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Savarino V, Visaggi P, Marabotto E, Bertin L, Pasta A, Calabrese F, Zentilin P, Ghisa M, Ribolsi M, Mari A, Tolone S, de Bortoli N, Savarino EV. Topical Protection of Esophageal Mucosa as a New Treatment of GERD. J Clin Gastroenterol 2025; 59:197-205. [PMID: 39777899 DOI: 10.1097/mcg.0000000000002128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Accepted: 12/08/2024] [Indexed: 01/11/2025]
Abstract
Among the various factors implicated in the pathogenesis of gastroesophageal reflux disease (GERD), visceral hypersensitivity and mucosal resistance have been recently re-evaluated in relation to the increasing phenomenon of proton pump inhibitor failure, particularly in patients with nonerosive reflux disease (NERD). Intensive research has allowed us to understand that noxious substances contained in the refluxate are able to interact with esophageal epithelium and to induce the elicitation of symptoms. The frequent evidence of microscopic esophagitis able to increase the permeability of the mucosa, the proximity of sensory afferent nerve fibers to the esophageal lumen favoring the higher sensitivity to noxious substances and the possible activation of inflammatory pathways interacting with sensory nerve endings are pathophysiological alterations confirming that mucosal resistance is impaired in GERD patients. Accordingly, the reinforcement of protective mechanisms of esophageal mucosa by topical therapies has become a novel treatment target. Alginate, the combination of hyaluronic acid+chondroitin sulphate and Poliprotect have been shown to adhere to esophageal mucosa and to have good protective properties. Several placebo-controlled clinical trials have shown that these compounds, given alone or as add-on therapy for short periods, enable to relieve symptoms and to improve the quality of life in NERD patients. Further studies are needed to confirm the above results and to find new mucosal protectants in order to improve the management of NERD patients.
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Affiliation(s)
- Vincenzo Savarino
- Department of Internal Medicine, Gastroenterology Unit, University of Genoa, Genoa
| | - Pierfrancesco Visaggi
- Department of Translational Research and New Technologies in Medicine and Surgery, Gastroenterology Unit, University of Pisa, Pisa
| | - Elisa Marabotto
- Department of Internal Medicine, Gastroenterology Unit, University of Genoa, Genoa
| | - Luisa Bertin
- Department of Surgery, Oncology and Gastroenterology, University of Padua
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua
| | - Andrea Pasta
- Department of Internal Medicine, Gastroenterology Unit, University of Genoa, Genoa
| | - Francesco Calabrese
- Department of Internal Medicine, Gastroenterology Unit, University of Genoa, Genoa
| | - Patrizia Zentilin
- Department of Internal Medicine, Gastroenterology Unit, University of Genoa, Genoa
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, University of Padua
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua
| | - Mentore Ribolsi
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Roma
| | - Amir Mari
- Department of Gastroenterology, Azrieli Faculty of Medicine, Nazareth EMMS Hospital, Bar Ilan University, Safed, Israel
| | - Salvatore Tolone
- School of Medicine Naples, Università degli Studi della Campania, Naples, Italy
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, Gastroenterology Unit, University of Pisa, Pisa
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua
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Lei WY, Hung JS, Wong MW, Liu TT, Yi CH, Gyawali CP, Chen CL. Effects of capsaicin on esophageal peristalsis in humans using high resolution manometry. Neurogastroenterol Motil 2024; 36:e14942. [PMID: 39385495 DOI: 10.1111/nmo.14942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Revised: 09/25/2024] [Accepted: 09/30/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Capsaicin-containing red pepper sauce suspension augments esophageal contraction amplitude on conventional manometry. This study used high-resolution manometry (HRM) to investigate if capsaicin infusion modulates segmental esophageal smooth muscle peristalsis in healthy adults. METHODS Sixteen healthy volunteers (mean age 37 years, 14 male) underwent HRM for the evaluation of primary peristalsis and secondary peristalsis using slow and rapid air distensions. Both primary and secondary peristalsis were assessed following infusions of capsaicin-containing red pepper sauce and saline. KEY RESULTS Capsaicin infusion significantly increased heartburn symptoms compared to saline infusion (p < 0.001), and significantly decreased threshold volumes of secondary peristalsis during rapid air distensions (p = 0.02). The frequency of secondary peristalsis during rapid air distensions was significantly increased by capsaicin infusion (p = 0.03). Neither capsaicin infusion (p = 0.06) nor saline infusion (p = 0.27) altered threshold volume during slow air distensions. Capsaicin infusion significantly increased distal contractile integral (DCI) of primary peristalsis (p = 0.04), particularly in the proximal smooth muscle segment (p = 0.048). It enhanced secondary peristalsis during rapid air distensions (p = 0.003) but not during slow air distension (p = 0.23). Saline infusion significantly increased DCI of secondary peristalsis during rapid air distension (p = 0.01). CONCLUSIONS AND INFERENCES Augmentation of distension-induced secondary peristalsis can be modulated by activation of capsaicin-sensitive afferents similar to mechanosensitive afferents. Capsaicin-induced augmentation of primary peristalsis isolates to the cholinergic-mediated proximal smooth muscle segment, which warrants study in ineffective esophageal motility to determine therapeutic potential.
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Affiliation(s)
- Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Bonazzi E, Lorenzon G, Maniero D, De Barba C, Bertin L, Barberio B, Salvador R, Valmasoni M, Zingone F, Ghisa M, Savarino EV. The Esophageal Microbiota in Esophageal Health and Disease. GASTROENTEROLOGY INSIGHTS 2024; 15:998-1013. [DOI: 10.3390/gastroent15040069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2025] Open
Abstract
The esophagus, traditionally viewed as a sterile conduit, is now recognized as a dynamic habitat for diverse microbial communities. The emerging evidence suggests that the esophageal microbiota plays an important role in maintaining esophageal health and contributing to disease. The aim of this systematic review was to synthesize the current knowledge on the esophageal microbiota composition, its variation between healthy individuals and those with esophageal diseases, and the potential mechanisms through which these microorganisms influence esophageal pathology. A systematic literature search was conducted using multiple databases, including PubMed, Scopus, and Web of Science, to identify relevant studies published up to July 2024. The inclusion criteria encompassed original research articles that used molecular techniques to characterize the esophageal microbiota in human subjects, comparing healthy individuals with patients affected by esophageal conditions such as gastroesophageal reflux disease (GERD), Barrett’s esophagus, eosinophilic esophagitis, and esophageal cancer. The primary outcomes were the composition and diversity of the esophageal microbiota, and the secondary outcomes included the correlations between microbial profiles and disease states. The esophageal microbiota of healthy individuals was dominated by Gram-positive bacteria, particularly Streptococcus. Conversely, the esophageal microbiota is considerably altered in disease states, with decreased microbial diversity and specific microbial signatures associated with these conditions, which may serve as biomarkers for disease progression and as targets for therapeutic intervention. However, the heterogeneous study designs, populations, and analytical methods underscore the need for standardized approaches in future research. Understanding the esophageal microbiota’s role in health and disease could guide microbiota-based diagnostics and treatments, offering novel avenues for managing esophageal conditions.
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Affiliation(s)
- Erica Bonazzi
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
| | - Greta Lorenzon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
| | - Caterina De Barba
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
| | - Luisa Bertin
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padua, Italy
| | - Brigida Barberio
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padua, Italy
| | - Renato Salvador
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
| | - Michele Valmasoni
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padova, 35128 Padua, Italy
| | - Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padua, Italy
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padua, Italy
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Hung JS, Lei WY, Yi CH, Liu TT, Wong MW, Liang SW, Chen CL. Influence of Menthol Infusion on Esophageal Peristalsis in Patients With Ineffective Esophageal Motility. J Neurogastroenterol Motil 2024; 30:447-452. [PMID: 39397622 PMCID: PMC11474559 DOI: 10.5056/jnm23098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/27/2024] [Indexed: 10/15/2024] Open
Abstract
Background/Aims Activation of the cold receptor, transient receptor potential melastatin 8 (TRPM8) by menthol inhibits esophageal secondary peristalsis in healthy adults. Ineffective esophageal motility (IEM) is common. This study is to evaluate the effects of acute infusion of menthol on esophageal peristalsis in patients with IEM. Methods Twenty patients with IEM (males 11, mean age 36) were studied for esophageal peristalsis using high-resolution manometry. All participant had primary peristalsis performed with 10 water swallows and secondary peristalsis generated with 10 rapid air injections of 20 mL via mid-esophageal infusion port. Two different sessions by randomly performing acute administration of placebo or menthol (3 mM) were used for testing their effects on esophageal peristalsis. Results Menthol infusion had no effects on distal contractile integral (P = 0.471), distal latency (P = 0.58), or complete peristalsis (P = 0.251). Menthol infusion did not change basal lower esophageal sphincter pressure (P = 0.321), esophagogastric junction contractile integral (P = 0.758), or integrated relaxation pressure (P = 0.375) of primary peristalsis, but reduced upper esophageal sphincter pressure (P = 0.037). Infusion of menthol significantly reduced the frequency of secondary peristalsis for air injects of 20 mL (P = 0.002), but did not affect distal contractile integral of secondary peristalsis for air injections of 20 mL. Conclusion This work has suggested that activation of TRPM8 by menthol can attenuate mechanosensitivity of secondary peristalsis in response to rapid air distension regardless of the presence of IEM.
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Affiliation(s)
- Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Marabotto E, Pasta A, Calabrese F, Ribolsi M, Mari A, Savarino V, Savarino EV. The Clinical Spectrum of Gastroesophageal Reflux Disease: Facts and Fictions. Visc Med 2024; 40:242-249. [PMID: 39398395 PMCID: PMC11466451 DOI: 10.1159/000536583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/30/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND This review addresses the intricate spectrum of gastroesophageal reflux disease (GERD), a condition affecting 10-30% of the Western population. GERD is characterized by the backflow of gastric contents into the esophagus, causing typical and atypical symptoms. Its pathophysiology involves various factors such as hiatal hernia, esophageal motor disorders, and dietary triggers. The review explores the complexities of GERD spectrum, including nonerosive reflux disease (NERD), reflux hypersensitivity (RH), and functional heartburn (FH). SUMMARY The diagnostic process for GERD, based on the Lyon Consensus 2.0 criteria, encompasses clinical evaluation, endoscopy, and functional tests, including pH-impedance and wireless-pH monitoring. NERD, a significant subset of GERD, is defined by reflux symptoms and abnormal reflux burden without mucosal damage. RH, classified under functional esophageal disorders by Rome IV criteria, presents with typical esophageal symptoms associated with reflux but lacks of structural, inflammatory, or motor causes. FH is identified by heartburn with normal endoscopy, reflux testing, and esophageal manometry results. The management of RH and FH, focusing on reducing esophageal hypersensitivity, varies from standard GERD treatments. KEY MESSAGES The review emphasizes the necessity of personalized treatment strategies due to the complexity and overlap of GERD subtypes. It highlights the importance of a multidisciplinary approach, involving gastroenterologists, psychologists, and other specialists, to improve patient outcomes and quality of life. The article underscores that understanding the distinctions and overlaps among NERD, RH, and FH is crucial for effective management, and the need for innovative approaches in diagnosis and treatment to address the unique challenges of each subtype.
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Affiliation(s)
- Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Pasta
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Francesco Calabrese
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Amir Mari
- Israel Institute of Technology, Hadera, Israel and Nazareth Hospital EMMS, Nazareth, Israel
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Padua, Italy
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Zhang X, Wang Z, Xu T, Wei L, Liu F, Liu C, Li L, Zhang W, Zhu S. Efficacy of Shugan Hewei formula combined with rabeprazole in refractory gastroesophageal reflux disease: randomized, double-blind, placebo-controlled trial. Eur J Med Res 2024; 29:466. [PMID: 39300586 PMCID: PMC11412052 DOI: 10.1186/s40001-024-02030-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 08/19/2024] [Indexed: 09/22/2024] Open
Abstract
OBJECTIVES To assess the efficacy of the Chinese herbal medication Shugan Hewei formula (SHF) combined with rabeprazole in patients with refractory gastroesophageal reflux disease (rGERD). METHOD A total of 264 participants were randomly assigned to the treatment group (n = 132) receiving SHF granules (20 mg) combined with rabeprazole (10 mg) and the control group (n = 132) receiving placebo SHF granules (20 mg) combined with rabeprazole (20 mg). Both groups undergo 8 weeks of treatment and 2 weeks of follow-up. RESULTS The treatment group showed higher total clinical symptom efficacy and lower total symptom scores compared to the control group. The treatment group was superior to the control group in reducing rGERD major symptom scores, including heartburn, retrosternal pain, regurgitation and belching, and acid regurgitation. Additionally, treatment group (Z = 8.169, P < 0.001) and control group (Z = 9.800, P < 0.001) treatments were all significantly attenuated esophageal inflammation, demonstrating comparable efficacy. Patients with esophagitis grade A decreased from 40.34% to 17.23%, and those with grade B decreased from 11.76% to 3.78% in the treatment group. The results of the SF-36 scale showed that combination therapy was more effective in improving role limitations due to physical health, vitality, general health, total somato-physical health, and psychiatric mental health. CONCLUSION Our study reveals that the combined treatment of SHF with rabeprazole is more efficacious in managing patients with rGERD when contrasted with sole rabeprazole treatment.
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Affiliation(s)
- Xiulian Zhang
- Department of Respiratory, Baoshan Hospital of Shanghai University of Traditional Chinese Medicine, No. 181 , Youyi Road, Baoshan District, Shanghai, 201900, China
| | - Zhongfu Wang
- Department of Respiratory, Baoshan Hospital of Shanghai University of Traditional Chinese Medicine, No. 181 , Youyi Road, Baoshan District, Shanghai, 201900, China
| | - Tingting Xu
- Department of Digestive System, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No. 110 , Ganhe Road, Shanghai, 200437, China
| | - Lei Wei
- Department of Respiratory, Baoshan Hospital of Shanghai University of Traditional Chinese Medicine, No. 181 , Youyi Road, Baoshan District, Shanghai, 201900, China
| | - Fangying Liu
- Department of Respiratory, Baoshan Hospital of Shanghai University of Traditional Chinese Medicine, No. 181 , Youyi Road, Baoshan District, Shanghai, 201900, China
| | - Chunfang Liu
- Department of Respiratory, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
| | - Li Li
- Department of Respiratory, Baoshan Hospital of Shanghai University of Traditional Chinese Medicine, No. 181 , Youyi Road, Baoshan District, Shanghai, 201900, China.
| | - Wei Zhang
- Department of Respiratory, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, No. 528, Zhangheng Road, Shanghai, 201203, China.
| | - Shengliang Zhu
- Department of Digestive System, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No. 110 , Ganhe Road, Shanghai, 200437, China.
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Yang W, Huang Y, He L, Chen D, Wu S, Tian Y, Zheng J, Yang J, Song G. Utilizing Esophageal Motility Tests in Diagnosing and Evaluating Gastroesophageal Reflux Disease. Diagnostics (Basel) 2024; 14:1467. [PMID: 39061603 PMCID: PMC11276196 DOI: 10.3390/diagnostics14141467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
Gastroesophageal reflux disease (GERD), a prevalent clinical condition, is often attributed to aberrant esophageal motility, leading to gastric content reflux and associated symptoms or complications. The rising incidence of GERD presents an escalating healthcare challenge. Endoscopic and esophageal reflux monitoring can provide a basis for the diagnosis of patients with gastroesophageal reflux disease, but when the diagnostic basis is at an inconclusive value, some additional supportive evidence will be needed. Advanced technology is the key to improving patient diagnosis, accurate assessment, and the development of effective treatment strategies. High-resolution esophageal manometry (HREM) and endoscopic functional lumen imaging probe (EndoFLIP) represent the forefront of esophageal motility assessment. HREM, an evolution of traditional esophageal manometry, is considered the benchmark for identifying esophageal motility disorders. Its widespread application in esophageal dynamics research highlights its diagnostic significance. Concurrently, EndoFLIP's emerging clinical relevance is evident in diagnosing and guiding the treatment of coexisting esophageal motility issues. This review integrates contemporary research to delineate the contributions of HREM, EndoFLIP, and novel technologies in GERD. It examines their efficacy in facilitating an accurate diagnosis, differentiating similar gastrointestinal disorders, quantifying the extent of reflux, assessing the severity of the disease, forecasting patient responsiveness to proton pump inhibitor therapy, and guiding decisions for surgical interventions. The overarching aim is to deepen the understanding of GERD's underlying mechanisms and advance the formulation of holistic, efficacious treatment approaches.
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Affiliation(s)
- Wangliu Yang
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Yurong Huang
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Lei He
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Dongmei Chen
- Department of Gastroenterology, Liupanshui Municipal People’s Hospital, Liupanshui 553000, China; (D.C.); (S.W.); (Y.T.)
| | - Sheng Wu
- Department of Gastroenterology, Liupanshui Municipal People’s Hospital, Liupanshui 553000, China; (D.C.); (S.W.); (Y.T.)
| | - Yan Tian
- Department of Gastroenterology, Liupanshui Municipal People’s Hospital, Liupanshui 553000, China; (D.C.); (S.W.); (Y.T.)
| | - Juan Zheng
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Jie Yang
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Gengqing Song
- Department of Gastroenterology and Hepatology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
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Babbar S, Omara M, Khan A, Knotts R. Manometric esophagogastric junction barrier metrics as predictors of gastroesophageal reflux. Esophagus 2024; 21:397-404. [PMID: 38691207 DOI: 10.1007/s10388-024-01057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 03/25/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND High-resolution manometry (HRM) tools, like esophagogastric junction contractile integral (EGJ-CI), assess EGJ barrier function. GOALS This study aimed to evaluate the relationships between manometric EGJ metrics with esophageal acid exposure. STUDY We conducted a retrospective review of 284 patients who underwent HRM and ambulatory reflux testing between 11/2017-1/2020. EGJ-CI and total-EGJ-CI were manually calculated. Pathologic acid exposure was defined as pH < 4 with esophageal acid exposure time (EAET) exceeding 6.0%. Pearson's correlation, univariable and multivariable regression models were utilized to assess the relationships between pathologic acid exposure and EGJ parameters. Sensitivity and specificity thresholds for EGJ-CI and total EGJ-CI were optimized with ROC analyses. RESULTS On univariable analysis, patients with pathologic acid exposure had increased odds of having lower mean basal LES pressures, EGJ-CI, and total EGJ-CI than patients without pathologic acid exposure. On multivariable analysis, age, EGJ-CI and mean DCI were significant predictors of pathologic acid exposure. There were significant, though weak, correlations between EAET and EGJ-CI and total EGJ-CI (r = - 0.18, - 0.19, p < 0.01, respectively). An EGJ-CI cutoff of 44.16 as a predictor for pathologic acid exposure had a sensitivity of 46% and specificity of 42% (AUC 0.60). Total EGJ-CI cutoff of 11,461.3 for pathologic acid exposure had a sensitivity of 44% and a specificity of 43% (AUC 0.62). CONCLUSION EGJ-CI can independently predict pathologic acid exposure. However, the poor correlation between EGJ-CI and acid exposure, as well as the low sensitivity and specificity of calculated thresholds, indicate that mechanisms other than EGJ barrier function may impact acid exposure.
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Affiliation(s)
- Shaili Babbar
- New York University Grossman School of Medicine, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA.
| | - Matthew Omara
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for Esophageal Health, NYU Langone Health, New York, NY, USA
| | - Abraham Khan
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for Esophageal Health, NYU Langone Health, New York, NY, USA
| | - Rita Knotts
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for Esophageal Health, NYU Langone Health, New York, NY, USA
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Lei WY, Liu TT, Chang WC, Yi CH, Hung JS, Wong MW, Liang SW, Lin L, Chen CL. Effects of Codeine on Esophageal Peristalsis in Patients With Ineffective Esophageal Motility: Studies Using High-resolution Manometry. J Neurogastroenterol Motil 2024; 30:38-45. [PMID: 38173157 PMCID: PMC10774797 DOI: 10.5056/jnm22131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/08/2023] [Accepted: 04/02/2023] [Indexed: 01/05/2024] Open
Abstract
Background/Aims This study aims to evaluate the effects of acute codeine administration on primary and secondary esophageal peristalsis in patients with ineffective esophageal motility (IEM). Methods Eighteen IEM patients (8 women; mean age 37.8 years, range 23-64 years) were enrolled in the study. The patients underwent high-resolution manometry exams, consisting of 10 single wet swallows, multiple rapid swallows, and ten 20 mL rapid air injections to trigger secondary peristalsis. All participants completed 2 separate sessions, including acute administration of codeine (60 mg) and placebo, in a randomized order. Results Codeine significantly increased the distal contractile integral (566 ± 81 mmHg∙s∙cm vs 247 ± 36 mmHg∙s∙cm, P = 0.001) and shortened distal latency (5.7 ± 0.2 seconds vs 6.5 ± 0.1 seconds, P < 0.001) for primary peristalsis compared with these parameters after placebo treatment. The mean total break length decreased significantly after codeine treatment compared with the length after placebo (P = 0.003). Codeine significantly increased esophagogastric junction-contractile integral (P = 0.028) but did not change the 4-second integrated relaxation pressure (P = 0.794). Codeine significantly decreased the frequency of weak (P = 0.039) and failed contractions (P = 0.009), resulting in increased frequency of normal primary peristalsis (P < 0.136). No significant differences in the ratio of impaired multiple rapid swallows inhibition and parameters of secondary peristalsis were detected. Conclusions In IEM patients, acute administration of codeine increases contraction vigor and reduces distal latency of primary esophageal peristalsis, but has no effect on secondary peristalsis. Future studies are required to further elucidate clinical relevance of these findings, especially in the setting of gastroesophageal reflux disease with IEM.
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Affiliation(s)
- Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Wei-Chuan Chang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Lin Lin
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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10
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Uno K, Masuda T, Watanabe A, Sato K, Takahashi K, Hara K, Yano F, Eto K. Visceral Obesity is Associated with Thoraco-abdominal Pressure Gradient (TAPG) and Gastroesophageal Reflux Disease. Obes Surg 2023; 33:3871-3878. [PMID: 37843786 DOI: 10.1007/s11695-023-06880-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/27/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Kohei Uno
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishimbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - Takahiro Masuda
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Atsushi Watanabe
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishimbashi, Minato-ku, Tokyo, 105-8471, Japan
- Department of Surgery, Saitama Jikei Hospital, 3-208 ishihara, Kumagaya-shi, Saitama, 360-0816, Japan
| | - Kazuhide Sato
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Keita Takahashi
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Keigo Hara
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Fumiaki Yano
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Ken Eto
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishimbashi, Minato-ku, Tokyo, 105-8471, Japan
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11
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Ribolsi M, Savarino E. Towards a better diagnosis of gastro esophageal reflux disease. Expert Rev Gastroenterol Hepatol 2023; 17:999-1010. [PMID: 37800858 DOI: 10.1080/17474124.2023.2267435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/03/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION GERD is a common disorder and is characterized by the presence of typical or atypical symptoms. In GERD patients, the presence of mucosal alterations in endoscopy is detected in up to 30% of individuals. The clinical presentation of GERD patients may be complex and their management is challenging, due to the heterogeneous clinical presentation. The present review has been performed searching all relevant articles in this field, over the past years, using PubMed database. AREAS COVERED The diagnosis and management of GERD have been significantly improved in the last years due to the increasing availability of reflux monitoring techniques and the implementation of new procedures in the therapeutic armamentarium. Beside traditional impedance-pH variables, new metrics have been developed, increasing the diagnostic yield of reflux monitoring and better predicting the treatment response. Traditional pharmacological treatments include acid-suppressive-therapy and/or anti-acid. On the other hand, surgical treatment and, more recently, endoscopic procedures represent a promising field in the therapeutic approach. EXPERT OPINION Diagnosis and treatment of GERD still represent a challenging area. However, we believe that an accurate upfront evaluation is, nowadays, necessary in addressing patients with GERD to a more accurate diagnosis as well as to the best treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
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12
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Dervin H, Bassett P, Sweis R. Esophagogastric junction contractile integral (EGJ-CI) complements reflux disease severity and provides insight into the pathophysiology of reflux disease. Neurogastroenterol Motil 2023:e14597. [PMID: 37094069 DOI: 10.1111/nmo.14597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Esophagogastric junction contractile integral (EGJ-CI) has not come into routine use due to methodological discrepancies and its unclear clinical utility. We aimed to determine which method of calculating EGJ-CI was best at discriminating between common reflux disease states. METHODS High-resolution manometry (HRM) and pH-Impedance measurements were acquired for 100 patients; 25 Barrett's esophagus (>3 cm/acid exposure time (AET) > 6), 25 endoscopy-negative reflux disease (ENRD; AET >6), 25 borderline reflux (AET 4-6), 25 functional heartburn (FH; AET <4), constituting the developmental cohort. EGJ-CI was calculated at 20 mmHg, 2 mmHg, and 0 mmHg isobaric contour. Empirical associations, univariable, multivariable and ROC analyses were performed between EGJ-CI and manometric/pH-impedance metrics. A validation cohort (n = 25) was used to test the new EGJ-CI cutoff. KEY RESULTS Significant correlations with AET were observed when EGJ-CI was calculated with an isobaric threshold of 20 mmHg (p < 0.001). Significant differences in EGJ-CI were observed between patients with FH and Barrett's esophagus (p = 0.004) and with ENRD (p = 0.01); however, LES basal pressure was unable to differentiate between these disease states (p = 0.09, p = 0.25, respectively). ROC analysis on the developmental cohort found that EGJ-CI 21.2 mmHg.cm demonstrated sensitivity 72% and specificity 72% between patients with reflux (Barrett's esophagus/ENRD) and FH. In the validation cohort, 92.8% with a low EGJ-CI had good/moderate improvement in symptoms following therapy compared to 54.5% with raised EGJ-CI (p = 0.026). CONCLUSIONS AND INFERENCES This study re-affirms EGJ-CI as a reliable discriminator between reflux disease (Barrett's esophagus/ENRD) and FH. In borderline reflux patients, patients with a lower EGJ-CI score (<21.2 mmHg) appear to respond better to anti-reflux therapies compared to those with a higher value.
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Affiliation(s)
- Humayra Dervin
- GI Physiology Unit, University College London, London, UK
| | | | - Rami Sweis
- GI Physiology Unit, University College London, London, UK
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13
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Layne SJ, Lorsch ZS, Patel A. Novel Diagnostic Techniques in the Evaluation of Gastroesophageal Reflux Disease (GERD). Dig Dis Sci 2023; 68:2226-2236. [PMID: 37071244 DOI: 10.1007/s10620-023-07901-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/21/2023] [Indexed: 04/19/2023]
Abstract
In our present clinical paradigm, patient symptoms and presentation in the setting of traditional findings from endoscopy (erosive esophagitis, Barrett's esophagus, reflux-mediated stenosis), esophageal high-resolution manometry, and/or ambulatory reflux monitoring (distal esophageal acid exposure time, numbers of reflux events, reflux-symptom association) guide the care of patients with suspected GERD. However, novel metrics and techniques acquired from or performed at endoscopy, manometry, or pH-impedance monitoring, beyond conventional evaluation, are of great interest to the gastroenterology community given the frequent (and sometimes challenging) presentation of suspected GERD. These novel and evolving diagnostic approaches have the potential to enhance the evaluation of these patients and optimize their management. In this invited review, we discuss the present evidence and potential clinical utility of selected GERD metrics and techniques of interest at endoscopy (dilated intercellular spaces, mucosal impedance), manometry (contractile integral, impedance analysis, straight leg raise, multiple rapid swallow maneuvers), and reflux monitoring (mean nocturnal baseline impedance, post-reflux swallow-induced peristaltic wave indices), and how these tools may be most optimally adopted and utilized for clinical care (Fig. 1).
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Affiliation(s)
- Sabrina J Layne
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
| | - Zachary S Lorsch
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
| | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Box 3913, Durham, NC, 27710, USA.
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14
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Li Y, Wang L, Yang D, Zhang Z, Sun X, Geng X, Lin J, Duan Z. Esophageal chemical clearance and mucosa integrity values in refractory gastroesophageal reflux disease patients with different esophageal dynamics. Scand J Gastroenterol 2023; 58:322-330. [PMID: 36259257 DOI: 10.1080/00365521.2022.2132534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Esophageal post-reflux swallow-induced peristaltic wave index (PSPWI) and mean nocturnal baseline impedance (MNBI), novel impedance-based markers of reflux burden, are associated with esophageal dynamics. We aim to investigate the characteristics of PSPWI and MNBI in Chinese refractory gastroesophageal reflux disease (RGERD) patients with different esophageal dynamic changes. MATERIALS AND METHODS 201 RGERD and 76 functional heartburn patients, undergone off-PPI endoscopy, esophageal manometry and impedance-pH monitoring, were included. Comparisons of conventional and novel impedance-pH metrics were made among different esophageal dynamics groups. Receiver operating-characteristic analyses were utilized to evaluate the diagnostic efficacy of PSPWI and MNBI in differentiating abnormal esophageal dynamics. Correlations were used to investigate their associated factors. RESULTS PSPWI and MNBI of RGERD with esophagogastric junction (EGJ) injury and esophageal dysmotility were lower than EGJ injury alone or normal dynamics (p < 0.05 for both comparisons). PSPWI with esophageal peristalsis abnormality was lower than EGJ injury (p = 0.049), while MNBI showed no statistical difference. PSPWI, MNBI and their combination have auxiliary diagnostic values for esophageal peristalsis [area under the curves (AUCs): 0.683, 0.656, 0.708)] while only their combination for EGJ injury (AUC: 0.610). And they positively correlated with esophageal motility while negatively correlated with ineffective swallows and acid reflux events. CONCLUSIONS PSPWI and MNBI, indicating impairment of esophageal chemical clearance and mucosa integrity, were lower in RGERD patients with multiple esophageal dynamic injuries than single injuries or normal dynamics. Moreover, they provided useful contributing information for potential dynamic injuries if manometry has already been found normal or marginal.
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Affiliation(s)
- Yanqiu Li
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lixia Wang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dong Yang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhifeng Zhang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoyu Sun
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoling Geng
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiarong Lin
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhijun Duan
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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15
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Zdrhova L, Bitnar P, Balihar K, Kolar P, Madle K, Martinek M, Pandolfino JE, Martinek J. Breathing Exercises in Gastroesophageal Reflux Disease: A Systematic Review. Dysphagia 2023; 38:609-621. [PMID: 35842548 PMCID: PMC9888515 DOI: 10.1007/s00455-022-10494-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 07/01/2022] [Indexed: 02/02/2023]
Abstract
The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial. The severity of abnormal reflux burden corresponds to the dysfunction of the antireflux barrier and inability to clear refluxate. The crural diaphragm is one of the main components of the esophagogastric junction and plays an important role in preventing gastroesophageal reflux. The diaphragm, as a skeletal muscle, is partially under voluntary control and its dysfunction can be improved via breathing exercises. Thus, diaphragmatic breathing training (DBT) has the potential to alleviate symptoms in selected patients with GERD. High-resolution esophageal manometry (HRM) is a useful method for the assessment of antireflux barrier function and can therefore elucidate the mechanisms responsible for gastroesophageal reflux. We hypothesize that HRM can help define patient phenotypes that may benefit most from DBT, and that HRM can even help in the management of respiratory physiotherapy in patients with GERD. This systematic review aimed to evaluate the current data supporting physiotherapeutic practices in the treatment of GERD and to illustrate how HRM may guide treatment strategies focused on respiratory physiotherapy.
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Affiliation(s)
- Lucie Zdrhova
- First Department of Internal Medicine, Pilsen University Hospital, Charles University in Prague, Alej Svobody 80, Pilsen, 304 06, Czech Republic.
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic.
| | - Petr Bitnar
- Department of Rehabilitation and Sports Medicine, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Karel Balihar
- First Department of Internal Medicine, Pilsen University Hospital, Charles University in Prague, Alej Svobody 80, Pilsen, 304 06, Czech Republic
| | - Pavel Kolar
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic
- Department of Rehabilitation and Sports Medicine, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Katerina Madle
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic
| | - Milan Martinek
- Faculty of Physical Education and Sport, Charles University in Prague, Prague, Czech Republic
| | - John Erik Pandolfino
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Evanston, USA
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, IKEM, Prague, Czech Republic
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16
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Jandee S, Keeratichananont S, Tack J, Vanuytsel T. Concise Review: Applicability of High-resolution Manometry in Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2022; 28:531-539. [PMID: 36250360 PMCID: PMC9577568 DOI: 10.5056/jnm22082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/13/2022] [Accepted: 09/13/2022] [Indexed: 11/29/2022] Open
Abstract
Manometry, particularly high-resolution manometry is the preferred diagnostic tool used to evaluate esophageal motor function. This investigation is strongly indicated in the setting of dysphagia, but is also useful in gastroesophageal reflux disease (GERD), especially in case of failure of conventional treatment to exclude alternative diagnoses and prior to anti-reflux surgery. Moreover, ineffective esophagogastric junction barrier function and esophageal motor dysfunction are pathophysiological mechanisms in GERD and can be identified by manometry. The recent international guidelines have positioned high-resolution manometry as an important part of functional diagnostic work up in GERD in order to identify the GERD phenotype to guide specific treatment. The proposed manometric identification and measurement is based on the Chicago classification version 4.0 adding with new established metrics for GERD evaluation.
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Affiliation(s)
- Sawangpong Jandee
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.,Nanthana-Kriangkrai Chotiwattanaphan Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Hat Yai, Songkhla, Thailand.,Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Suriya Keeratichananont
- Nanthana-Kriangkrai Chotiwattanaphan Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Hat Yai, Songkhla, Thailand
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium.,Division of Gastroenterology and Hepatology, Leuven University Hospitals, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium.,Division of Gastroenterology and Hepatology, Leuven University Hospitals, Leuven, Belgium
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17
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Jain M. Esophageal manometry findings in patients with refractory symptoms of gastroesophageal reflux disease. Indian J Gastroenterol 2022; 41:508-512. [PMID: 36327003 DOI: 10.1007/s12664-022-01259-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/27/2022] [Indexed: 11/05/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder. High-resolution esophageal manometry (HREM) and 24-h pH study help to properly evaluate GERD patients. The aim of the present study was to classify patients with refractory GERD symptoms into various groups based on endoscopic and physiological testing. The present study is a retrospective analysis of patients referred for HREM and 24-h pH recording between 2019 and 2021. We included all adult patients (age > 18 years) who were referred for evaluation of refractory GERD symptoms. Upper gastrointestinal endoscopy findings, HREM, and 24-h pH findings were noted. Patients were divided into erosive reflux disease (ERD), non-erosive reflux disease (NERD), reflux hypersensitivity (RH), and functional heartburn (FH) based on test results. Demographic details and HREM parameters were compared in the four groups. Statistics used are one-way analysis of variance (ANOVA) and Chi-squared tests. A p-value of <0.05 was considered statistically significant. A total of 144 patients were included-NERD (56, 38.9%), ERD (42, 29.2%), RH (28, 19.5%), and FH (18, 12.5%). Age (p 0.74), and sex distribution (p 0.47), and symptom profile (p 0.12) were similar. The presence of type 2/3 esophagogastric junction (EGJ) morphology was commoner in ERD and NERD (p <0.001). Moreover, the esophagogastric junction contractile integral (EGJ-CI) and basal inspiratory pressures were significantly lower in these two groups (p<0.05). EGJ-CI was low in 32 cases of ERD (76.2%), 41 cases with NERD (73.2%), 7 cases with RH (25%), and 3 cases with FH (16.7%), respectively (p-value < 0.00001). FH and RH account for 32% of cases with refractory GERD symptoms. Impaired EGJ function was more common in ERD and NERD patients compared to FH and RH patients.
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Affiliation(s)
- Mayank Jain
- Department of Gastroenterology, Arihant Hospital and Research Centre, 283-A Gumasta Nagar, Indore, 452 009, India.
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18
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Fujiyoshi Y, Inoue H, Shimamura Y, Fujiyoshi MRA, de Santiago ER, Nishikawa Y, Toshimori A, Tanabe M, Sumi K, Ono M, Iwaya Y, Ikeda H, Onimaru M. Association between endoscopic pressure study integrated system (EPSIS) and high-resolution manometry. Endosc Int Open 2022; 10:E762-E768. [PMID: 35692910 PMCID: PMC9187419 DOI: 10.1055/a-1790-6141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background and study aims The endoscopic pressure study integrated system (EPSIS), a novel diagnostic tool for gastroesophageal reflux disease (GERD), allows evaluation of the anti-reflux barrier using endoscopy by monitoring the intragastric pressure (IGP) during insufflation. In this study, we evaluated the association between EPSIS results and lower esophageal sphincter (LES) function measured by high-resolution manometry (HRM) to elucidate whether EPSIS can evaluate the LES function. Patients and methods A retrospective, single-center study of patients with GERD symptoms who underwent endoscopy, pH-impedance monitoring, EPSIS, and HRM was conducted. The primary outcome was basal LES pressure and the secondary outcomes were end-respiratory LES pressure and integrated relaxation pressure (IRP). As EPSIS parameters, the following were measured: 1) pressure difference (mmHg), the difference between maximum and basal IGP; and 2) pressure gradient (mmHg/s), calculated by dividing pressure difference by the insufflating time. Pressure difference < 4.7 mmHg or pressure gradient < 0.07 mmHg/s was defined as an EPSIS GERD pattern. Results Forty-seven patients (median age: 53 years, 37 female) were analyzed. Pressure difference and pressure gradient significantly correlated with basal LES pressure (ρ = 0.29; P = 0.04 and ρ = 0.29; P = 0.04). Patients with EPSIS GERD pattern showed significantly lower basal LES pressure [13.2 (4.8-26.6) vs 25.3 (10.4-66.7) mmHg, P = 0.002], lower end-respiratory LES pressure [8.5 (1.1-15.9) vs 15.5 (1.9-43.9) mmHg, P = 0.019] and lower IRP [5.9 (1.0-12.0) vs 9.8 (1.3-17.8) mmHg, P = 0.020]. Conclusions This study showed a close association between EPSIS results and LES pressures measured by HRM. This indicates that EPSIS can evaluate the LES function during endoscopy and endorse the role of EPSIS as a diagnostic tool for GERD.
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Affiliation(s)
- Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Yohei Nishikawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Akiko Toshimori
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuya Sumi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Masashi Ono
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yugo Iwaya
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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19
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Lei WY, Liang SW, Hung JS, Wong MW, Liu TT, Yi CH, Lin L, Orr WC, Chen CL. Effects of menthol on esophageal motility in humans: Studies using high-resolution manometry. Neurogastroenterol Motil 2022; 34:e14267. [PMID: 34520608 DOI: 10.1111/nmo.14267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIM The cold receptor, transient receptor potential melastatin 8 (TRPM8), has been reported to be expressed in esophageal vagal afferents. Esophageal infusion of menthol modulates esophageal perception in reflux patients via TRPM8, but the effects of menthol on esophageal motility are not well investigated. This study aimed to test the hypothesis whether the infusion of menthol into the esophagus could affect esophageal peristaltic characteristics. METHODS Eighteen healthy adults (men 13, mean age 27) underwent high-resolution manometry (HRM) using a catheter with the injection port located in mid-esophagus. Primary peristalsis was performed with ten wet swallows, while secondary peristalsis was generated by 10 rapid air injections. Two different sessions were randomly performed including acute administration of menthol (3 mM) and the placebo. RESULTS Menthol significantly decreased upper esophageal (UES) pressure of primary peristalsis than the placebo (p = 0.019). There was no difference in distal contractile integral (p = 0.33), distal latency (p = 0.86), basal lower esophageal sphincter pressure (p = 0.19), or 4-second integrated relaxation pressure (p = 0.75) between menthol and placebo. Menthol significantly decreased the frequency of secondary peristalsis subsequent to the administration of menthol during rapid injections with 20 mL air (p = 0.04). CONCLUSIONS Intraluminal infusion of menthol reduces UES basal pressure and inhibits peristaltic frequency of secondary peristalsis. The data suggest that the triggering of secondary peristalsis is probably modulated by TRPM8-sensitive mechanoreceptors; however, the activation of TRPM8 from menthol does not alter esophageal motility following deglutition or distension-induced secondary peristalsis.
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Affiliation(s)
- Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Lin Lin
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - William C Orr
- Lynn Institute for Healthcare Research, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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20
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Ineffective esophageal motility in Chicago Classification version 4.0 better predicts abnormal acid exposure. Esophagus 2022; 19:197-203. [PMID: 34378104 DOI: 10.1007/s10388-021-00867-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The updated Chicago Classification version 4.0 (CCv4.0) establishes a more stringent criteria to diagnose ineffective esophageal motility (IEM). This study aims to investigate the clinical significance of IEM in CCv4.0 in the context of gastroesophageal reflux disease (GERD). METHODS A retrospective study was conducted among suspected GERD patients who had heartburn and/or regurgitation as their chief complaints and completed esophageal function tests in our center from 2017 to 2019. Patients were further grouped as "CCv3.0 IEM" and normal motility according to Chicago Classification version 3.0 (CCv3.0), and as "CCv4.0 IEM" and normal motility according to CCv4.0. The clinical characteristics, high-resolution manometry, esophageal reflux monitoring, and proton pump inhibitor (PPI) efficacy were compared between different groups. Multivariate analyses were performed to identify esophageal motility parameters associated with reflux burden and symptom outcome. RESULTS Of 172 subjects included, 93 patients were identified as CCv3.0 IEM, 69 as CCv4.0 IEM. IEM in either version was concomitant with elevated acid burden and impaired esophageal clearance as compared to normal motility in corresponding diagnostic criteria, while the only presence of IEM in CCv4.0 was predictive to abnormal acid exposure (AET > 6%: OR = 2.66, 95% CI [1.27-5.56], p < 0.01). The presence of "CCv3.0 IEM" and low EGJ-CI (EGJ-CI < 39.1 mmHg·cm) had no added value in predicting increased reflux burden. No interaction effect was found between the presence of IEM and a weakened EGJ. None of the manometric variables was capable of predicting PPI response. CONCLUSIONS Stringent criteria of IEM in CCv4.0 can better predict abnormal acid exposure as compared to CCv3.0.
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21
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Visaggi P, Mariani L, Svizzero FB, Tarducci L, Sostilio A, Frazzoni M, Tolone S, Penagini R, Frazzoni L, Ceccarelli L, Savarino V, Bellini M, Gyawali PC, Savarino EV, de Bortoli N. Clinical use of mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index for the diagnosis of gastro-esophageal reflux disease. Esophagus 2022; 19:525-534. [PMID: 35768671 PMCID: PMC9436885 DOI: 10.1007/s10388-022-00933-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/07/2022] [Indexed: 02/03/2023]
Abstract
The clinical diagnosis of gastro-esophageal reflux disease (GERD) is based on the presence of typical esophageal troublesome symptoms. In clinical practice, heartburn relief following a proton pump inhibitor (PPI) trial or endoscopy can confirm a diagnosis of GERD. In cases of diagnostic uncertainty or before anti-reflux interventions, combined impedance-pH monitoring (MII-pH) provides a comprehensive assessment of both physical and chemical properties of the refluxate, allowing to achieve a conclusive diagnosis of GERD. Recently, the Lyon Consensus proposed the use of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPW-I) as novel MII-pH metrics to support the diagnosis of GERD. The calculation of MNBI and PSPW-I currently needs to be performed manually, but artificial intelligence systems for the automated analysis of MII-pH tracings are being developed. Several studies demonstrated the increased diagnostic yield MNBI and PSPW-I for the categorization of patients with GERD at both on- and off-PPI MII-pH monitoring. Accordingly, we performed a narrative review on the clinical use and diagnostic yield of MNBI and PSPW-I when the diagnosis of GERD is uncertain. Based on currently available evidence, we strongly support the evaluation of PSPW-I and MNBI as part of the standard assessment of MII-pH tracings for the evaluation of GERD, especially in patients with endoscopy-negative heartburn.
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Affiliation(s)
- Pierfrancesco Visaggi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Lucia Mariani
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Federica Baiano Svizzero
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Luca Tarducci
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Andrea Sostilio
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, University of Caserta Luigi Vanvitelli, Caserta, Italy
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Linda Ceccarelli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine "DiMI", University of Genoa, Genoa, Italy
| | - Massimo Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy
| | - Prakash C Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA
| | - Edoardo V Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, School of Medicine, University of Pisa, Pisa, Italy.
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22
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Chen CL, Wong MW, Hung JS, Liang SW, Liu TT, Yi CH, Lin L, Orr WC, Lei WY. Effects of codeine on esophageal peristalsis in humans using high resolution manometry. J Gastroenterol Hepatol 2021; 36:3381-3386. [PMID: 34322907 DOI: 10.1111/jgh.15641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/24/2021] [Accepted: 07/16/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Opioid receptors agonists have been demonstrated to impair lower esophageal sphincter (LES) relaxation and induce spastic esophageal dysmotility, but little was known for their impact on distension-induced secondary peristalsis. The aim of the study was to investigate the hypothesis whether acute administration of codeine can influence physiological characteristics of primary and secondary peristalsis in healthy adults. METHODS Eighteen healthy volunteers (13 men, mean age 27.5 years, aged 20-43 years) underwent high resolution manometry (HRM) with a catheter containing an injection port in mid-esophagus. Secondary peristalsis was performed with 10 and 20 mL rapid air injections. Two different sessions including acute administration of codeine (60 mg) or the placebo were randomly performed. RESULTS Codeine significantly increased 4-s integrated relaxation pressure (IRP-4s) (P = 0.003) and shortened distal latency (DL) (P = 0.003) of primary peristalsis. The IRP-4s of secondary peristalsis was also significantly higher after codeine than the placebo during air injections with 10 mL (P = 0.048) and 20 mL (P = 0.047). Codeine significantly increased the frequency of secondary peristalsis during air injections with 10 mL than the placebo (P = 0.007), but not for air injection with 20 mL (P = 0.305). CONCLUSIONS In addition to impair LES relaxation and reduce distal latency of primary peristalsis, codeine impairs LES relaxation of secondary peristalsis and increases secondary peristaltic frequency. Our study supports the notion in human esophagus that the impact of opioids on peristaltic physiology appears to be present in both primary and secondary peristalsis.
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Affiliation(s)
- Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Lin Lin
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - William C Orr
- Lynn Institute for Healthcare Research, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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23
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Balla A, Meoli F, Palmieri L, Corallino D, Sacchi MC, Ribichini E, Coletta D, Pronio A, Badiali D, Paganini AM. Manometric and pH-monitoring changes after laparoscopic sleeve gastrectomy: a systematic review. Langenbecks Arch Surg 2021; 406:2591-2609. [PMID: 33855600 PMCID: PMC8803809 DOI: 10.1007/s00423-021-02171-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/05/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE Aim of this systematic review is to assess the changes in esophageal motility and acid exposure of the esophagus through esophageal manometry and 24-hours pH-monitoring before and after laparoscopic sleeve gastrectomy (LSG). METHODS Articles in which all patients included underwent manometry and/or 24-hours pH-metry or both, before and after LSG, were included. The search was carried out in the PubMed, Embase, Cochrane, and Web of Science databases, revealing overall 13,769 articles. Of these, 9702 were eliminated because they have been found more than once between the searches. Of the remaining 4067 articles, further 4030 were excluded after screening the title and abstract because they did not meet the inclusion criteria. Thirty-seven articles were fully analyzed, and of these, 21 further articles were excluded, finally including 16 articles. RESULTS Fourteen and twelve studies reported manometric and pH-metric data from 402 and 547 patients, respectively. At manometry, a decrease of the lower esophageal sphincter resting pressure after surgery was observed in six articles. At 24-hours pH-metry, a worsening of the DeMeester score and/or of the acid exposure time was observed in nine articles and the de novo gastroesophageal reflux disease (GERD) rate that ranged between 17.8 and 69%. A meta-analysis was not performed due to the heterogeneity of data. CONCLUSIONS After LSG a worsening of GERD evaluated by instrumental exams was observed such as high prevalence of de novo GERD. However, to understand the clinical impact of LSG and the burden of GERD over time further long-term studies are necessary.
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Affiliation(s)
- Andrea Balla
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Francesca Meoli
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Livia Palmieri
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Diletta Corallino
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Maria Carlotta Sacchi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Emanuela Ribichini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Diego Coletta
- Department of General Surgery, Emergency Department, Emergency and Trauma Surgery Unit, Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Annamaria Pronio
- Digestive Endoscopy Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Danilo Badiali
- Department of Translational and Precision Medicine, Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Alessandro M Paganini
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
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24
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Rettura F, Bronzini F, Campigotto M, Lambiase C, Pancetti A, Berti G, Marchi S, de Bortoli N, Zerbib F, Savarino E, Bellini M. Refractory Gastroesophageal Reflux Disease: A Management Update. Front Med (Lausanne) 2021; 8:765061. [PMID: 34790683 PMCID: PMC8591082 DOI: 10.3389/fmed.2021.765061] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.
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Affiliation(s)
- Francesco Rettura
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesco Bronzini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michele Campigotto
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Christian Lambiase
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Andrea Pancetti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Ginevra Berti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Santino Marchi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Massimo Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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25
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Jung HK, Tae CH, Song KH, Kang SJ, Park JK, Gong EJ, Shin JE, Lim HC, Lee SK, Jung DH, Choi YJ, Seo SI, Kim JS, Lee JM, Kim BJ, Kang SH, Park CH, Choi SC, Kwon JG, Park KS, Park MI, Lee TH, Kim SY, Cho YS, Lee HH, Jung KW, Kim DH, Moon HS, Miwa H, Chen CL, Gonlachanvit S, Ghoshal UC, Wu JCY, Siah KTH, Hou X, Oshima T, Choi MY, Lee KJ. 2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2021; 27:453-481. [PMID: 34642267 PMCID: PMC8521465 DOI: 10.5056/jnm21077] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the "proven GERD" with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.
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Affiliation(s)
- Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyung Ho Song
- Division of Gastroenterology, Department of Internal Medicine, CHA Ilsan Medical Center, CHA University School of Medicine, Ilsan, Jeollabuk-do, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Gangnam Center, Seoul, Korea
| | - Jong Kyu Park
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Chungcheongnam-do, Korea
| | - Hyun Chul Lim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Jin Choi
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung In Seo
- Division of Gastroenterology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jung Min Lee
- Digestive Disease Center, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sun Hyung Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Suck Chei Choi
- Department of Internal Medicine and Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Jeollabuk-do, Korea
| | - Joong Goo Kwon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Seung Young Kim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan, Hospital, Cheonan, Chungcheongnam-do, Korea
| | - Han Hong Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hirota Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Chien-Lin Chen
- Institute of Medical Sciences, Tzu Chi University, and Department of Public Health, College of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Sutep Gonlachanvit
- Center of Excellence on Neurogastroenterology and Motility, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Uday C Ghoshal
- Departments of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India
| | - Justin C Y Wu
- Institute of Digestive Disease, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, China
| | - Kewin T H Siah
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Hospital, Singapore
| | - Xiaohua Hou
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Mi-Young Choi
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
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Kahrilas PJ, Mittal RK, Bor S, Kohn GP, Lenglinger J, Mittal SK, Pandolfino JE, Serra J, Tatum R, Yadlapati R. Chicago Classification update (v4.0): Technical review of high-resolution manometry metrics for EGJ barrier function. Neurogastroenterol Motil 2021; 33:e14113. [PMID: 33655610 PMCID: PMC8410874 DOI: 10.1111/nmo.14113] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/21/2021] [Accepted: 02/09/2021] [Indexed: 01/02/2023]
Abstract
Esophagogastric junction (EGJ) barrier function is of fundamental importance in the pathophysiology of gastroesophageal reflux disease. Impaired EGJ barrier function leads to excessive distal esophageal acid exposure or, in severe cases, esophagitis. Hence, proposed high-resolution manometry (HRM) metrics assessing EGJ integrity are clinically important and were a focus of the Chicago Classification (CC) working group for inclusion in CC v4.0. However, the EGJ is a complex sphincter comprised of both crural diaphragm (CD) and lower esophageal sphincter (LES) component, each of which is subject to independent physiological control mechanisms and pathophysiology. No single metric can capture all attributes of EGJ barrier function. The working group considered several potential metrics of EGJ integrity including LES-CD separation, the EGJ contractile integral (EGJ-CI), the respiratory inversion point (RIP), and intragastric pressure. Strong recommendations were made regarding LES-CD separation as indicative of hiatus hernia, although the numerical threshold for defining hiatal hernia was not agreed upon. There was no agreement on the significance of the RIP, only that it could localize either above the LES or between the LES and CD in cases of hiatus hernia. There was agreement on how to measure the EGJ-CI and that it should be referenced to gastric pressure in units of mmHg cm, but the numerical threshold indicative of a hypotensive EGJ varied widely among reports and was not agreed upon. Intragastric pressure was endorsed as an important metric worthy of further study but there was no agreement on a numerical threshold indicative of abdominal obesity.
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Affiliation(s)
- Peter J. Kahrilas
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Ravinder K. Mittal
- Department of Medicine, University of California, San Diego, California, USA
| | - Serhat Bor
- Division of Gastroenterology, Ege University School of Medicine, Izmir, Turkey
| | - Geoffrey P. Kohn
- Department of Surgery, Monash University, Melbourne, Vic, Australia; Melbourne Upper GI Surgical Group, Melbourne, Vic, Australia
| | - Johannes Lenglinger
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | - John E. Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Jordi Serra
- Digestive System Research Unit. University Hospital Vall d’Hebron. Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd). Barcelona, Spain
| | - Roger Tatum
- Department of Surgery, University of Washington, and VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Rena Yadlapati
- Department of Medicine, University of California, San Diego, California, USA
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27
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Bardini R, Battaglia S, Scarpa M, Savarino E. How a modified Nissen procedure works: a mechanistic study using intraoperative esophageal high-resolution manometry. Langenbecks Arch Surg 2021; 407:123-129. [PMID: 34564758 DOI: 10.1007/s00423-021-02317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed at demonstrating how a modified Nissen procedure works by analyzing intraoperatively the variations of the low esophageal sphincter pressure values using high resolution manometry. METHODS This study included 15 patients with documented gastroesophageal reflux disease who underwent a laparoscopic modified Nissen procedure. Data regarding the changes in the pressure values were recorded at each step of the procedures using high resolution manometry and after the progressive insufflation of air in the stomach. Categorical data were compared between the preoperative and postoperative periods using Fisher's test, and continuous data were compared using Mann-Whitney U non-parametric test. Preoperative versus postoperative variations in continuous data were assessed using Wilcoxon's non-parametric test for paired data. RESULTS Intraoperative manometric data showed a rise of basal LES pressure until the creation of the wrap. An evident increase of pressure values was recorded after gastric air insufflation, as consequence of the increase of intragastric pressure. No intraoperative and postoperative complications were observed. All patients experienced a significant reduction in terms of intensity and frequency of gastroesophageal reflux symptoms and no patients complained of dysphagia. CONCLUSIONS Intraoperative high resolution manometry was feasible in all patients and demonstrated that the modified Nissen procedure works by increasing the LES pressure in response to gastric distension, without impeding the progression of the bolus into the stomach.
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Affiliation(s)
- Romeo Bardini
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy. .,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy. .,Department of Surgery, Oncology and Gastroenterology - DiSCOG, University of Padua, Via Giustiniani, 2, 35128, Padova, Italy.
| | - Silvia Battaglia
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Marco Scarpa
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Edoardo Savarino
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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28
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Wang Y, Ding Y, Lin L, Jiang LQ. Esophagogastric junction contractile integral abnormalities in patients with proton pump inhibitor-refractory symptoms. J Dig Dis 2021; 22:529-535. [PMID: 34387020 DOI: 10.1111/1751-2980.13038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/26/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Esophagogastric junction contractile integral (EGJ-CI) is a novel indicator to evaluate quantitatively the esophagogastric junction (EGJ) barrier function. We aimed to assess the role of EGJ-CI in patients with refractory gastroesophageal reflux disease (GERD) symptoms and the correlation between EGJ-CI and impedance-pH monitoring characteristics. METHODS In total 82 patients with proton pump inhibitors (PPIs)-refractory gastroesophageal reflux symptoms (heartburn or regurgitation) were enrolled. These patients were further divided into two groups based on their EGJ-CI value (39 mmHg·cm). The mean nocturnal baseline impedance (MNBI) was measured to explore its association with EGJ-CI. RESULTS The median EGJ-CI in patients with PPI-refractory symptoms was 30.8 mmHg·cm. EGJ-CI was inversely correlated with acid exposure time and reflux episodes; while it was positively correlated with MNBI, distal contractile integral, lower esophageal sphincter basal pressure and integrated relaxation pressure. Patients were further divided into the high (n = 27) and low (n = 55) EGJ-CI groups using a cut-off value of 39.0 mmHg·cm. Patients with a low EGJ-CI had a lower MNBI level than those with a high EGJ-CI (2703 Ω vs 3545 Ω, P = 0.034). CONCLUSIONS In patients with PPIs-refractory symptoms, EGJ-CI is associated with acid exposure and conventional high-resolution manometry parameters. EGJ-CI may play an important role in the diagnosis and treatment of patients with refractory GERD.
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Affiliation(s)
- Yan Wang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yu Ding
- Department of Gastroenterology, Changshu Hospital Affiliated to Soochow University, First People's Hospital of Changshu City, Changshu, Jiangsu Province, China
| | - Lin Lin
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Liu Qin Jiang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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29
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Patel D, Fass R, Vaezi M. Untangling Nonerosive Reflux Disease From Functional Heartburn. Clin Gastroenterol Hepatol 2021; 19:1314-1326. [PMID: 32246998 DOI: 10.1016/j.cgh.2020.03.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have nonerosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common phenotype of gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. A diagnosis of NERD requires endoscopy and reflux testing, whereas a diagnosis of functional heartburn also requires esophageal manometry. NERD is treated most commonly with medical, endoscopic, and surgical antireflux approaches, whereas functional heartburn as well as NERD can be treated with neuromodulators, psychological intervention, and complementary medicine options.
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Affiliation(s)
- Dhyanesh Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth System, Case Western Reserve University, Cleveland, Ohio
| | - Michael Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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30
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Alves JR. Importance of esophageal pH monitoring and manometry in indicating surgical treatment of gastroesophageal reflux disease. ACTA ACUST UNITED AC 2021; 67:131-139. [PMID: 34161486 DOI: 10.1590/1806-9282.67.01.20200354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To demonstrate the need of performing esophageal pH monitoring and manometry in patients with clinical suspicion of Gastroesophageal reflux disease, as more accurate and practical complementary exams in the indication of surgical treatment. METHODS A systematic review was carried out in the PubMed/Medline database, based on the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol, selecting studies in humans, published in Portuguese, Spanish, and English, from January 1, 2009 to August 5, 2020. The following descriptors were used: "reflux gastroesophageal" AND "surgery" AND "surgical treatment" AND "esophageal manometry" OR "pH monitoring". After that, retrospective or prospective observational studies with a sample of less than 100 individuals, or with limited access, reports or case series, review articles, letters, comments, or book chapters were excluded. To facilitate the application of the exclusion criteria, the Rayyan management base was used. RESULTS Out of the 676 studies found, 19 valid and eligible studies were selected to make inferences. CONCLUSIONS Based on the best evidence, currently, considering national particularities, performing a 24-hour esophageal pH monitoring and esophageal manometry for all patients undergoing anti-reflux surgery.
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Affiliation(s)
- José Roberto Alves
- Universidade Federal de Santa Catarina, Curso de Medicina, Departamento de Cirurgia - Florianópolis (SC), Brasil
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31
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Rogers BD, Rengarajan A, Abrahao L, Bhatia S, Bor S, Carlson DA, Cisternas D, Gonlachanvit S, Hani A, Hayat J, Kawamura O, Lee YY, Leguizamo AM, Pauwels A, de la Serna JP, Ramos RI, Remes-Troche JM, Roman S, Savarino E, Serra J, Sifrim D, Tolone S, Wong Z, Zerbib F, Pandolfino J, Gyawali CP. Esophagogastric junction morphology and contractile integral on high-resolution manometry in asymptomatic healthy volunteers: An international multicenter study. Neurogastroenterol Motil 2021; 33:e14009. [PMID: 33094875 PMCID: PMC9380029 DOI: 10.1111/nmo.14009] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/22/2020] [Accepted: 09/21/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Esophagogastric junction contractile integral (EGJ-CI) and EGJ morphology are high-resolution manometry (HRM) metrics that assess EGJ barrier function. Normative data standardized across world regions and HRM manufacturers are limited. METHODS Our aim was to determine normative EGJ metrics in a large international cohort of healthy volunteers undergoing HRM (Medtronic, Laborie, and Diversatek software) acquired from 16 countries in four world regions. EGJ-CI was calculated by the same two investigators using a distal contractile integral-like measurement across the EGJ for three respiratory cycles and corrected for respiration (mm Hg cm), using manufacturer-specific software tools. EGJ morphology was designated according to Chicago Classification v3.0. Median EGJ-CI values were calculated across age, genders, HRM systems, and regions. RESULTS Of 484 studies (28.0 years, 56.2% F, 60.7% Medtronic studies, 26.0% Laborie, and 13.2% Diversatek), EGJ morphology was type 1 in 97.1%. Median EGJ-CI was similar between Medtronic (37.0 mm Hg cm, IQR 23.6-53.7 mm Hg cm) and Diversatek (34.9 mm Hg cm, IQR 22.1-56.1 mm Hg cm, P = 0.87), but was significantly higher using Laborie equipment (56.5 mm Hg cm, IQR 35.0-75.3 mm Hg cm, P < 0.001). 5th percentile EGJ-CI values ranged from 6.9 to 12.1 mm Hg cm. EGJ-CI values were consistent across world regions, but different between manufacturers even within the same world region (P ≤ 0.001). Within Medtronic studies, EGJ-CI and basal LESP were similar in younger and older individuals (P ≥ 0.3) but higher in women (P < 0.001). CONCLUSIONS EGJ morphology is predominantly type 1 in healthy adults. EGJ-CI varies widely in health, with significant gender influence, but is consistent within each HRM system. Manufacturer-specific normative values should be utilized for clinical HRM interpretation.
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Affiliation(s)
- Benjamin D. Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Luiz Abrahao
- University Hospital Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Shobna Bhatia
- Department of Gastroenterology, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Serhat Bor
- Department of Gastroenterology, Ege University, Izmir, Turkey
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago de Chile, Chile
| | - Sutep Gonlachanvit
- Center of Excellence on Neurogastroenterology and Motility, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Albis Hani
- Departamento de Gastroenterología y Laboratorio de Motilidad, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Jamal Hayat
- Department of Gastroenterology, St. George’s University Hospitals NHS Trust, London, UK
| | - Osamu Kawamura
- Department of Gastroenterology, Kamimoku SPA Hospital, Minakami, Gunma, Japan
| | - Yeung Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia,Gut Research Group, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Ana Maria Leguizamo
- Departamento de Gastroenterología y Laboratorio de Motilidad, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ans Pauwels
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Julio Perez de la Serna
- Unidad de Motilidad, Servicio de Aparto Digestivo, Hospital Clinico San Carlos, Madrid, Spain
| | - Rosa I. Ramos
- Motility Lab, Department of Gastroenterology, British Hospital and El Cruce Hospital, Buenos Aires, Argentina
| | - Jose Maria Remes-Troche
- Digestive Physiology and Motility Lab, Medical Biological Research Institute, Universidad Veracruzana, Veracruz, México
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hopital E Herriot, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Jordi Serra
- Motility and Functional Gut Disorders Unit, University Hospital Germans Trias I Pujol. CIBERehd, Badalona, Barcelona, Spain
| | - Daniel Sifrim
- Upper GI Physiology Unit, Barts and the London School of Medicine and Dentistry, London, UK
| | - Salvatore Tolone
- General, Mininvasive and Bariatric Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Zhiqin Wong
- Gut Research Group, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, Bordeaux, France
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
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32
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Jiang Y, Jiang L, Ye B, Lin L. Value of adjunctive evidence from MII-pH monitoring and high-resolution manometry in inconclusive GERD patients with AET 4-6. Therap Adv Gastroenterol 2021; 14:17562848211013484. [PMID: 34104208 PMCID: PMC8170342 DOI: 10.1177/17562848211013484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/08/2021] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Gastro-esophageal reflux disease (GERD) is a common disease in gastroenterology outpatients. However, some patients with typical reflux symptoms does not satisfy diagnostic criteria. This study was to explore the value of adjunctive evidence from multichannel intraluminal impedance-pH (MII-pH) monitoring and esophageal high-resolution manometry (HRM) in inconclusive GERD patients with acid exposure time (AET) 4-6%. METHODS Endoscopy, MII-pH monitoring and esophageal HRM were retrospectively analyzed from consecutive patients with typical reflux symptoms in a tertiary hospital from 2013 to 2019. Patients were categorized as conclusive or inconclusive GERD according to AET. Adjunctive evidence for GERD diagnosis from Lyon Consensus were collected and analyzed. RESULTS Among 147 patients with typical reflux symptoms, conclusive GERD was found in only 31.97% of patients (N = 47). The remaining 100 patients (68.03%) were inconclusive GERD, of whom 28% (N = 28) had AET 4-6%. These patients suffered similar reflux burden and impaired esophageal movement. Inconclusive GERD patients with AET 4-6% had lots of positive adjunctive evidence from HRM and MII-pH monitoring. In receiver operating characteristic analysis, mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPWI) had an area under the curve (AUC) of 0.839 (CI: 0.765-0.913, p < 0.001) and 0.897 (CI: 0.841-0.953, p < 0.001), respectively, better than total reflux episode (AUC of 0.55, p = 0.33). When MNBI was combined with PSPWI, the AUC was elevated to 0.910 (CI: 0.857-0.963, p < 0.001). CONCLUSIONS Inconclusive GERD patients with AET 4-6% have similar acid burden and esophagus motility dysfunction to GERD patients. MNBI and PSPWI are pivotal adjunctive evidence for diagnosing GERD when AET is borderline.
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Affiliation(s)
| | | | - Bixing Ye
- Department of Gastroenterology, the First
Affiliated Hospital of Nanjing Medical University, Nanjing, China
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33
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Zerbib F, Bredenoord AJ, Fass R, Kahrilas PJ, Roman S, Savarino E, Sifrim D, Vaezi M, Yadlapati R, Gyawali CP. ESNM/ANMS consensus paper: Diagnosis and management of refractory gastro-esophageal reflux disease. Neurogastroenterol Motil 2021; 33:e14075. [PMID: 33368919 DOI: 10.1111/nmo.14075] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/11/2020] [Accepted: 12/13/2020] [Indexed: 02/08/2023]
Abstract
Up to 40% of patients with symptoms suspicious of gastroesophageal reflux disease (GERD) do not respond completely to proton pump inhibitor (PPI) therapy. The term "refractory GERD" has been used loosely in the literature. A distinction should be made between refractory symptoms (ie, symptoms may or may not be GERD-related), refractory GERD symptoms (ie, persisting symptoms in patients with proven GERD, regardless of relationship to ongoing reflux), and refractory GERD (ie, objective evidence of GERD despite adequate medical management). The present ESNM/ANMS consensus paper proposes use the term "refractory GERD symptoms" only in patients with persisting symptoms and previously proven GERD by either endoscopy or esophageal pH monitoring. Even in this context, symptoms may or may not be reflux related. Objective evaluation, including endoscopy and esophageal physiologic testing, is requisite to provide insights into mechanisms of symptom generation and evidence of true refractory GERD. Some patients may have true ongoing refractory acid or weakly acidic reflux despite PPIs, while others have no evidence of ongoing reflux, and yet others have functional esophageal disorders (overlapping with proven GERD confirmed off therapy). In this context, attention should also be paid to supragastric belching and rumination syndrome, which may be important contributors to refractory symptoms.
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Affiliation(s)
- Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | | | - Ronnie Fass
- Digestive Health Center, MetroHealth System, Cleveland, OH, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Sabine Roman
- Hospices Civils de Lyon, Hôpital E Herriot, Digestive Physiology, Université de Lyon, Inserm U1032, LabTAU, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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34
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Abstract
The esophagogastric junction (EGJ) is a complex barrier between the thoracic and abdominal luminal gut compartments, comprised primarily of the lower esophageal sphincter (LES) and crural diaphragm. Although closed at rest, the EGJ relaxes to allow antegrade bolus transit and retrograde venting of air. Abnormal relaxation is the hallmark of achalasia spectrum disorders, while increased frequency of transient lower esophageal sphincter relaxations and/or EGJ disruption are seen in gastroesophageal reflux disease. High resolution manometry (HRM) is the modern day gold standard for assessment of EGJ morphology and function, with better performance characteristics compared with endoscopy and barium esophagography. Conventional LES metrics defining EGJ function include resting LES pressure as well as postswallow residual pressures. Newer HRM-based metrics include EGJ contractile integral, which measures static barrier function at rest, and EGJ morphology, which characterizes the relationship between LES and crural diaphragm. Provocative maneuvers assess dynamic EGJ function during physiological or pharmacologic stress. The most useful of these maneuvers, the rapid drink challenge, assesses for latent obstruction, while multiple rapid swallows evaluate adequacy of deglutitive inhibition. Amyl nitrate and cholecystokinin administration can segregate motor from structural obstruction. Newer provocative tests (straight leg raise maneuver, abdominal compression) and novel diagnostic tools (functional lumen imaging probe) complement HRM evaluation of the EGJ. Although current HRM metrics and maneuvers show promise in identifying clinically relevant EGJ abnormalities, future investigations evaluating management outcomes will improve segregation of normal from abnormal EGJ morphology and function.
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35
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Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, Prakash Gyawali C, Roman S, Babaei A, Mittal RK, Rommel N, Savarino E, Sifrim D, Smout A, Vaezi MF, Zerbib F, Akiyama J, Bhatia S, Bor S, Carlson DA, Chen JW, Cisternas D, Cock C, Coss-Adame E, de Bortoli N, Defilippi C, Fass R, Ghoshal UC, Gonlachanvit S, Hani A, Hebbard GS, Wook Jung K, Katz P, Katzka DA, Khan A, Kohn GP, Lazarescu A, Lengliner J, Mittal SK, Omari T, Park MI, Penagini R, Pohl D, Richter JE, Serra J, Sweis R, Tack J, Tatum RP, Tutuian R, Vela MF, Wong RK, Wu JC, Xiao Y, Pandolfino JE. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0 ©. Neurogastroenterol Motil 2021; 33:e14058. [PMID: 33373111 PMCID: PMC8034247 DOI: 10.1111/nmo.14058] [Citation(s) in RCA: 540] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.
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Affiliation(s)
- Rena Yadlapati
- Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, CA, USA
| | - Peter J Kahrilas
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark R Fox
- Division of Gastroenterology and Hepatology, University Hospital, Zurich, Switzerland
- Department of Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - C Prakash Gyawali
- Division of Gastroenterology & Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Université Lyon I, Univ Lyon, Lyon, France
- Hospices Civils de Lyon, INSERM, LabTAU, Université Lyon I, Univ Lyon, Lyon, France
| | | | - Ravinder K Mittal
- Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, CA, USA
- Veteran Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Nathalie Rommel
- Department of Gastroenterology, Neurosciences, Experimental ORL, Neurogastroenterology & Motility, Deglutology - University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - André Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, INSERM CIC 1401, Université de Bordeaux, Bordeaux, France
| | - Junichi Akiyama
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Serhat Bor
- Div. Gastroenterology, Ege University School of Medicine, Izmir, Turkey
| | - Dustin A Carlson
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo. Santiago, Chile
| | | | - Enrique Coss-Adame
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición, Ciudad de México, CDMX, Mexico
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Ronnie Fass
- MetroHealth System and case Western Reserve University, Cleveland, OH, USA
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sutep Gonlachanvit
- Excellence Center on Neurogastroenterology and Motility, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Albis Hani
- Pontificia Universidad Javeriana-Hospital San Ignacio, Bogota, Colombia
| | - Geoffrey S Hebbard
- Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | - Abraham Khan
- Langone Health, New York University, New York, NY, USA
| | | | | | | | | | - Taher Omari
- College of Medicine & Public Health, Flinders University, Adelaide, SA, Australia
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Roberto Penagini
- Gastroenterology Unit, Fondazione IRCCS Ca, Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Joel E Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Jordi Serra
- CIBERehd, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Rami Sweis
- University College London Hospital, London, UK
| | - Jan Tack
- TARGID, University of Leuven, Leuven, Belgium
| | - Roger P Tatum
- Department of Surgery/VA Puget Sound HCS, University of Washington, Seattle, WA, USA
| | - Radu Tutuian
- Bürgerspital Solothurn, University of Bern, Bern, Switzerland
- Bürgerspital Solothurn, University of Zurich, Zurich, Switzerland
| | | | - Reuben K Wong
- Yong Loo Lin of Medicine, National University of Singapore, Singapore, Singapore
| | - Justin C Wu
- The Chinese University of Hong Kong, Hong Kong SAR
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - John E Pandolfino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Savarino E, di Pietro M, Bredenoord AJ, Carlson DA, Clarke JO, Khan A, Vela MF, Yadlapati R, Pohl D, Pandolfino JE, Roman S, Gyawali CP. Use of the Functional Lumen Imaging Probe in Clinical Esophagology. Am J Gastroenterol 2020; 115:1786-1796. [PMID: 33156096 PMCID: PMC9380028 DOI: 10.14309/ajg.0000000000000773] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The functional lumen imaging probe (FLIP) measures luminal dimensions using impedance planimetry, performed most often during sedated upper endoscopy. Mechanical properties of the esophageal wall and opening dynamics of the esophagogastric junction (EGJ) can be objectively evaluated in esophageal motor disorders, eosinophilic esophagitis, esophageal strictures, during esophageal surgery and in postsurgical symptomatic states. Distensibility index, the ratio of EGJ cross sectional area to intraballoon pressure, is the most useful FLIP metric. Secondary peristalsis from balloon distension can be displayed topographically as repetitive anterograde or retrograde contractile activity in the esophageal body, similar to high-resolution manometry. Real-time interpretation and postprocessing of FLIP metadata can complement the identification of esophageal outflow obstruction and achalasia, especially when findings are inconclusive from alternate esophageal tests in symptomatic patients. FLIP can complement the diagnosis of achalasia when manometry and barium studies are inconclusive or negative in patients with typical symptoms. FLIP can direct adequacy of disruption of the EGJ in achalasia when used during and immediately after myotomy and pneumatic dilation. Lumen diameter measured using FLIP in eosinophilic esophagitis and in complex strictures can potentially guide management. An abbreviated modification of the Grading of Recommendations Assessment, Development, and Evaluation was used to determine the quality of available evidence and recommendations regarding FLIP utilization. FLIP metrics that are diagnostic or suggestive of an abnormal motor pattern and metrics that define normal esophageal physiology were developed by consensus and are described in this review.
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Affiliation(s)
| | | | | | | | | | | | | | - Rena Yadlapati
- University of California in San Diego, La Jolla, California, USA
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Savarino E, Frazzoni M, Marabotto E, Zentilin P, Iovino P, Costantini M, Tolone S, Battaglia E, Cicala M, Usai-Satta P, de Bortoli N, Penagini R, Savarino V. A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring. Dig Liver Dis 2020; 52:966-980. [PMID: 32513632 DOI: 10.1016/j.dld.2020.04.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.
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Affiliation(s)
- Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Paola Iovino
- Gastroenterology Unit, University of Salerno, Salerno, Italy
| | - Mario Costantini
- Clinica Chirurgica III, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaja Hospital, Asti, Italy
| | - Michele Cicala
- Unit of Digestive Diseases, Campus Bio Medico University, Rome, Italy
| | | | - Nicola de Bortoli
- Gastrointestinal Unit-Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56124 Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit - Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico - University of Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Wong MW, Hung JS, Lei WY, Yi CH, Liu TT, Chen CL. Influence of sildenafil on esophageal motor function in humans: Studies using high-resolution manometry. Neurogastroenterol Motil 2020; 32:e13840. [PMID: 32329184 DOI: 10.1111/nmo.13840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/26/2020] [Accepted: 03/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIM Sildenafil induces smooth muscle relaxation of the esophagus by blocking type 5 phosphodiesterase that degrades cyclic guanine monophosphate. We aimed to characterize the effects of sildenafil on esophageal peristalsis and contraction reserve using high-resolution manometry (HRM). METHODS Fifteen healthy adults (12 men, age 21-39, mean 27 years) participated in this study using HRM following either sildenafil 50 mg or placebo. HRM with ten wet swallows and five multiple rapid swallows was performed in all participants. HRM metrics included esophagogastric junction contractile integral (EGJ-CI), basal lower esophageal sphincter (LES) pressure, 4-second integrated relaxation pressure (IRP-4s), distal contractile integral (DCI), distal latency, resting upper esophageal sphincter pressure (UESP), and the response to MRS. RESULTS Sildenafil significantly lowered EGJ-CI (P < .001), LES pressure (P = .04), IRP-4s (P = .02), and DCI (P < .001). There was no difference in UESP (P = .87) between sildenafil and placebo. Sildenafil significantly decreased peristaltic vigor, inducing absent peristalsis in 12 subjects and ineffective esophageal motility in 3 subjects. Peristaltic response and augmentation following MRS were significantly inhibited following sildenafil (7% vs 100%, P < .001, and none vs 73%, P < .001). CONCLUSIONS Sildenafil attenuates EGJ barrier function, resting LES pressure, and LES relaxation. Both esophageal body contractility and contraction reserve are inhibited by sildenafil in healthy adults.
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Affiliation(s)
- Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,PhD program in Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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Ghisa M, Barberio B, Savarino V, Marabotto E, Ribolsi M, Bodini G, Zingone F, Frazzoni M, Savarino E. The Lyon Consensus: Does It Differ From the Previous Ones? J Neurogastroenterol Motil 2020; 26:311-321. [PMID: 32606254 PMCID: PMC7329153 DOI: 10.5056/jnm20046] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is a complex disorder with heterogeneous symptoms and a multifaceted pathogenetic basis, which prevent a simple diagnostic algorithm or any categorical classification. Clinical history, questionnaires and response to proton pump inhibitor (PPI) therapy are insufficient tools to make a conclusive diagnosis of GERD and further investigations are frequently required. The Lyon Consensus goes beyond the previous classifications and defines endoscopic and functional parameters able to establish the presence of GERD. Evidences for reflux include high-grade erosive esophagitis, Barrett’s esophagus, and peptic strictures at endoscopy as well as esophageal acid exposure time > 6% on pH-metry or combined pH-impedance monitoring. Even if a normal endoscopy does not exclude GERD, its combination with distal acid exposure time < 4% on off-PPI pH-impedance monitoring provides sufficient evidence refuting this diagnosis. Reflux-symptom association on pH-monitoring provides supportive evidence for reflux-triggered symptoms and may predict a better treatment outcome, when present. Also recommendations to perform pH-impedance “on” or “off” PPI are well depicted. When endoscopy and pH-metry or combined pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (eg, microscopic esophagitis), high-resolution manometry (ie, ineffective esophagogastric barrier and esophageal body hypomotility), and novel impedance metrics, such as mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index, can contribute to better identify patients with GERD. Definition of individual patient phenotype, based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the esophagogastric junction, and clinical presentation, will lead to manage GERD patients with a tailored approach chosen among different types of therapy.
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Affiliation(s)
- Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology, Campus Bio-Medico University, Rome, Italy
| | - Giorgia Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Ang D, Lee Y, Clarke JO, Lynch K, Guillaume A, Onyimba F, Kamal A, Gyawali CP. Diagnosis of gastroesophageal reflux: an update on current and emerging modalities. Ann N Y Acad Sci 2020; 1481:154-169. [DOI: 10.1111/nyas.14369] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Daphne Ang
- Department of Gastroenterology Changi General Hospital Singapore Singapore
| | - Yeong‐Yeh Lee
- Department of Gastroenterology, Hepatology and Internal Medicine, School of Medical Sciences Universiti Sains Malaysia Kota Bharu Malaysia
- Gut Research Group, Faculty of Medicine National University of Malaysia Kuala Lumpur Malaysia
- St George and Sutherland Clinical School University of New South Wales Sydney New South Wales Australia
| | - John O. Clarke
- Division of Gastroenterology and Hepatology Stanford University Stanford California
| | - Kristle Lynch
- Division of Gastroenterology, Department of Medicine Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania
| | - Alexandra Guillaume
- Division of Gastroenterology and Hepatology, Stony Brook Medicine Stony Brook University Hospital Stony Brook New York
| | - Frances Onyimba
- Division of Gastroenterology and Hepatology University of Maryland School of Medicine Baltimore Maryland
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology Stanford University Stanford California
| | - C. Prakash Gyawali
- Division of Gastroenterology Washington University School of Medicine St. Louis Missouri
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Ayazi S. Quantifying Esophagogastric Junction Barrier Competency Using High-Resolution Manometry. J Am Coll Surg 2020; 230:755-757. [PMID: 32334740 DOI: 10.1016/j.jamcollsurg.2020.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 11/17/2022]
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Ribolsi M, Gyawali CP, Savarino E, Rogers B, Rengarajan A, Della Coletta M, Ghisa M, Cicala M. Correlation between reflux burden, peristaltic function, and mucosal integrity in GERD patients. Neurogastroenterol Motil 2020; 32:e13752. [PMID: 31670453 DOI: 10.1111/nmo.13752] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/14/2019] [Accepted: 10/07/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Mean nocturnal baseline impedance (MNBI) augments the diagnostic yield of multichannel intraluminal impedance-pH (MII-pH) monitoring. While acid exposure time (AET) correlates with MNBI, it remains unclear whether esophageal motility affects MNBI values. The present study was aimed at evaluating the respective roles of esophageal motor function and AET on MNBI. METHODS High-resolution manometry (HRM) studies and ambulatory 24-hour MII-pH monitoring tracings were retrospectively analyzed from consecutive endoscopy-negative GERD patients with typical symptoms responsive to previous acid-suppressive therapy from three tertiary care centers. Univariate and multivariate analyses were performed to determine predictors of pathologic MNBI values at 3 cm and 5 cm above the lower esophageal sphincter (LES). KEY RESULTS Patients with pathological AET displayed lower MNBI values at 3 cm and 5 cm (P < .01) compared to patients with non-pathological AET. Similarly, significantly lower MNBI values were also noted at both sites with type 3 EGJ compared to type 1 EGJ (P ≤ .02 for each comparison), and with absent contractility compared to normal peristalsis (P ≤ .02 for each comparison). On multivariate analysis, the presence of type 2 or 3 EGJ and absent contractility were associated with a significantly higher probability of pathological MNBI values at 3 cm and 5 cm above the LES. CONCLUSIONS AND INFERENCES Disruption of the EGJ and absent contractility on HRM are both associated with lower MNBI values. HRM findings complement reflux testing using MII-pH monitoring.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology, Campus Bio Medico University, Rome, Italy
| | - Chandra Prakash Gyawali
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Benjamin Rogers
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Arvind Rengarajan
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Marco Della Coletta
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Michele Cicala
- Unit of Gastroenterology, Campus Bio Medico University, Rome, Italy
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Sleeve Gastrectomy, GERD, and Barrett's Esophagus: It Is Time for Objective Testing. Obes Surg 2020; 29:2312-2313. [PMID: 31062277 DOI: 10.1007/s11695-019-03902-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Tolone S, Savarino E, de Bortoli N, Frazzoni M, Frazzoni L, Savarino V, Docimo L. Esophageal High-Resolution Manometry Can Unravel the Mechanisms by Which Different Bariatric Techniques Produce Different Reflux Exposures. J Gastrointest Surg 2020; 24:1-7. [PMID: 31621023 DOI: 10.1007/s11605-019-04406-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/07/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Bariatric surgery is increasingly performed. Since there are numerous surgical techniques, the effects of these on the esophageal function are still poorly understood. We aimed at assessing the effect of different techniques on esophagogastric junction (EGJ), esophageal peristalsis and reflux exposure using high-resolution manometry (HRM), and impedance-pH monitoring (MII-pH). METHODS All obese patients underwent symptomatic questionnaires, endoscopy, HRM, and MII-pH before and 1 year after surgery. Esophageal function and EGJ were classified according to Chicago Classification V. 3.0. Intragastric pressure (IGP) and gastroesophageal pressure gradient (GEPG) were assessed. Total acid exposure time (AET %), total number of refluxes, and symptom association probability (SAP) were assessed. A group of healthy volunteers (HVs) served as control. RESULTS One hundred and twelve obese subjects and 15 HVs (normal weight) were studied. Thirteen underwent endoscopic balloon placement (BIB), 12 gastric banding (GB), 26 sleeve gastrectomy (SG), 18 Roux-en-Y gastric bypass (RYGB), 15 mini-gastric bypass (MGB), 16 biliointestinal bypass (BIBP), and 12 biliopancreatic diversion (BPD). IGP and GEPG significantly decreased after RYGP, BPD, and BPBP, whereas they significantly increased after GB and SG. Post-operative greater AET (p < 0.05) and increased total number of reflux (p < 0.001) were present after GB and SG. RYGB and MGB showed a significant decrease in AET (p < 0.05) and total number of reflux (p < 0.001). CONCLUSIONS HRM verified that different bariatric techniques produced different modification of IGP and GEPG, leading to different reflux exposure. Only GB and SG can negatively impact on esophageal function and reflux exposure.
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Affiliation(s)
- Salvatore Tolone
- Division of General, Mininvasive and Bariatric Surgery, University of Campania "Luigi Vanvitelli", Via Pansini 5, ZIP 80100, Naples, Italy.
| | | | | | | | | | | | - Ludovico Docimo
- Division of General, Mininvasive and Bariatric Surgery, University of Campania "Luigi Vanvitelli", Via Pansini 5, ZIP 80100, Naples, Italy
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Hung JS, Yi CH, Liu TT, Lei WY, Wong MW, Chen CL. Effects of GABA-B agonist baclofen on esophageal motility: Studies using high-resolution manometry. Neurogastroenterol Motil 2019; 31:e13716. [PMID: 31565828 DOI: 10.1111/nmo.13716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIM Baclofen inhibits transient lower esophageal sphincter (LES) relaxation. This study aimed to investigate the effect of baclofen on esophageal peristaltic function and contraction reserve in healthy adults using high-resolution manometry (HRM). METHODS Fifteen subjects underwent HRM with ten water swallows and five multiple rapid swallows (MRS) 90 minutes after oral intake of either baclofen or placebo on separate days at least 1 week apart. HRM parameters assessed included esophagogastric junction contractile integral (EGJ-CI), resting LES pressure, 4-second integrated relaxation pressure (IRP-4s), distal contractile integral (DCI), distal latency, peristaltic breaks, resting upper esophageal sphincter (UES) pressure, and contractile response to MRS. RESULTS Baclofen significantly increased EGJ-CI (P = .007), IRP-4s (P = .003), and LES pressure (P = .004). UES pressure, latency, and DCI were similar between baclofen and placebo (P = .87, P = .84, and P = .54, respectively). There was no difference in contractile response and peristaltic augmentation following MRS between baclofen and placebo (93% vs 100%, P = .30; 53% vs. 73%, P = .26, respectively). CONCLUSIONS Baclofen increases resting LES pressure and EGJ barrier function, but has no effect on primary peristalsis or contraction reserve.
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Affiliation(s)
- Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
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Lin S, Li H, Fang X. Esophageal Motor Dysfunctions in Gastroesophageal Reflux Disease and Therapeutic Perspectives. J Neurogastroenterol Motil 2019; 25:499-507. [PMID: 31587540 PMCID: PMC6786454 DOI: 10.5056/jnm19081] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/20/2019] [Indexed: 01/01/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a very common disease, and the prevalence in the general population has recently increased. GERD is a chronic relapsing disease associated with motility disorders of the upper gastrointestinal tract. Several factors are implicated in GERD, including hypotensive lower esophageal sphincter, frequent transient lower esophageal sphincter relaxation, esophageal hypersensitivity, reduced resistance of the esophageal mucosa against the refluxed contents, ineffective esophageal motility, abnormal bolus transport, deficits initiating secondary peristalsis, abnormal response to multiple rapid swallowing, and hiatal hernia. One or more of these mechanisms result in the reflux of stomach contents into the esophagus, delayed clearance of the refluxate, and the development of symptoms and/or complications. New techniques, such as 24-hour pH and multichannel intraluminal impedance monitoring, multichannel intraluminal impedance and esophageal manometry, high-resolution manometry, 3-dimensional high-resolution manometry, enoscopic functional luminal imaging probe, and 24-hour dynamic esophageal manometry, provide more information on esophageal motility and have clarified the pathophysiology of GERD. Proton pump inhibitors remain the preferred pharmaceutical option to treat GERD. The ideal target of GERD treatment is to restore esophageal motility and reconstruct the anti-reflux mechanism. This review focuses on current advances in esophageal motor dysfunction in patients with GERD and the influence of these developments on GERD treatment.
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Affiliation(s)
- Sihui Lin
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical Colleg e, Beijing, China.,Department of Gastroenterology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian Province, China
| | - Hua Li
- Department of Gastroenterology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian Province, China
| | - Xiucai Fang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical Colleg e, Beijing, China
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Ghisa M, Marinelli C, Savarino V, Savarino E. Idiopathic pulmonary fibrosis and GERD: links and risks. Ther Clin Risk Manag 2019; 15:1081-1093. [PMID: 31564886 PMCID: PMC6733342 DOI: 10.2147/tcrm.s184291] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/11/2019] [Indexed: 01/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) and idiopathic pulmonary fibrosis (IPF) are two pathological conditions often strictly related, even if a clear relationship of causality has not been demonstrated. GERD is a frequent comorbidity in IPF patients, as demonstrated using combined multichannel intraluminal impedance-pH, despite being mostly clinically silent. According to that, it has been hypothesized that microaspiration of gastric material may play a fundamental role in the fibrotic transformation of pulmonary parenchyma. In contrast, it cannot be excluded that IPF may favor GERD by increasing the negative intrathoracic pressure. Therefore, this relationship is uncertain as well as not univocal. Nevertheless, the latest international guidelines recommend the use of proton pump inhibitors (PPIs) in IPF based on several data showing that PPIs can stabilize lung function, reduce disease flares and hospitalizations. On the contrary, recent studies not only question the relevance of these results, but also associate the use of PPIs with an increased risk of lung infections and a negative prognostic outcome. The aim of this review is to analyze the possible links between GERD and IPF and their possible therapeutic implications, trying to translate this scientific evidence into useful information for clinical practice.
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Affiliation(s)
- Matteo Ghisa
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Carla Marinelli
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Ghisa M, Della Coletta M, Barbuscio I, Marabotto E, Barberio B, Frazzoni M, De Bortoli N, Zentilin P, Tolone S, Ottonello A, Lorenzon G, Savarino V, Savarino E. Updates in the field of non-esophageal gastroesophageal reflux disorder. Expert Rev Gastroenterol Hepatol 2019; 13:827-838. [PMID: 31322443 DOI: 10.1080/17474124.2019.1645593] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.
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Affiliation(s)
- Matteo Ghisa
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Marco Della Coletta
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Ilenia Barbuscio
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Brigida Barberio
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | | | - Nicola De Bortoli
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa , Pisa , Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Salvatore Tolone
- Surgery Unit, Department of Surgery, University of Campania Luigi Vanvitelli , Caserta , Italy
| | - Andrea Ottonello
- Department of Surgical Science and Integrated Diagnostics, University of Genoa , Genoa , Italy
| | - Greta Lorenzon
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
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Garbarino S, Horton A, Patel A. The Utility of Esophageal Motility Testing in Gastroesophageal Reflux Disease (GERD). Curr Gastroenterol Rep 2019; 21:37. [PMID: 31289922 DOI: 10.1007/s11894-019-0704-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
PURPOSE OF REVIEW Here, we discuss how esophageal motor testing plays important roles in patients with suspected gastroesophageal reflux disease (GERD). In addition to guiding appropriate placement of catheters for ambulatory reflux monitoring, esophageal high-resolution manometry (HRM) rules out confounding diagnoses, such as achalasia spectrum disorders, that can present with symptoms similar to that of GERD, but are managed very differently. RECENT FINDINGS HRM performed with impedance in the post-prandial setting (PP-HRIM) can assess for rumination syndrome or supragastric belching, which should be directed towards behavioral interventions. The recent GERD Classification of Motor Function recommends a hierarchical approach, focusing on (1) the esophagogastric junction (EGJ), (2) the esophageal body, and (3) esophageal contraction reserve, which can be assessed with provocative maneuvers at HRM, such as multiple rapid swallows (MRS). This approach can inform the appropriate tailoring of antireflux surgery. Novel esophageal motility metrics, such as the EGJ-contractile integral from HRM, or post-reflux swallow-induced peristaltic wave indices from 24-h pH-impedance monitoring, may also assist with GERD diagnosis. Assessment of esophageal motor function can contribute in a significant manner to the care of patients with suspected GERD, particularly when esophageal symptoms do not improve with antisecretory therapy, and/or when surgical or endoscopic antireflux therapies are under consideration.
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Affiliation(s)
- Stephanie Garbarino
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, 10207 Cerny St, Suite 210, Raleigh, NC, 27617, USA
| | - Anthony Horton
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, 10207 Cerny St, Suite 210, Raleigh, NC, 27617, USA
| | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, 10207 Cerny St, Suite 210, Raleigh, NC, 27617, USA.
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Braghetto I, Korn O. Late esophagogastric anatomic and functional changes after sleeve gastrectomy and its clinical consequences with regards to gastroesophageal reflux disease. Dis Esophagus 2019; 32:5487969. [PMID: 31076757 DOI: 10.1093/dote/doz020] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Gastroesophageal reflux disease (GERD) is described as a complication after sleeve gastrectomy. Most studies have used only clinical symptoms or upper gastrointestinal endoscopy for evaluation of reflux after surgery. Manometry, acid reflux tests, and esophageal barium swallow have not been commonly used. The objective of this study is to evaluate the short- and long-term incidence of clinical gastroesophageal reflux, the lower esophageal sphincter (LES) pressure, acid reflux, and endoscopic and radiological changes after sleeve gastrectomy (SG). A total of 315 patients were studied after SG; 248 (78.3%) completed more than 5 years of follow-up and 67 (21.4%) have more than 8 years (range 8-10 years) of follow-up. The preoperative weight was 106 + 14.1 kg with a mean body mass index 38.4 + 3.4 kg/m2. Patients with prior GERD were excluded for SG. During the follow-up patients were subjected to clinical, endoscopic, radiological, manometric, and 24-hour pH monitoring and duodenogastric reflux evaluations. Reflux symptoms were observed in 65.1% of patients at late follow-up. Patients without reflux symptoms presented an LES resting pressure of 13.3 ± 4.2 mmHg while patients with reflux symptoms presented an LES resting pressure of 9.8 + 2.1 mmHg. In patients with reflux symptoms, a positive acid reflux test was observed in 77.5% of patients with a mean DeMeester score of 41.7 ± 2.9 (range 14.1-131.7). During endoscopy, esophagitis was found in 29.4%, hiatal hernia in 5.7%, and Barrett's esophagus was diagnosed in 4.8%. Positive duodenogastric reflux was found in 31.8% of patients and 57.7% of our patients received proton pump inhibitor treatment after SG. Sleeve gastrectomy presents anatomic and functional changes that are associated with increased GERD.
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Affiliation(s)
- Italo Braghetto
- Department of Surgery, Hospital 'Dr. José J. Aguirre', Faculty of Medicine, University of Chile
| | - Owen Korn
- Department of Surgery, Hospital 'Dr. José J. Aguirre', Faculty of Medicine, University of Chile
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