Background
Acid exposure time (AET) is considered the most useful parameter to predict response of reflux‐related heartburn to medical or surgical treatment. However, recent studies showed high rates ...of heartburn response to proton pump inhibitor (PPI) therapy in patients with normal AET.
We aimed to compare the efficacy of postreflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) with AET in linking PPI‐responsive heartburn to reflux.
Methods
Off‐therapy impedance‐pH tracings from 425 patients, 317 with PPI‐responsive and 108 with PPI‐refractory heartburn were blindly re‐analyzed. Demographic and endoscopic characteristics, conventional impedance‐pH variables, PSPW index, and MNBI were assessed with multivariate logistic regression to identify factors independently associated with PPI responsiveness. Prediction models were developed to assess the strength of reflux linkage with factors independently associated with PPI responsiveness by calculating the area under the curve (AUC) at receiver‐operating‐characteristic (ROC) analysis.
Key Results
At multivariate logistic regression analysis, AET, MNBI, and PSPW index were the only factors independently associated with PPI responsiveness, abnormal values found in 60%, 76%, and 92% of PPI‐responsive cases (P<.017). At ROC analysis, PSPW index (AUC:.794, P=.002) and MNBI (AUC: 0.742, P=.003), both separately and combined (AUC: 0.811, P<.001) linked reflux with PPI‐responsiveness better than AET (AUC: 0.687).
Conclusions & Inferences
AET, PSPW index, and MNBI are independently associated with PPI‐responsive heartburn. PSPW index and MNBI can link PPI‐responsive heartburn to reflux better than AET and should become part of the standard analysis of impedance‐pH tracings.
The diagnostic sensitivity of acid exposure time (AET) is limited. Postreflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) can increase the diagnostic yield of impedance‐pH monitoring. AET, PSPW index, and MNBI were the only variables independently associated with heartburn response to PPIs. PSPW index and MNBI were significantly more efficient than AET in linking PPI‐responsive heartburn with reflux. Routine assessment of impedance‐pH tracings should include calculation of PSPW index and MNBI in order to increase our ability to establish a direct relationship between PPI‐responsive heartburn and reflux.
Inflammatory bowel diseases (IBD) are chronic relapsing disorders that have a negative impact on quality of life. They can be highly disabling and have been associated with sleep disturbance. The aim ...of our study was to evaluate the sleep quality of a large cohort of IBD patients to identify possible associated cofactors. We prospectively recruited consecutive patients attending the IBD Unit of "Azienda Ospedaliera" of Padua from November 2018 to May 2019 and collected demographics and clinical characteristics. The patients completed the Pittsburgh Sleep Quality Index (PSQI), the IBD questionnaire (IBDQ), the IBD-Disability Index (IBD-DI) questionnaire, and the Hospital Anxiety and Depression Scale (9-HADS). A multivariate regression model was applied to assess independent risk factors of sleep disturbance among IBD-related variables, disability, quality of life, anxiety, and depression. We investigated the sleep quality of 166 patients with IBD, finding 67.5% of them suffering from sleep disturbance. In particular, low quality of life, presence of disability and extraintestinal manifestations were identified as independent risk factors of sleep disturbance. We discovered that all depressed patients were also affected by sleep disturbance, while we found no difference in sleep disturbance between patients with or without anxiety state. However, a positive correlation was reported between both anxiety and depression scores and PSQI score (Spearman correlation: r = 0.31 and r = 0.38 respectively). Our study showed that sleep quality is not directly associated with an active or inactive IBD state or with the ongoing treatment, but it is mostly correlated with the patients' mood state, disability, and quality of life. Gastroenterologists and psychologists should join forces during clinical outpatients' visits to evaluate emotional states for a better IBD management.
Background
An international group of experts evaluated and revised recommendations for ambulatory reflux monitoring for the diagnosis of gastro‐esophageal reflux disease (GERD).
Methods
Literature ...search was focused on indications and technical recommendations for GERD testing and phenotypes definitions. Statements were proposed and discussed during several structured meetings.
Key Results
Reflux testing should be performed after cessation of acid suppressive medication in patients with a low likelihood of GERD. In this setting, testing can be either catheter‐based or wireless pH‐monitoring or pH‐impedance monitoring. In patients with a high probability of GERD (esophagitis grade C and D, histology proven Barrett's mucosa >1 cm, peptic stricture, previous positive pH monitoring) and persistent symptoms, pH‐impedance monitoring should be performed on treatment. Recommendations are provided for data acquisition and analysis. Esophageal acid exposure is considered as pathological if acid exposure time (AET) is greater than 6% on pH testing. Number of reflux episodes and baseline impedance are exploratory metrics that may complement AET. Positive symptom reflux association is defined as symptom index (SI) >50% or symptom association probability (SAP) >95%. A positive symptom‐reflux association in the absence of pathological AET defines hypersensitivity to reflux.
Conclusions and Inferences
The consensus group determined that grade C or D esophagitis, peptic stricture, histology proven Barrett's mucosa >1 cm, and esophageal acid exposure greater >6% are sufficient to define pathological GERD. Further testing should be considered when none of these criteria are fulfilled.
The consensus group proposes to define pathological GERD as at least one of the following criteria: Grade C or D esophagitis, peptic stricture, Barrett's mucosa >1 cm and esophageal acid exposure >6%. Number of reflux episodes and baseline impedance should be considered as exploratory tools for further research.
Background
On‐therapy impedance‐pH monitoring in proton pump inhibitor (PPI)‐refractory gastroesophageal reflux disease (GERD) yielded conflicting results. We aimed to assess the diagnostic value of ...postreflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) in PPI‐refractory heartburn.
Methods
On‐therapy impedance‐pH tracings from 189 consecutive patients with PPI‐refractory heartburn were blindly reviewed. Patients were subdivided into refractory reflux esophagitis (RRE), healed reflux esophagitis (HRE), non‐erosive reflux disease (NERD), and functional heartburn (FH) according to endoscopic and conventional impedance‐pH findings. The diagnostic accuracy of PSPW index and MNBI in separating NERD from FH was assessed with receiver‐operating‐characteristic (ROC) analysis. Objectively documented persistent reflux remission at 3‐year follow‐up in 53 patients who underwent laparoscopic fundoplication served to evaluate PSPW index and MNBI as independent predictors of PPI‐refractory GERD confirmed by positive surgical outcome.
Key Results
Median PSPW index and MNBI values were significantly lower in 39 RRE (16%; 1145 Ω) than in 41 HRE (25%; 1741 Ω) and in 68 NERD (29%; 2374 Ω) patients, and in all three GERD subgroups compared to 41 FH cases (67%; 3488 Ω) (P<.008). At ROC analysis, comparing NERD to FH the area under the curve was 0.886 with PSPW index and 0.677 with MNBI (P=.005). PSPW index was an independent predictor of PPI‐refractory GERD (odds ratio 0.6983, P=.012).
Conclusions & Inferences
At on‐therapy impedance‐pH monitoring, PSPW index and MNBI efficiently distinguish PPI‐refractory NERD from FH. The PSPW index represents an independent predictor of PPI‐refractory GERD.
On‐therapy impedance‐pH monitoring establishes the relationship between PPI‐refractory heartburn and reflux. Post‐reflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) were highly efficient in distinguishing PPI‐refractory non‐erosive reflux disease (NERD) from functional heartburn (FH) and refractory reflux esophagitis (RRE) from healed reflux esophagitis (HRE). Abnormal PSPW index and MNBI characterize reflux‐related PPI‐refractory heartburn.
Background
Recently, it has been suggested that low esophageal basal impedance may reflect impaired mucosal integrity and increased acid sensitivity. We aimed to compare baseline impedance levels in ...patients with heartburn and pathophysiological characteristics related to functional heartburn (FH) divided into two groups on the basis of symptom relief after proton pump inhibitors (PPIs).
Methods
Patients with heartburn and negative endoscopy were treated with esomeprazole or pantoprazole 40 mg daily for 8 weeks. According to MII‐pH (off therapy) analysis, patients with normal acid exposure time (AET), normal reflux number, and lack of association between symptoms and refluxes were selected; of whom 30 patients with a symptom relief higher than 50% after PPIs composed Group A, and 30 patients, matched for sex and age, without symptom relief composed Group B. A group of 20 healthy volunteers (HVs) was enrolled. For each patient and HV, we evaluated the baseline impedance levels at channel 3, during the overnight rest, at three different times.
Key Results
Group A (vs Group B) showed an increase in the following parameters: mean AET (1.4 ± 0.8% vs 0.5 ± 0.6%), mean reflux number (30.4 ± 8.7 vs 24 ± 6.9), proximal reflux number (11.1 ± 5.2 vs 8.2 ± 3.6), acid reflux number (17.9 ± 6.1 vs 10.7 ± 6.9). Baseline impedance levels were lower in Group A than in Group B and in HVs (p < 0.001).
Conclusions & Inferences
Evaluating baseline impedance levels in patients with heartburn and normal AET could achieve a better understanding of pathophysiology in reflux disease patients, and could improve the distinction between FH and hypersensitive esophagus.
SUMMARY
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 Barrett's 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.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Aliment Pharmacol Ther 2011; 34: 476–486
Summary
Background Limited data are available regarding the frequency of oesophageal motility and bolus transit abnormalities in subgroups of patients with ...gastro‐oesophageal reflux disease (GERD).
Aim To assess oesophageal motility and bolus transit in endoscopically defined GERD subgroups.
Methods Patients (N = 755) with typical reflux symptoms underwent upper endoscopy, conventional or impedance oesophageal manometry and/or impedance‐pH testing. They were divided into: erosive oesophagitis (EO; N = 340), Barrett Oesophagus (BO; N = 106), non‐erosive reflux disease (NERD; endoscopy−, abnormal pH and/or SAP/SI+; N = 239) and functional heartburn (FH; endoscopy−, normal pH and SAP/SI−; N = 70). Manometric patterns and bolus transit were defined according to previously published criteria.
Results Increasing GERD severity was associated with decreased lower oesophageal sphincter resting pressure (P < 0.05) and distal oesophageal amplitude (P < 0.01), higher prevalence of hiatal hernia (P < 0.01) and increased prevalence of ineffective oesophageal motility (P < 0.01). Patients with EO and BO had a significantly lower percentage of complete bolus transit compared with NERD and FH (P < 0.01). Overall, abnormal bolus transit (ABT) for liquid swallows was found in 12% of FH, 20% of NERD, 54% of EO and 56% of BO (P < 0.01). Combined impedance‐manometry showed abnormal oesophageal function in 4% of FH, 4% of NERD, 22% of EO and 21% of BO patients with normal oesophageal manometry.
Conclusions Oesophageal motility abnormalities increase in parallel with the severity of GERD from NERD to EO and BO. Bolus transit abnormalities in severe reflux disease underscore the importance of impaired oesophageal function in the development of mucosal injury.
Functional dyspepsia and non-erosive reflux disease (NERD) are prevalent gastrointestinal conditions with accumulating evidence regarding an overlap between the two. Still, patients with NERD ...represent a very heterogeneous group and limited data on dyspeptic symptoms in various subgroups of NERD are available.
To evaluate the prevalence of dyspeptic symptoms in patients with NERD subclassified by using 24 h impedance-pH monitoring (MII-pH).
Patients with typical reflux symptoms and normal endoscopy underwent impedance-pH monitoring off proton pump inhibitor treatment. Oesophageal acid exposure time (AET), type of acid and non-acid reflux episodes, and symptom association probability (SAP) were calculated. A validated dyspepsia questionnaire was used to quantify dyspeptic symptoms prior to reflux monitoring.
Of 200 patients with NERD (105 female; median age, 48 years), 81 (41%) had an abnormal oesophageal AET (NERD pH-POS), 65 (32%) had normal oesophageal AET and positive SAP for acid and/or non-acid reflux (hypersensitive oesophagus), and 54 (27%) had normal oesophageal AET and negative SAP (functional heartburn). Patients with functional heartburn had more frequent (p<0.01) postprandial fullness, bloating, early satiety and nausea compared to patients with NERD pH-POS and hypersensitive oesophagus.
The increased prevalence of dyspeptic symptoms in patients with functional heartburn reinforces the concept that functional gastrointestinal disorders extend beyond the boundaries suggested by the anatomical location of symptoms. This should be regarded as a further argument to test patients with symptoms of gastro-oesophageal reflux disease in order to separate patients with functional heartburn from patients with NERD in whom symptoms are associated with gastro-oesophageal reflux.
In Italy, the spread of the COVID-19 pandemic has stressed the entire healthcare system and required a huge re-organization of many Divisions, including those of Gastroenterology.
to assess the ...impact of COVID-19 pandemic on Gastroenterology Divisions across Italy.
All members of the Italian Society of Gastroenterology (SIGE) were invited to answer a web-based survey.
Data of 121 hospitals from all 20 Italian regions were analyzed. Overall, 10.7% Gastroenterology Divisions have been converted to Covid Units. Outpatients consultations, endoscopic and ultrasound procedures were limited to urgencies and oncology indications in 85.1%, 96.2% and 72.2% of Units, respectively, and 46.7% of them suspended the screening for colorectal cancer.
Moreover, 72.2% of the staff received a training for use of personal protective equipment, although 45.5% did not have sufficient devices for adequate replacement. Overall, 132 healthcare workers in 41 Gastroenterology Divisions were found to be infected.
This is the first study to evaluate, at a country level, the impact of COVID-19 outbreak on Gastroenterology Divisions. Substantial changes of practice and reduction of procedures have been recorded in the entire country. The long-term impact of such modifications is difficult to estimate but potentially very risky for many digestive diseases.
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