Summary
Background
The prevalence of duodenogastroesophageal reflux (DGER) and its effect on symptoms and oesophageal lesions in gastroesophageal reflux disease (GERD) is unclear.
Aims
To conduct a ...systematic review to determine the prevalence of DGER among patients with GERD, the effect of DGER on symptoms and oesophageal lesions, and the treatment of DGER.
Methods
We searched Pubmed and MEDLINE for full text, English language articles until October 2020 that evaluated DGER prevalence among patients with GERD, the effect of DGER on symptoms and oesophageal lesions, and the treatment of DGER.
Results
We identified 3891 reports and included 35 which analysed DGER prevalence in GERD, 15 which evaluated its effect in non‐erosive reflux disease (NERD), 17 on erosive oesophagitis, 23 in Barrett's, and 13 which evaluated the treatment of DGER. The prevalence of DGER, when evaluated by Bilitec, among all GERD patients ranged from 10% to 97%, in NERD 10%‐63%, in erosive oesophagitis 22%‐80% and in Barrett's 50%‐100%. There were no differences in the presence or degree of DGER among patients who were asymptomatic or symptomatic on proton pump inhibitors (PPI). The most commonly evaluated treatments for DGER were PPIs and DGER reduced post‐PPI therapy in all studies.
Conclusions
The prevalence of DGER increased with more advanced oesophageal lesions and did not explain persisting symptoms among patients taking PPI therapy. PPIs appear to be effective in the treatment of DGER. DGER remains an important consideration in patients with GERD and future therapies deserve more study.
Prevalence of duodenogastroesophageal (biliary) reflux in oesophageal lesions.
Hip fractures represent an increasing public health burden with a simple fall to the floor as the most common cause. Because nursing home residents are particularly at risk, nursing homes should ...implement a broad range of fall prevention strategies. However, not all fall incidents can be avoided and external hip protectors may contribute to prevent hip fractures. A major problem in studying the effectiveness of hip protectors is residents’ poor adherence. In nursing homes, adherence is dependent not only on the resident, but also on staff knowledge of and attitudes about hip protectors.
To describe (1) attitudes of day versus night shift caregivers towards the use of a soft hip protector, (2) residents’ adherence about the use of such protectors, and (3) differences in characteristics between adherent and non-adherent residents.
Survey and observational study.
Nursing home.
: Survey of care staff (n=37) in a nursing home after 8 months of continued application of a soft hip protector policy in residents (n=68). Adherence to wearing the hip protector, measured by weekly unannounced, randomly determined checks during day and night in the 8 months after the start of the study.
Overall, 85% agreed to wear a hip protector. At 8 months, only 29% was still wearing their hip protector; with significant differences between day and night shifts. Although virtually all caregivers (97%) considered a hip protector policy in residential care as feasible, the attitude towards hip protectors was found to be significantly different between day and night caregivers. Pain and discomfort, patient insight in the usefulness of these devices, interference with incontinence materials, and the overall resident mix and care acuity were reported as major barriers.
Implementing a hip protector policy for injury prevention in long-term care is not an issue of whether or not to use the devices. Rather, it is a continued clinical nursing decision process about when and when not, by whom and by whom not, why and why not, for how long, and to what clinical benefit – considering both the needs of the individual resident and the feasibility of such a policy in the context of resident mix and nursing staff.
Summary
Background
Proton pump inhibitors (PPI) have no effect on non‐acid reflux events which can continue to provoke gastro‐oesophageal reflux disease (GERD) symptoms. Baclofen, a γ‐aminobutyric ...acid agonist, can decrease non‐acid reflux but its symptomatic benefit in refractory GERD symptoms is understudied.
Aims
To assess the efficacy of baclofen 10 mg t.i.d. vs placebo as add‐on therapy in PPI‐refractory GERD symptoms, in a randomised, double‐blind, placebo‐controlled study.
Methods
Patients with persisting typical GERD symptoms on b.i.d. PPI therapy were randomised to 4 weeks of baclofen 10 mg or placebo t.i.d. Before and after treatment, patients underwent 24 h impedance‐pH monitoring on‐PPI. Throughout the study, patients filled out ReQuest diaries. Data were analysed using mixed models.
Results
About 60 patients were included (age 47.5 years range 19–73, 41f/19 m), 31 patients were randomised to baclofen. One patient withdrew consent and five in the baclofen group stopped treatment due to side effects. There was a trend towards a better response for general wellbeing in the baclofen‐treated group compared to placebo (p = 0.06). When subdividing patients according to symptom association probability (SAP), only the SAP+ (n = 25) group improved significantly with baclofen (pcorr = 0.02), and worsened with placebo (pcorr = 0.008). The total number of reflux events decreased over time (p = 0.01), mainly due to the baclofen condition (pcorr = 0.1). The number of reflux events with a high proximal extent dropped significantly after baclofen (pcorr = 0.009), but not placebo.
Conclusion
Baclofen decreases several reflux parameters in PPI refractory GERD symptoms, but pH‐impedance monitoring is necessary before treatment as only SAP+ patients experience clinical benefit after 4 weeks.
Baclofen add‐on for refractory GERD symptoms.
Background
The Chicago classification primarily utilizes ten 5 mL liquid swallows in a supine position as the standard high‐resolution esophageal manometry (HRM) protocol. HRM can be performed with ...varying volumes and consistencies and in an upright position. We aimed to determine the impact on HRM results by (1) position, (2) swallows of differing volume and consistency, and (3) perception of bolus passage.
Methods
HRM was performed in healthy volunteers (HV) with the following protocol of swallows: liquids 10 × 5 mL, 5 × 10 mL, and 3 × 10 mL multiple rapid swallows; applesauce 5 × 5 mL and 5 × 10 mL; and bread 5 × 2 × 2 cm and 5 × 4 × 4cm. HV rated difficulty of each swallow on a 5‐point Likert scale. All HVs performed the protocol in supine position first and then in “semi‐upright” (sitting 70 degrees in a bed) and “upright” (sitting in a chair) in a randomized order.
Key Results
Thirty‐seven HVs, median age 27 years, 64% female completed this study. Median distal contractile integral (DCI) and integrated relaxation pressure 4 s (IRP4) of 5 mL liquid swallows significantly differed (all p < 0.01) between position performed. Large volume swallows resulted in higher DCI and lower IRP4. IRP4 results were significantly increased for 2 × 2 cm pieces of bread compared to 5 mL water swallows. DCI results were higher for 2 × 2 cm pieces of bread compared to 5 mL water swallows. Distal latency was shorter in more upright positions. Among this cohort of HV, perceived difficulty of bolus passage was more likely to occur with solid boluses.
Conclusions and Inferences
The volume and consistency of a swallow and the position it is performed in, significantly alter HRM metrics. Interpretation of HRM studies should incorporate different normative values which are specific to the position and bolus type.
Our study demonstrates the impact of differing positions (supine, semi‐upright, and upright), types of bolus (water, applesauce, and bread), and size of bolus (5 mL, 10 mL, 2 cm, and 4 cm) on HRM metrics on healthy volunteers.
Background
Administration of a bitter compound can alter the intragastric pressure (IGP) after a meal. Additionally, a negative correlation between IGP and the number of transient lower esophageal ...sphincter relaxations (TLESRs) has been demonstrated. However, the effect of a bitter tastant on the number of TLESRs and subsequent reflux episodes has never been investigated and it is unclear whether bitter food items should be avoided in gastro‐esophageal reflux disease. We hypothesize that bitter administration in healthy volunteers (HVs) will lead to an increase in the number of TLESRs.
Methods
After an overnight fast, 20 female HVs (36 years 21–63) underwent a high‐resolution impedance manometry (HRiM) measurement. After placement of the HRiM probe, 0.1 ml/kg of a 10 mM denatonium benzoate solution (bitter) or an identical volume of water (placebo) was administered directly into the stomach. The number of TLESRs and reflux episodes was quantified 30 min before and 2 h after consumption of a high caloric meal.
Key Results
There was no significant difference in the number of TLESRs or reflux episodes between the bitter and placebo condition. Additionally, no differences were observed in the nature (gas or liquid) and extent of reflux events. Lower esophageal sphincter pressures dropped significantly in the first postprandial hour to start recovering slowly back to baseline values during the second postprandial hour (p < 0.0001), without any difference between both conditions.
Conclusions & Interferences
Administration of the bitter tastant denatonium benzoate has no influence on the number of TLESRs or reflux episodes.
The number of transient lower esophageal sphincter relaxations was not different between the bitter and placebo condition.
Background
Esophageal hypersensitivity is considered an important pathophysiological mechanism in refractory gastroesophageal reflux disease (GERD) patients. Serotonin (5‐HT) plays an important role ...in the regulation of GI (gastrointestinal) secretion, motility and sensitivity. Previous studies found that altered 5‐HT availability has no clear effects on esophageal/GI sensations. Our aim was therefore to investigate the role of 5‐HT in esophageal sensitivity in healthy volunteers (HV).
Methods
Esophageal sensitivity to thermal, mechanical, electrical, and chemical stimuli was assessed in 3 different placebo‐controlled studies. In the first study, the effect of citalopram (40 mg; 5‐HT reuptake inhibitor; intravenous) was investigated (n = 14). In the second study, the effect of buspirone (20 mg; 5HT1A agonist; oral) was investigated (n = 10). In the third study, acute tryptophan depletion (ATD) was used to decrease 5‐HT levels to investigate the effect of reduced 5‐HT availability on esophageal sensitivity (n = 15).
Key Results
No difference was observed in esophageal sensitivity after the administration of citalopram or buspirone (all p > 0.06). In contrast, pain perception threshold to chemical stimulation was increased after ATD (p = 0.017, Cohen's d+ = 0.67). No effect was found on the first perception or pain tolerance threshold. ATD had no influence on esophageal sensitivity to thermal, mechanical, and electrical stimulation compared with placebo.
Conclusions and Inferences
ATD, which induces 5‐HT depletion, significantly decreased pain perception threshold during chemical stimulation, without affecting sensitivity to mechanical, thermal, or electrical stimulation. These findings confirm the involvement of 5‐HT in the control of esophageal acid sensitivity, but identifying the receptors involved requires more ligands and studies.
Results of esophageal chemical stimulation after ATD or in the control condition. A significant decrease in PPT was seen after ATD compared to control. ATD, which induces 5‐HT depletion, significantly decreased pain perception threshold during chemical stimulation, without affecting sensitivity to mechanical, thermal or electrical stimulation. These findings confirm involvement of 5‐HT in the control of esophageal acid sensitivity, but identifying the receptors involved requires more ligands and studies. ATD, acute tryptophan depletion; PPT, pain perception threshold; PTT, pain tolerance threshold. *p < 0.05, corrected for multiple testing.
Background
Chronic opioid use can induce esophageal dysfunction with symptoms resembling achalasia and a manometric pattern of esophagogastric junction—outflow obstruction (EGJ‐OO). However, the ...effect of opioids in acute setting on pharyngeal function and esophageal body contractility has not been investigated.
Methods
After positioning the high‐resolution impedance manometry (HRiM) catheter, codeine (60 mg) or placebo (glucose syrup) was infused intragastrically. Forty‐five minutes post‐infusion, participants received liquid, semi‐solid, and solid boluses to assess esophageal and pharyngeal function. HRiM analysis was performed adhering to the Chicago classification v3.0. (CC v3.0). Pressure flow analysis (PFA) for the esophageal body and the pharynx was performed using the SwallowGateway™ online platform.
Key Results
Nineteen healthy volunteers (HV) 5 male; age 38.3 were included. After codeine administration, higher integrated relaxation pressure 4 s values resulted in significantly reduced deglutitive EGJ relaxation and distal latency was significantly shorter. Distal contractility was similar in both conditions. Bolus flow resistance at the EGJ and distention pressures increased significantly after codeine infusion. Based on CC v3.0, acute infusion of codeine induced EGJ‐OO in six HV (p = 0.0003 vs. placebo). Codeine administration induced no significant alterations in any of the pharyngeal PFA metrics.
Conclusions & Inferences
In HV, acute administration of codeine increased bolus resistance at the EGJ secondary to induced incomplete EGJ relaxation leading to major motility disorders in a subset of subjects including EGJ‐OO. However, an acute single dose of codeine did not affect motility or bolus flow in pharynx and UES. ClinicalTrials.gov number, NCT03784105.
In HV, acute administration of codeine increased bolus resistance at the EGJ secondary to induced incomplete EGJ relaxation leading to major motility disorders in a subset of subjects including EGJ‐OO. A) Change (in absolute numbers) for esophageal motility disorders assessed by the Chicago classification v3.0 before and after codeine administration. B) HRiM read‐out from one healthy volunteer who developed an EGJ‐OO after acute codeine administration. 1) After placebo administration: IRP4 = 12 mmHg; DCI = 1473 mmHg*cm*s; DL = 7.4 s: normal 2) After one single maximum dose of codeine administration: IRP4 = 30 mmHg; DCI = 2006 mmHg*cm*s; DL = 7.1 s: EGJ‐OO (major motility disorder). Abbreviations: HRiM= high resolution impedance manometry; EGJ‐OO= esophagogastric junction – outflow obstruction; IRP4= integrated relaxation pressure 4 seconds; DCI= distal contractile integral; DL= distal latency.
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