Sheldon Sloan

Determinants of gastroesophageal junction incompetence : hiatal hernia, lower esophageal sphincter, or both ?

OBJECTIVE To examine the effects of hiatal hernia and lower esophageal sphincter (LES) pressure on the competence of the gastroesophageal junction under conditions of abrupt increases in intra-abdominal pressure. DESIGN Acute experiments. SETTING University-hospital-based gastroenterology practice. PARTICIPANTS Sixteen asymptomatic volunteers and 34 patients with endoscopic findings suggestive of hiatal hernia. INTERVENTION A series of eight provocative maneuvers entailing abrupt changes in intra-abdominal pressure. MEASUREMENTS Five radiographic measurements relevant to the presence and extent of hiatal hernia were made from videotaped barium-swallow examinations. Lower esophageal sphincter pressure was measured immediately before each maneuver. The percentage of maneuvers that resulted in gastroesophageal reflux was calculated as the reflux score. A stepwise regression analysis was then used to model the relation between measured variables of the gastroesophageal junction (manometric and radiographic) with reflux score. RESULTS Patients with hiatal hernia had substantially higher reflux scores and lower LES pressures than either patients without hernias or volunteers. In diminishing order of significance, the terms in the model of susceptibility to reflux were axial length of hernia measured between swallows; LES pressure; and an interaction term in which a progressive increase occurred in the risk for reflux associated with a hypotensive lower esophageal sphincter as hernia size increased. CONCLUSIONS Gastroesophageal junction competence during abrupt increases in intra-abdominal pressure is compromised by both hiatal hernia and low LES pressure. These factors interact with each other to determine susceptibility to reflux.

Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease

OBJECTIVE:Although reflux esophagitis is a multifactorial disease, the relative importance of these pathogenetic factors has not been clearly established. In this study, regression analysis was used to model the major determinants of esophagitis in patients with symptomatic gastroesophageal reflux disease (GERD).METHODS:Sixty-six GERD patients and 16 asymptomatic controls were evaluated. All patients underwent upper endoscopy, esophageal manometry, and 24-h pH monitoring. Esophagrams were performed in 38 of the GERD patients and all controls. Stepwise regression was performed using esophagitis severity as the dependent variable. Logistic regression was performed grouping subjects as controls, nonerosive GERD, or erosive esophagitis.RESULTS:Hiatal hernia size, lower esophageal sphincter pressure, esophageal acid exposure, and number of reflux episodes >5 min significantly correlated with esophagitis severity. Stepwise regression identified hiatal hernia size (p = 0.0001) and lower esophageal sphincter pressure (p = 0.0024) as significant predictors of esophagitis. Logistic regression also identified hiatal hernia size (χ2 = 17.07, p < 0.0001) and lower esophageal sphincter pressure (χ2 = 5.97, p = 0.0146) as significant predictors of erosive esophagitis.CONCLUSION:Esophagitis severity is best predicted by hiatal hernia size and lower esophageal sphincter pressure. Of these, hiatal hernia size is the strongest predictor.

Efficacy of Rabeprazole in the Treatment of Symptomatic Gastroesophageal Reflux Disease

The purpose of this study was to assess the rapidity of symptom relief and 4-week efficacy of rabeprazole 20 mg in patients with moderately severe nonerosive gastroesophageal reflux disease. Data were analyzed from 2 similarly designed, double-blind, placebo-controlled, multicenter, U.S. trials. After a 2-week placebo run-in period, patients (N = 261) were randomized to 4 weeks of rabeprazole 20 mg once daily or placebo. Patients kept symptom diaries and scored symptom severity. Median time to first 24-hour heartburn-free interval was 3.5 days for the rabeprazole group compared with 19.5 days for the placebo group (P ≤ .0002). Complete heartburn relief at week 4 was 32% with rabeprazole and 3.8% with placebo (P ≤ .001). Rabeprazole also significantly improved other GERD-associated symptoms (e.g., regurgitation, belching, early satiety) by week 4 compared with placebo (P ≤ .05). Rabeprazole provides fast and potent relief from heartburn and other symptoms of nonerosive gastroesophageal reflux disease.

Safety and efficacy of delayed release rabeprazole in 1- to 11-month-old infants with symptomatic GERD.

Aim: The efficacy and safety of rabeprazole, a proton pump inhibitor, were studied in infants with gastroesophageal reflux disease (GERD). Methods: Infants ages 1 to 11 months, with symptomatic GERD resistant to conservative therapy and/or previous exposure to acid-suppressive medications, were screened. After scoring >16 on a GERD symptom score (Infant Gastroesophageal Reflux Questionnaire-Revised [I-GERQ]), 344 infants were enrolled in a 1- to 3-week open-label (OL) phase and received rabeprazole 10 mg/day. Following caregiver-rated clinical improvement during the OL phase, patients were randomized to placebo, rabeprazole 5 mg, or rabeprazole 10 mg in the ensuing 5-week double-blind (DB) withdrawal phase. Primary endpoints evaluated from DB baseline to the end of the DB withdrawal phase included frequency of regurgitation, weight-for-age z score, and daily and weekly GERD symptom scores. Results: Overall, 231 (86%) of the 268 randomized infants (placebo: 90; rabeprazole 5 mg: 90; rabeprazole 10 mg: 88) completed the study. Efficacy endpoints were similarly improved during the OL phase in all of the groups, and continued improving during the DB withdrawal phase with no difference between the placebo and combined rabeprazole groups. Mean decrease in frequency of regurgitation (−0.79 vs −1.20 times per day; P = 0.168), in I-GERQ-Revised scores (−3.6 [−25%] vs −3.9 points [−27%]; P = 0.960), in I-GERQ-Daily Diary scores (−1.87 [−19%] vs −1.85 [−19%]; P = 0.968), and increase in weight-for-age z scores (mean [standard deviation]: 0.11 [0.329] vs 0.14 [0.295]; P = 0.440) indicated equal improvement. Equal percentages (47%) reported adverse events in placebo and combined rabeprazole groups, with no new safety signals emerging. Conclusions: In those infants with GERD who improved with rabeprazole during the OL phase, improvements in symptoms and weight were similar in those who continued rabeprazole and those withdrawn to placebo during a 5-week DB phase.

Severity and frequency of regurgitation decreases with rabeprazole (RAB) treatment in endoscopy-negative gastroesophageal reflux disease (GERD)

Purpose: Although numerous studies have shown the efficacy of proton pump inhibitor treatment in relieving heartburn, regurgitation is also a troublesome symptom for patients with GERD. Two clinical trials assessed symptom control, including control of regurgitation, with RAB versus placebo (PBO) in endoscopy-negative GERD patients.

Heartburn frequency can predict the presence of pathologic esophageal reflux in GERD patients without esophagitis during treatment with rabeprazole

Heartburn frequency can predict the presence of pathologic esophageal reflux in GERD patients without esophagitis during treatment with rabeprazole

Fasting gastric pH can predict the likelihood of pathologic esophageal reflux in gerd patients treated with a proton pump inhibitor

Fasting gastric pH can predict the likelihood of pathologic esophageal reflux in gerd patients treated with a proton pump inhibitor

A successful Switch from prednisone to budesonide for neuropsychiatric adverse effects in a patient with ileal Crohn's disease [15]

A successful switch from prednisone to budesonide for neuropsychiatric adverse effects in a patient with ileal Crohns disease

Rabeprazole results in global improvement in symptoms of nonerosive gastroesophageal reflux disease

Rabeprazole results in global improvement in symptoms of nonerosive gastroesophageal reflux disease

Rabeprazole relieves heartburn and associated symptoms in nonerosive gastroesophageal reflux disease

Rabeprazole relieves heartburn and associated symptoms in nonerosive gastroesophageal reflux disease