affecting up to a quarter of the USA adult population. Recent studies have shown that the disorder has a profound impact on patients quality of life and is associated with marked increase in utilization of healthcare resources. Non‐cardiac chest pain is a heterogeneous disorder with gastrointestinal and non‐gastrointestinal causes. After excluding a cardiac cause, most NCCP patients are treated by cardiologists or primary care physicians and only the minority are referred to a gastroenterologist for further work‐up. Gastro‐oesophageal reflux disease (GORD) is the most common cause for NCCP. The role of oesophageal dysmotility in NCCP has been discounted in recent years. However, visceral hyperalgesia has been shown to play an important role in symptom generation of non‐GORD‐related NCCP. The main therapeutic interventions in GORD‐related NCCP patients are potent antireflux modalities and pain modulators in those with non‐GORD‐related NCCP.

Comparison of clinical characteristics of patients with gastroesophageal reflux disease who failed proton pump inhibitor therapy versus those who fully responded.

Background/Aims Refractory gastroesophageal reflux disease (GERD) is very common, affecting up to 40% of the patients receiving proton pump inhibitor (PPI) therapy. However, there is not much information about the clinical characteristics of these patients. The aim of the study is to compare the clinical characteristics of PPI responders vs non-responders. Methods Consecutive GERD patients receiving PPI once or twice daily were evaluated by a questionnaire and a personal interview regarding their demographics, habits, clinical characteristics and endoscopic findings. The patients were divided into 3 groups: Patients who fully responded to PPI once daily (Group A, n = 111), patients who failed PPI once daily (Group B, n = 78) and patients who failed PPI twice daily (Group C, n = 56). Results A total of 245 patients (59.3% females, 52 ± 17.2 years of age) were included in this study. Cross-group differences (A vs B vs C) were detected for hiatal hernia (33% vs 51% vs 52%, P = 0.011); erosive esophagitis (19% vs 51% vs 30%, P < 0.0001); cough (24% vs 44% vs 43%, P = 0.007); sleep disturbances (19% vs 30% vs 38%, P = 0.033); chest symptoms (21% vs 35% vs 41%, P = 0.010); Helicobacter pylori status (25% vs 33% vs 48%, P < 0.0001), disease duration (1.6 ± 0.8 vs 1.9 ± 1.0 vs 2.0 ± 1.1 years, P = 0.007), performed lifestyle interventions (68.5% vs 46.7% vs 69.6%, P = 0.043) and compliance (84% vs 55% vs 46%, P < 0.0001). Conclusions PPI failure (either once or twice daily) appears to be significantly associated with atypical GERD symptoms, disease duration and severity, H. pylori status, obesity, performed lifestyle interventions and compliance as compared with PPI responders.

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.

Clinical trial: the effect of Johrei on symptoms of patients with functional chest pain.

Background  Patients with functional chest pain (FCP) represent a therapeutic challenge for practising physicians.

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.