See all Gastroenterology and Hepatology locations. During an upper endoscopy: You receive an anesthetic to help relax your gag reflex. You may also receive pain medication and a sedative. You lie on your left side, referred to as the left lateral position. Your doctor inserts the endoscope through your mouth and pharynx into the esophagus.
The endoscope transmits an image of the esophagus, stomach and duodenum to a monitor that your physician is watching. Reflux Testing Wireless pH testing allows your doctor to evaluate your reflux activity over a hour period while you continue your normal activities.
The two methods are: Wireless pH Testing Wireless pH testing allows your doctor to evaluate your reflux activity over a hour period while you continue your normal activities. To perform wireless pH testing: Your doctor performs an endoscopy and places a small chip in your lower esophagus The chip records the acid level in your esophagus for 48 hours.
The chip transmits your acid level to a wireless recording device that you wear around your belt. The data from the recording device can gauge your reflux severity. During pH impedance: Your doctor places a thin, flexible catheter with an acid-sensitive tip through your nose into your esophagus.
The catheter is placed in separate recording spots to evaluate the flow of liquid from your stomach into your esophagus. The catheter stays in your nose for a period of 24 hours. Your doctor is able to evaluate whether you have GERD, the severity of your reflux, the presence of non-acid reflux and the correlation between your reflux and symptoms. This procedure helps in the design of a course of treatment for you.
During an esophageal manometry: Your doctor places a pressure-sensitive catheter into the esophagus. This may be performed right before esophageal pH impedance studies, as it determines where your doctor should place the catheter. The catheter evaluates the strength and coordination of your muscle contractions. It also tests the strength and relaxation function of the lower esophageal sphincter. Indeed, GERD prevalence ranged from Regarding GERD incidence, the rate was assessed between 0.
Particularly, data are still lacking from important countries such as Japan, Brazil, India, Russia and from an entire continent such as Africa. In this regard, a study by Wall et al. As demonstrated in several studies, only a minority of BE patients develop EAC with an estimated risk of 0. In keeping with the former hypothesis patients tend to remain in the same class during the whole life, whereas they can pass from one class to another according to the spectrum hypothesis.
Such a different vision has a relevant impact on our therapeutic approach and surveillance programs. In fact, a categorial disease requires focus on symptom control rather than on endoscopic surveillance and vice versa.
Unfortunately, the analysis of medical literature on this point does not help us in favoring one or the other hypothesis. In fact, the majority of published studies are retrospective, only small numbers of patients are assessed, the adopted medical therapies are heterogeneous and this makes difficult to interpret their influence on the disease outcome and, finally, endoscopic examinations aimed at verifying the evolution of the different clinical conditions and the fluctuation from one class to another are often done with different intervals and without uniform methods of classification.
So, it is not surprising that some Authors sustain that progression from endoscopy-negative reflux disease through ERD to BE is rarely observed and esophageal physiology and mucosal biology is not shared across the all forms of the disease spectrum, while others are firmly convinced that NERD represents mild illness, increasing grades of endoscopic esophagitis are the reflection of a progressively worsening disease and BE is the most severe form of GERD and the transition from one severity class to another as a continuum still holds true.
Table 1 reports the most relevant studies on GERD natural history published in the last 15 years. On the other hand, according to a systematic review by Fullard et al. Cohort studies of the natural history of reflux disease published between and In , a large multicenter prospective study named pro-GERD assessed the progression versus regression of the various GERD forms over 2 years in a cohort of almost patients under routine clinical care in Germany, Austria and Switzerland.
At the discretion of their physician, these patients were treated with PPIs, H2 antagonists and antacids on a regular or on-demand basis, and underwent endoscopy with biopsy at the end of the 2-year follow-up. Among patients with ERD at baseline, In detail, the incidence of histologically-confirmed BE was 0.
Overall, this study showed a relevant rate of changes between GERD categories, thus supporting the spectrum disease hypothesis. In the same year, a study by Sontag et al. Thus, they concluded that the overwhelming majority of patients with disturbing GERD symptoms will never develop complications when treatment is symptom-driven, even after a decade of antireflux therapy interruption.
However, the length of the study was such that patients enrolled pertained to both pre- and post-PPI era, making the results heterogeneous and difficult to interpret.
Kawanishi et al. In keeping with these findings, Pace et al. In keeping with these findings, the Authors concluded that the majority of patients with GERD do not appear to develop BE in the short period, when this metaplastic condition is not present on index endoscopy. In contrast, in patients with ERD a progression to BE was clearly demonstrated and, of note, patients who progressed to a more severe disease had prior demonstration of mild degree esophagitis Grade A and B. Falkenback and coworkers in reported on a small cohort of patients referred for reflux symptoms and objectively diagnosed with pathological reflux at pH-testing, between and At mean follow-up of Interestingly, patients with esophagitis were less likely to have a positive Helicobacter pylori test than NERD.
Thus, the Authors concluded that after 20 years a considerable part of the cohort still experienced GERD symptoms and showed endoscopic progression. Furthermore, they suggested that H. In , Malfertheiner et al. Most patients remained stable or showed improvement in their esophagitis, indicating that current therapeutic management is usually adequate.
Patients who remained unhealed after initial treatment were predisposed to GERD progression. Recently, a large longitudinal year follow-up study included patients who had typical GERD symptoms at baseline, that was heartburn or regurgitation at a frequency of more than once a week, and collected as part of an investigation recruiting a population for H. The Authors evaluated the behavior of these symptoms at 10 years and observed that they persisted in one-third of individuals Among the individuals who were asymptomatic at study entry, 7.
While no predictors of persistent GERD symptoms were identified, the new-onset GERD symptoms were associated with poor quality of life or presence of irritable bowel syndrome at baseline and higher body mass index at 10 years. At last, a retrospective study evaluating the natural history of 96 asymptomatic ERD patients showed that most of them did not experience GERD symptoms and exhibited unchanged endoscopic findings Of particular importance is the fact that subjects having taken antisecretory drugs, such as PPIs and H2-receptor antagonists, were excluded from the study.
Up to now, data from different studies did not help to definitively understand the natural history of GERD. The evaluated studies are mainly retrospective and different in their methodology, and are confounded by a range of factors that make comment on progression rates quite difficult: duration and dosage of PPI treatment, the presence of anti-secretory therapy at the moment of endoscopic evaluation and the overlap between functional gastrointestinal symptoms and GERD diagnosis.
The lack of prospective longitudinal studies regards mainly the period before the widespread availability of powerful antisecretory agents PPIs and it is well known that retrospective analyses are not useful to look consistently at the natural history of a disease and, in particular, GERD.
We don't have information on the results of pathophysiological tests that might have been performed at least once during the clinical history of patients, although they are the only tool which is able to address an adequate therapy in GERD patients. Anyway, the largest number of studies showed that GERD rarely causes serious complications when treatment is symptom-driven; if initial endoscopy excludes BE and EAC, repeated endoscopies are not necessary to document complete healing and to search for cancer, unless alarm symptoms appear.
It is likely that those patients who remain unhealed after initial treatment are predisposed to have GERD progression. They probably need continuous treatment and strict endoscopic surveillance. Strictures and other complications are very rare. However, further studies are necessary with particular regard to data from pathophysiological investigations in order to exclude those patients who are affected by functional disorders and do not pertain anymore to the realm of GERD. Edoardo Savarino, MD, PhD : data collection and ana-lysis, writing of the manuscript, approving final version.
Nicola de Bortoli, MD, PhD : data collection and an-alysis, writing of the manuscript, approving final version. Chiara De Cassan, MD : data collection and an-alysis, approving final version.
Marco Della Coletta, MD : writing of the manus-cript, approving final version. Ottavia Bartolo, MD : data collection and analysis, approving final version. Manuele Furnari, MD : data collection, approving final version. Andrea Ottonello, MD : data collection, approving final version. Elisa Marabotto, MSD : data collection, approving final version. Giorgia Bodini, MD : data collection, approving final version. Vincenzo Savarino, MD : data analysis, writing of the manuscript, approving final version.
Prevalence, clinical spectrum and atypical symptoms of gastro-oesophageal reflux in Argentina: a nationwide population-based study. Aliment Pharmacol Therapeut ; 22 4 : — Google Scholar. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Asan-si, Korea. Am J Gastroenterol ; 4 : — Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota.
Gastroenterology ; 5 : — Prevalence, clinical spectrum and health care utilization of gastro-oesophageal reflux disease in a Chinese population: a population-based study. Aliment Pharmacol Therapeut ; 18 6 : — Kennedy T , Jones R.
The prevalence of gastro-oesophageal reflux symptoms in a UK population and the consultation behaviour of patients with these symptoms.
Aliment Pharmacol Therapeut ; 14 12 : — Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gastro-oesophageal reflux is more prevalent in Western dyspeptics: a prospective comparison of British and South-East Asian patients with dyspepsia. Aliment Pharmacol Therapeut ; 21 12 : — Differences in the risk factors of reflux esophagitis according to age in Korea. Dis Esophagus ; 27 2 : — Overweight is a risk factor for both erosive and non-erosive reflux disease.
Dig Liver Dis ; 43 12 : — 5. Impact of anthropometric measures and serum leptin on severity of gastroesophageal reflux disease. Dis Esophagus ; 28 7 : — 8. Voluntary and controlled weight loss can reduce symptoms and proton pump inhibitor use and dosage in patients with gastroesophageal reflux disease: a comparative study. Dis Esophagus ; 29 2 : — Adherence to a predominantly Mediterranean diet decreases the risk of gastroesophageal reflux disease: a cross-sectional study in a South Eastern European population.
Dis Esophagus Jul Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review.
El-Serag H B. Time trends of gastroesophageal reflux disease: a systematic review. Clin Gastroenterol Hepatol ; 5 1 : 17 — Changes in prevalence, incidence and spontaneous loss of gastro-oesophageal reflux symptoms: a prospective population-based cohort study, the HUNT study.
Gut ; 61 10 : — 7. Functional heartburn has more in common with functional dyspepsia than with non-erosive reflux disease. Gut ; 58 9 : — Characteristics of reflux episodes and symptom association in patients with erosive esophagitis and nonerosive reflux disease: study using combined impedance-pH off therapy. Am J Gastroenterol ; 5 : — High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a Kalixanda study report.
Scand J Gastroenterol ; 40 3 : — Gastro-oesophageal reflux symptoms, oesophagitis and Barrett's oesophagus in the general population: the Loiano-Monghidoro study. Gut ; 57 10 : — 9. The impact of pre-endoscopy proton pump inhibitor use on the classification of non-erosive reflux disease and erosive oesophagitis. Aliment Pharmacol Ther ; 32 10 : — Erosive esophagitis is a risk factor for Barrett's esophagus: a community-based endoscopic follow-up study.
Am J Gastroenterol ; 11 : — Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. Gross's opinion. Increases in risk of Clostridium difficile and pneumonia are also possible concerns in PPI patients. But you don't have to worry about timing with clopidogrel, as it's no longer thought that the blood thinner needs to be taken at a different time of day from a PPI.
You can be on both medications and it's overall felt to be safe. For various reasons, PPIs may not be the complete solution to GERD for some patients, in which case, the next line of treatment is histamine H2-receptor antagonists. Other medications should be reserved for rare cases. For example, metoclopramide can treat severe acid reflux, especially in patients who also have gastroparesis, but a major side effect concern is tardive dyskinesia. Baclofen may be helpful to patients with laryngopharyngeal reflux, but there's no reason to use sucralfate for GERD in nonpregnant patients, he advised.
For patients who are pregnant, it's safe to take PPIs. Surgical therapy, such as laparoscopic fundoplication, can be an option, but perhaps perversely, it works best in patients whose GERD responds to medication. Patients who don't respond to PPIs may not see any improvement in their symptoms from surgery, plus they could develop new issues, including bloating and difficulty swallowing. If the patient expressing interest in surgery to treat acid reflux is obese, you may want to suggest bariatric surgery as a possible alternative.
In a few years, there may be additional surgical treatment options for GERD, but they're still in the experimental stage. But, for most cases, treatment can be much simpler.
Also from ACP, read new content every week from the most highly cited internal medicine journal. Visit Annals. Photo by Kevin Berne The diagnostic process usually begins when a patient presents with symptoms.
0コメント